Homeless persons

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Homelessness refers not only to sleeping rough. It also includes staying with friends or relatives with no other usual address (e.g., couch surfing), staying in specialist homelessness services, and living in boarding houses or caravan parks with no secure lease and no private facilities. As highlighted in the Australian Government White Paper on homelessness, homelessness does not simply mean that people are without shelter. A stable home provides safety and security as well as connections to friends, family, and a community [1099].

There tend to be higher rates of AOD use and mental health conditions among homeless people as compared to the Australian general population (see Table 49) [42, 1100, 1101]. A 2007–2008 survey of homeless individuals from Sydney reported complex AOD use histories and extensive polydrug use [1102]. Forty-two percent of participants reported severe levels of depression and 57% screened positive for current PTSD. More than one third (37%) had received a lifetime diagnosis of schizophrenia or another psychotic disorder.

People who are homeless present with a range of physical, financial, housing, substance, social, and psychological problems, and they are at high risk of victimisation [1102, 1103]. Hence it is important to adopt a holistic and pragmatic view when identifying treatment needs (see Chapter B4). The complexity of problems experienced by people who are homeless is compounded by having reduced access to services and resources [1104], and it is very difficult to provide mental health or AOD treatment to those without access to stable housing [1101]. Attention to immediate basic needs is often more important than diagnosing a specific condition, as successful treatment is difficult if basic needs are not met [1104]. Do they have access to primary care and from whom? Is the client likely to be able to follow through with treatment and recommendations? Will they seek help in the future? Can they afford specific treatments/medications? Thus, treatment should be guided by the perceived needs of the client, as well as AOD worker judgement.

Recent evidence indicates that homeless clients from less integrated services are more likely to experience additional difficulties accessing help due to the lack of coordination between homelessness, mental health, and AOD services [360]. Services working together and coordinating care into a cohesive approach has been identified by clients as an area of great importance. Clients from more integrated services are more likely to have a case coordinator and report positive outcomes than those from less integrated services [360]. Lack of integration between services can not only result in clients ‘falling through the gaps’ and being bounced between homelessness, AOD, and mental health services, but can also result in a need for clients to continuously retell details of distressing stories, confusion, and lack of client and service awareness [360]. Chapter B4 contains further information about care coordination and working with other services.

Table 49: Prevalence of mental health disorders among homeless people in inner Sydney and the general Australian population

  Homeless in inner Sydney Australian population
  Men % Women % All people %
Psychotic disorders
Schizophrenia 23 46 0.5
AOD use disorders
Alcohol dependence-abuse 49 15 6
Opiate dependence-abuse 34 44 3
Cannabis dependence-abuse 22 18 2
Sedative dependence-abuse 10 13 0.5
Stimulant dependence-abuse 8 10 0.3
Other AOD dependence-abuse 9 13 -
Mood disorders
Any mood disorder 28 48 7
Any major depression 22 38 6
Dysthymic disorder 4 8 1
Anxiety disorders
Any anxiety disorder 22 36 6
Any panic disorder 7 19 1
Social phobia 8 10 3
Generalised anxiety disorder 8 10 3
Any mental disorder 73 81 18

Source: Teesson et al. [1100].

Being homeless involves additional stigmatisation to the already marginalising attitudes directed towards individuals with AOD and mental health conditions. It is important to recognise the additional difficulties faced by these clients and be patient and attentive during treatment despite obvious difficulties [1105]. The following strategies may be useful when working with homeless clients [360, 1104]:

  • Become familiar with any street outreach programs or resettlement services operating in your area.
  • Help the client establish skills and knowledge in obviously deficient areas, as this may provide practical living abilities. It may be necessary to read documents for the client, and assist in the filling out of forms, and other basic tasks due to low literacy levels or other difficulties.
  • Be patient and flexible, and aware that homeless people are unlikely to attend all appointments or complete homework tasks. AOD workers need to remain optimistic, non-judgemental, process- oriented, and focused on long-term treatment goals.
  • Where possible and beneficial, encourage clients to consider family relationships, and engage with clients’ families. Be aware that this may not be easy or practicable, and ensure clients are engaged in the decision to contact their family.
  • Be proactive in following up clients, and work with other services to coordinate care.