Homelessness

The 2016 Australian Census estimated more than 116,000 people experiencing homelessness in Australia, which increased by 5% from 2011; Table 62 [1782]. Homelessness refers not only to sleeping rough or being without shelter. 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. A stable home provides safety and security as well as connections to friends, family, and a community [1783].

There tend to be higher rates of AOD use and mental health conditions among homeless people as compared to the Australian general population. A recent study examining the electronic medical records of active patients (defined as =3 visits within the past two years) of a multi-site specialist homelessness GP service in Perth found 68% had at least one diagnosed mental health condition, 62% at least one AOD use disorder, and 48% had been diagnosed with a co-occurring AOD and mental health condition (Figure 21) [1784]. More than one third (38%) of people had also been diagnosed with a chronic physical health condition in addition to their co-occurring AOD and mental health condition. Compared to people who are not homeless, those who are homeless are also more likely to be hospitalised for AOD and mental health issues [1785].

As described in Chapter B5, however, it can be extremely difficult for a person to engage in and maintain progress in relation to their AOD or mental health treatment if they do not know where they are going to live, or how they are going to feed themselves or their family. Therefore, addressing housing as part of treatment is vital, and is also in line with the approach of ‘treating the person, not the illness’ [9]. In addition to problems relating to housing, AOD and mental health, people experiencing homelessness present with a range of physical, financial, and social issues, and are at high risk of victimisation [1786, 1787]. High rates of exposure to other forms of trauma are also evident. In one sample of homeless adults, 88% reported having experienced adverse childhood events, and level of exposure was positively associated with negative outcomes for mental health and AOD use [1788]. For these reasons, a trauma-informed approach to treating people who experience homelessness is essential [1787]. The Trauma and Homelessness Initiative similarly emphasises the unique opportunity for homelessness agencies, as a primary contact for homeless people, to engage with homeless people to facilitate trauma recovery [1789].

Given the range and complexity of issues faced by people who are homeless it is important to adopt a holistic and pragmatic view when identifying treatment needs (see Chapter B5). The complexity of problems experienced by people who are homeless is compounded by having reduced access to services and resources [1790, 1791], and it is very difficult to provide mental health or AOD treatment to those without access to stable housing [650, 1792]. 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 [1791]. For example, consideration of whether the client has 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 client’s perceived needs, as well as AOD worker judgement.

Clients and service providers have highlighted the importance of providing integrated services for people who are homeless whereby services work together and coordinate care in a cohesive approach [1793–1795]. Homeless clients from less integrated services are more likely to experience difficulties accessing help due to the lack of coordination between homelessness, AOD, and mental health services [1796]. By contrast, clients from more integrated services are more likely to have a case coordinator and report positive outcomes than those from less integrated services [1797]. 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 [1798]. Chapter B5 contains further information about coordinating care and working with other services.

Source: Vallesi et al. [1784].

A further barrier to people who are homeless accessing care is stigma [1799]. Being homeless involves additional stigmatisation to the already marginalising attitudes directed towards people with AOD and mental health conditions. Approximately one in three homeless people report having experienced stigma related to their homelessness, with 9% having experienced homelessness-related stigma from healthcare providers [1800]. As described in Chapter B5, perceived and actual stigma can lead to a mistrust of healthcare providers and services. It is important to be patient and attentive, and take the time to establish trust and rapport with the client, as homeless people who mistrust practitioners may conceal their needs [1801, 1802]. The following strategies may be useful when working with homeless clients [599, 1803]:

• 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.

There have been several interventions developed for people who are homeless, although they have not been evaluated extensively. These include:

• Housing First interventions: interventions which provide stable housing and other health services without first requiring people to be ‘housing ready’ (i.e., attending treatment and being abstinent from AOD use [1804]), and are endorsed by the Alcohol and Drug Foundation as an effective intervention for homeless people [1805]. A systematic review of Housing First relative to Treatment First programs (i.e., programs that require people to achieve abstinence and be attending treatment before being offered access to housing [1804]) concluded that Housing First programs improved housing stability and reduced hospitalisation more effectively, though both programs led to similar reductions in mental health symptoms and AOD use [1804]. Evidence from interviews with homeless people attending Housing First programs suggest that the sense of security and dignity associated with stable housing is the most influential factor supporting changes in mental and physical health, self-esteem, and interpersonal relationships [1799].
• Mindfulness-Oriented Recovery Enhancement (MORE): a manualised mindfulness-based group intervention for people with co-occurring psychological distress and AOD use [1177]. An RCT conducted among homeless men with co-occurring mental health conditions and AOD use found that compared to CBT, those who received MORE experienced greater improvements in posttraumatic stress, negative affect, and AOD cravings from pre to post treatment [1177].
• EQIIP SOL: an intensive outreach intervention team for homeless people with co-occurring conditions. A prospective longitudinal study found homeless youth with co-occurring psychosis and AOD use reported reductions in the severity of psychotic symptoms and the likelihood of reaching the diagnostic threshold for an AOD disorder following 6 months of EQIIP SOL [956].