1. Homelessness and Mental Health
Nicholas Pleace

2. Overview Mental health and the causes of homelessness
What we thought was happening
What is actually happening
Changing practice

3. Mental health and homelessness
Our images of homelessness, as a society, are people on the street
People experiencing homelessness are associated with mental illness
Ancient historical and cultural ideas, about the ”mad beggar” from the middle ages onwards
While we now say ‘entrenched rough sleeper with high and complex needs’, how different is the actual image?

4. The 1980s and 1990s Out of the wards and onto the streets
American researchers connect the rise in sustained and recurrent street homelessness with the closure of long stay psychiatric hospitals
Increases in European - and UK – homelessness prompt the same question

5. The 1980s and 1990s
…rates of severe mental illness amongst the long-term homeless are considerably in excess of what might be expected given general population rates of these disorders (Craig and Timms, 1992)
Prevalence of neurotic disorders…around two and a half times the proportion among people living in private households (Gill et al, 1996)

6. Mental health Association seemed strong
Rough sleepers and people in emergency accommodation and hostels
High rates of mental illness
High rates of severe mental illness
Plus addiction – alcohol in the 1960s-1980s – drugs and alcohol from the 1980s onwards
High and complex needs

7. Wait a minute though
If people are becoming homeless because they are mentally ill
Where is everyone?
And what if you are not mentally ill before you become homeless
But become mentally ill as a consequence of homelessness or the experiences that make you homeless?

8. Homeless, mentally ill?
Mainstream psychiatry conceptualizes people who are homeless and mentally ill as distinct from other homeless persons because it is thought that their status stems from their mental disorder and the poor implementation of deinstitutionalization. The authors believe this dichotomy is illusory. They present data indicating that recent socioeconomic and political shifts contributed greatly to homelessness among all groups, regardless of mental illness; that those with and without mental illness have similar biographical and demographic profiles; that high levels of mental distress are common to all homeless persons; and that few mentally ill homeless persons require involuntary hospitalization. Cohen and Thompson, 1992.

9. Big data Dennis Culhane, University of Pennsylvania
Had the idea of looking at everyone using homeless shelters over a year or more
Might not sound that revolutionary
But it showed almost everything that was thought to be true, up to that point, had been wrong

10. Longitudinal data
There were homeless people with very high and complex needs, usually severe mental illness and drug/alcohol addiction
But they were not present in high numbers
A lot of people used the emergency shelters for short periods of time and did not have mental health problems

11. Longitudinal data
Earlier work was cross-sectional, it took a snapshot survey over a day or a few days
The people who had severe mental illness and other high needs were in the emergency accommodation for long periods or very frequently
So if you looked at emergency accommodation over short periods, that is who you found
Long term and recurrently homeless people had high rates of mental health problems, but they were a minority of homeless people

12. Longitudinal data
Of 340,151 days, chronic stayers [long-term homeless people] consume 170,878 days (50.2%), transitional stayers use 110,674 days (32.5%), and episodic clients [recurrently homeless people] take up 58,599 days (17.2%). Kuhn and Culhane, 1998.
20% of shelter using homeless people used 67% of the bed- nights available (Philadelphia, similar pattern in New York)
And those 20% had high rates of severe mental illness and addiction, along with other treatment and support needs

13. UK research And this same broad pattern is evident here in the UK
Here in Wales, more precisely
So, yes, mental health is associated with homelessness
With the worst forms of homelessness, long-term and repeated
But it is a relatively small group of people

14. And then More American research
A lot of long-term and recurrently homeless people do not appear to have started out with high support needs, or mental health problems
Instead there is evidence of mental health problems arising in association with sustained and repeated homelessness
Similar pattern found in Ireland
Back to questioning the idea that mental health is always a cause, rather than a possible effect of homelessness

15. Changing practice
We’ve known for a long time that not all homelessness is the same
We know that long-term and repeated homelessness is associated with poor mental health
Also that the relationship is not straightforward, mental health problems may arise in association with homelessness, not beforehand

16. Changing practice
With single homeless people the approach has been to treat and house
Housing ready
Variations on (and sometimes replication of) a clinical model for resettling former psychiatric patients
Usually not very well resourced (compared to services for other groups with similar levels of need)

17. Emergence of Housing First
Services that focus on making homeless people with complex needs ‘housing ready’ obviously can and do work
But some people get stuck within a service
Some get stuck within the system
Some do not engage or run away from services (less of an issue here than in some other countries)

18. Housing First Housing-led Housing comes ‘first’ rather than ‘last’
Housing and support are separated
Intensive case management to support someone in their own home

19. Housing First

20. Housing First
Effective in terms of ending homelessness among people with high and complex needs
75%-90%+ success rates (housed for one year)
Evidence is less clear in respect of
Health and wellbeing
Alcohol and drug addiction
Mental health
Social and economic integration

21. Housing First Housing First Guide Europe
Canadian Housing First toolkit
Homeless Link (England)

22. Housing First and mental health
Where Housing First is being used at scale, i.e. as part of national strategies, it is being used as a service for homeless people with severe mental illness
In Canada and France, national programmes are led by – funded by – mental health
Clearly targeted on people with mental health problems in many countries

23. Housing First and mental health
Original Housing First service in New York required a psychiatric diagnosis
Downside of targeting services this way is that diagnosis criteria might block access to some people experiencing long-term and recurrent homelessness
Arguably better to target all homeless people with high and complex needs

24. Using Housing First
Where Housing First works, it is one service within an integrated – coordinated - homelessness strategy
Working alongside prevention – where Wales is leading the rest of the UK – because some low need homeless people can become high need if their homelessness is not quickly resolved
Alongside lower intensity floating support, specialist accommodation based services and some provision of emergency accommodation
Housing First cannot ‘replace’ everything, though it may replace some services over time

25. Using Housing First
The other area to watch is the extent to which Housing First delivers positive results beyond housing sustainment
Improvements to mental health can occur, but Housing First will need to be coordinated with other services to ensure the right range of treatment and support is accessible
Have to think about ‘full fat’ Housing First (ACT) and whether that makes sense compared to ‘diet’ Housing First (intensive case management only) but full-fat needs at least some health money

26. Summing up Homelessness and mental health are clearly associated
But it is a minority of long-term and recurrently homeless people where the problem is acute
Existing ‘housing ready’ services do not always work for this particular group
Housing First can provide a route out of homelessness for most of them – there is a good case for using it
But Housing First is not a perfect solution and is designed only for a specific group of homeless people

27. Thanks for listening Nicholas Pleace University of York
European Observatory on Homelessness
Housing First Guide Europe