The relationships between mental health and homelessness are not straightforward. Since the 1960s, there has been a belief that homeless people are often individuals who have had – or should have had – contact with mental health services. In the US, Europe and also the UK, the closure of long-stay psychiatric hospitals was long thought to be the major cause of rising levels of homelessness.
In the early 1990s, one American article summarised homelessness as being the result of people passing 'out of the [psychiatric] wards and onto the streets'. Research in the UK, as well as in other industrialised countries, reported very high levels of severe mental illness among people living rough and in emergency shelters during the 1980s and 1990s.
However, criticisms began to be directed at the idea that mental health problems acted as the primary trigger for homelessness. One problem was that the population of people with the kinds of mental illness associated with homelessness hugely outnumbered the homeless population. In other words, if homelessness was 'caused' primarily by mental illness, why were there not far more homeless people? Another problem was the possibility that mental health problems could sometimes arise because of homelessness, or be made worse by homelessness, i.e. mental illness could sometimes be an effect, rather than cause of homelessness.
In the late 1990s, an American academic, Dennis P. Culhane and his colleagues started to think about looking at homeless people in a different way. Up until that point, homeless people had tended to be surveyed using short surveys, with researchers going to people in emergency accommodation and to people sleeping rough and gathering information from them over the course of a few days. This kind of research tended to find a lot of mental health problems.
When Culhane and his colleagues looked at homelessness, they used an alternative approach, looking at everyone using homelessness services over time, what is sometimes called longitudinal research. This work found that many homeless people did not have mental health problems, but that there were small groups of homeless people with very high and complex needs, usually involving addiction and severe mental illness, who were repeatedly homeless or homeless for long periods of time. It had looked like most homeless people had mental health issues, but this was because whenever homelessness services were visited for only a short period, it was this group of high need homeless people who were most likely to be there.
The reasons why this was happening – and UK research and European research started to show similar patterns – was that addiction made some mental health services inaccessible, while severe mental illness also made some addiction services inaccessible. Homeless people's combined need for drug/alcohol and mental health services could be a barrier to those services.
Specific interventions that offered a combined addiction/mental health service were developed for homeless people, but coverage could be patchy, it was often only practical to organise such services in major cities. Medical practitioners also quickly realised that unless homeless people with mental health problems were adequately and sustainably housed, ensuring continuity of care and successful treatment was extremely difficult. Combining drug and alcohol and mental health services was not enough to tackle homelessness among people with high needs, they needed housing as well.
Initially, services tried to meet housing need by providing treatment first, the idea being that someone could be made 'housing-ready' through a process which brought them to a point where they were physically and mentally able to manage on their own and their addiction issues had been resolved. These 'treatment first' services can achieve positive results, but there are concerns about the quite high numbers of homeless people that do not engage successfully with these services and remained homeless, the more so because these services are expensive. One reason why these services did not work for everyone is that they could have sometimes harsh regimes, e.g. ejecting homeless people for being caught taking drugs or drinking just once, but equally, there was evidence that homeless people were getting 'stuck' in these services, not ever reaching a position where they were assessed as 'housing ready'.
Housing First, which is becoming a mainstream policy in the UK, several European countries and in Canada and the USA, is specifically targeted on homeless people with mental illnesses and addiction, alongside other high and complex needs. Housing is provided immediately, within personalised, harm reduction service framework and support is from mobile workers providing intensive housing related support and case management. Typically, around eight out of every ten people that Housing First services work with are stably housed for at least one year. Both in the UK and internationally, Housing First appears much more successful in ending homelessness among people with complex needs.
| Period | 4 Jul 2017 |
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| Held at | Cymorth Cymru |
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- Homelessness
- Mental health