New guidance on mental health and homelessness

Homelessness services need to develop more understanding of the emotional needs that underlie clients’ chaotic lives, writes Robin Johnson, author of new guidance on the issue

Until homelessness services can recognise that many of their clients will have suffered emotional trauma, a lot of the help on offer will only scratch the surface. That is the message from new guidance issued by the Department for Communities and Local Government and the government’s National Mental Health Development Unit, of which I was one of the main authors.

Depression among homeless people is double that for the rest of the population, and rates of psychosis may be anything between four and 15 times higher. Deliberate self-harm and suicidal thoughts are much higher, especially among women and young people. Homeless people are far more likely to appear at A&E; but that may be connected with the reluctance of some GPs to register them – and the service they receive when they do.

But one statistic in this new guidance that may still surprise many is the suggestion that among street homeless and hostel residents, the number of people with personality disorders may be as high as 60%, compared with 10% for the population as a whole.

What this guidance has to say about personality disorder is radically different from the media stereotypes of deranged axemen and cold-blooded killers.

Stigma of medical labels

In fact, the guidance suggests that the term “personality disorder” may itself not help much in the homelessness world. This is partly because of the persisting stigma and “therapeutic nihilism” that goes with the term, but mainly because it locates, by implication, most of the problem in the individual. Instead, the guidance suggests, we have to consider how poor some services are at recognising the real emotional needs underlying chaotic behaviour, and the equally chaotic way services in some areas do not join up and gear up to manage more challenging behaviour.

Nevertheless, there is always the risk that some will complain that any use of medical or psychological terms means “medicalising” what is really a social problem. For those who have argued that homelessness results from a lack of social capital, so that any sudden shock leaves the individual without support, this kind of approach may seem unhelpful. For Big Issue sellers, used to a spirit of independence and self-reliance, the assumption that homeless people need extra help may seem jarring.

Still, the guide says it “deliberately tries to avoid the polarised argument about homelessness being either the fault of the individual or the fault of society, but rather sees homelessness as resulting from an interaction of the two”.

Whether that in itself is enough to forestall a new wave of pigeon-holing of homeless people remains to be seen. But this attempt to straddle the medical-social divide reflects the main target audience for this guidance, which is not homeless people but services and those that commission and manage them, in particular primary care and secondary mental health services.

Underlying this report – and the timing of the guidance – is the stubborn fact that there will be public spending cuts. For the past 10 years, most of the funding for homelessness resettlement services has come from Supporting People, a budget managed by local authorities. It was ring-fenced, so the money could not be hived off to fund over-stretched social care services. That ring-fencing ended last year; now there are fears that the budget can be raided to pay for more mainstream care.

So this guidance says, loud and clear, that homelessness services are meeting mental health needs for some of those with the poorest physical and mental health in the country. If these needs are just as much the concern of health and social care services, the buck cannot be passed back to housing, when the cuts bite. If we are serious about protecting healthcare in all its forms, we must protect that kind of care whether in a homeless hostel or in an A&E department.

Robin Johnson is head of research at RJA consultancy, which specialises in mental health and housing.

Meeting the Psychological and Emotional Needs of People Who Are Homeless

This article is published in the 12 August 2010 edition of Community Care magazine under the headline Medical-Social Divide Hindering Homeless People