Homelessness: more than just a housing Issue Emily Van Der Pol-Harney, SHP PsychologistFor Mental Health Awareness Week, SHP Psychologist Emily Van Der Pol-Harney reflects on the role that mental health plays as an underlying cause of homelessness, and on the challenges of tackling it effectively. In homelessness, housing is only part of the story. Without addressing people’s mental and physical health - and underlying issues such as trauma, abuse, and social stigma - attempts to house people will likely fail. Homeless individuals are much more likely than the general population to have experienced trauma, abuse, family violence, and neglect. Figures from Homeless Link show that 45 per cent of people experiencing homelessness have been diagnosed with a mental health condition - almost double that of the general population – while four in every five homeless people report suffering from some form of mental health issue. Despite this, when I started working in the UK homelessness sector, I was shocked to find how little psychological support was available for service users. I had come from working in Australian prisons and public drug and alcohol services, where there was a huge focus on psychological intervention. Trauma, often rooted in childhood experiences, can lead to chronic stress and changes in the development of the nervous, endocrine, and immune systems, leading to impaired cognitive, social and emotional functioning, and ongoing physiological damage. In the longer term, as well as poorer physical and mental health, this can lead to the adoption of high risk and health-damaging behaviours in order to cope with these social and emotional struggles. We can all admit to using unhelpful coping strategies when we are stressed, feeling down, or experiencing grief (a few too many glasses of wine, binge-watching TV, ignoring emails…). So it’s perhaps unsurprising that up to 63 per cent of people experiencing homelessness have drug and/or alcohol use problems, while 27 per cent have been charged with a criminal offence, 30 per cent engage in deliberate self-harm, and 38 per cent have attempted suicide (Fitzpatrick, Bramley, & Johnsen, 2012). We can all admit to using unhelpful coping strategies when we are stressed, feeling down or experiencing grief (a few too many glasses of wine, binge-watching TV, ignoring emails...) so it's unsurprising that 63 per cent of homeless people have drug or alcohol problems.There is no single reason for homelessness, nor is there one simple solution. In fact, 60 per cent of SHP clients come from a position of multiple disadvantage - facing challenges in numerous areas including mental health, substance use, offending behaviour, and physical health. Many of our clients are living with unaddressed trauma but have been unable to access appropriate treatment from statutory mental health services because they are also struggling with substance use – a Catch-22 situation known as ‘dual diagnosis’. As a result, clients are often bandied about between services – mental health services cannot support them due to their drug and alcohol use, and drug and alcohol services cannot support them because of their mental ill health. Referrals can bounce back and forth, leaving service users feeling abandoned, uncared for, and most importantly, untreated. Homelessness in England has been increasing since 2010, which in combination with the current climate of austerity, has lead to diminishing resources and increased demand. The public health system does an amazing job helping those that it can, but in order to cope with high demand, many public services have increased their care thresholds, can have months-long waiting lists, and often cannot cater to people with multiple and enduring support needs. For SHP, this means that being able to provide therapeutic support for mental health needs, within our own services, has become more and more important. Despite the scarcity of funding for this kind of provision, over the past year we have broadened the range of clients to whom we can offer in-house therapeutic support. We now have a psychotherapist and two psychologists embedded in our services, who are providing therapeutic counselling to clients who have complex psychological and emotional needs. In many cases, despite lifelong struggles with their mental health, the sessions at SHP are the first time they have ever had this kind of support. Having in-house support can help clients access therapy despite fears and anxieties around leaving their homes and engaging with services which they might otherwise find intimidating. People who have experienced trauma may struggle to articulate what is causing their distress, to understand and regulate their emotions, and to approach and maintain personal and professional relationships. This can mean that it can take a long time to foster trust. Having in-house psychology means that these pre-therapy relationships can be established informally, and that once clients are ready, therapy can move at the client’s pace, without time restrictions. Many people experiencing anxiety, neurological deficits, or drug and alcohol dependency may also struggle to attend scheduled appointments, and thus are often discharged from services for non-attendance. In-house psychological services enable us to approach therapy sessions more flexibly to ensure that clients are able to engage when they are comfortable doing so. While we’re proud of the progress we have made, chronic lack of funding means that extending this provision to sufficient levels remains a constant challenge. Meanwhile, as public services continue to struggle with the effects of austerity, the sad reality is that far too many people who are homeless or at risk of homelessness remain unable to access the support they need.