EDITORIALS Homelessness and mental health;

Tom Craig

The term 'homeless' has been used to describe units between 1981 and 1988: a figure that populations in a continuum of unsatisfactory continued to rise right through the early 1990s housing from cardboard boxes through long-stay (Greve, 1991). In comparison to their domiciled hostels. Not surprisingly, therefore, estimates of peers, young homeless people are not only less the size of the homeless population vary enor likely to obtain independent housing but are also mously from survey to survey depending on the less likely to have successfully completed basic definition and on less scientific influences of a education, less likely to have ever held employ political or campaigning nature. For example, ment and far more likely to have experienced estimates of the numbers of homeless people in parental neglect, abuse and rejection throughout England and Wales range from around 2000 at their childhood, with as many as 40% having any point in time when denned as people been in children's homes and other institutions sleeping rough to as many as 75 000 if extended (Fischer et al, 1986; Cohen & Thompson, 1992: to those in hostels, squats and bed and breakfast Craig et al, 1996). (Office of Population Censuses and Surveys, While there is therefore reasonable evidence to 1991; Moore et al. 1995). Similarly, estimates of support the impression of a rise in the numbers the numbers of hospital admissions for people of of homeless people and by extrapolation, an no fixed abode vary widely, partly because of increase in the numbers with a mental illness, differences in the use of the term between the changing demography of the population is psychiatrists even when they all work within also associated with a rather different profile of one health authority (Cowan & MacMillan, psychiatric disorders to that described in earlier 1996). studies of homeless populations, with affective While these issues of definition call for great disorders, substance dependence and personal care in interpreting data, there is a consensus ity disorder being the most frequently reported that, however defined, there has been an explo problems. Comorbid mental illness and sub sion in the numbers of homeless people in stance use disorder is the rule rather than the Britain's major cities during the past decade. exception and this creates major problems for The number of households placed in temporary treatment and rehabilitation (Shaffer & Catón, accommodation by local authorities doubled 1984; Craig et al, 1996). from 23 000 in 1986 to over 40 000 in 1989, It has also been suggested that the increase in and the numbers claiming board and lodging the number of mentally ill homeless people payments quadrupled between 1979 and 1986 occurred as a result of the closure of the (Central Statistical Office. 1991). This expansion psychiatric hospitals and failures in the com was largely accounted for by young men, women, munity care alternatives that were designed to families and ethnic minorities which paralleled take its place. But there is good evidence that wider changes in the social economy - a scarcity this was not a very important factor, fewer than of low-cost housing, high unemployment, the 5% of long-stay residents lost to follow-up erosion of traditional family networks and down following the closure of Friern Barnet were sizing in the organisation and delivery of thought to have had a spell of homelessness supportive services (Bachrach, 1984; Craig & (Leff, 1991); and only 1 in 10 homeless people Timms, 1992). Of all these factors, the shortage with a functional psychosis seen in the London- of entry-level accommodation is probably the wide Homeless Mentally 111Initiative had spent most important. There was an 85% decline in the more than 12 months in hospital in their lifetime, production of new council housing output the most common experience being of multiple, between the mid-1970s and the end of the brief admissions (Craig et al, 1995). 1980s that coupled with a shortfall in predicted But if the closure of the psychiatric hospitals voluntary and private sector supply amounted to did not directly contribute to the problem, a net loss in London alone of 243 000 rental there can be little doubt of the importance of deinstitutionalisation in the wider sense. The community reprovision of the old psychiatric hospital bed catered solely for the existing 'See pp. 207-210, this issue. long-stay patients with no immediate capacity

Psychiatric Bulletin {1998), 22, 195-197 195 EDITORIALS to cope with newly accumulating cases of have been addressed. This flexible, non-coercive patients whose disorders have failed to strategy for engagement must be balanced by the respond to treatment and who are unable to parallel duty to maintain a therapeutic focus, the manage independently. There are relatively few lack of which is sometimes linked to libertarian community-based facilities that can cope with tendencies to emphasise the patients' right to the level of disability and disruption of many refuse treatment rather than his right to receive patients with chronic, treatment-resistant psy treatment. Second, while there is consensus on choses and even fewer 'wet' hostels that will the need for a multi-disciplinary input, there is tolerate comorbid mental illness and substance little consensus on the therapeutic options that use disorder. In many instances, bed and should be available within teams and relatively breakfast is the only viable residential option few are able to offer equally skilled interventions for these most vulnerable cases, from which it for mental illness and substance dependency is all too easy to drift out of contact with despite the common co-occurrence of these mental health services. The result has been the disorders in the target population. Third, generic many well-documented failures in the care of teams, operating a single keyworker system may patients discharged from acute wards and in not be enough to ensure continued service the treatment histories of many severely ill uptake, probably because basing services homeless people. Not only has there been a around a single lead agency still excludes too failure to provide enough suitable residential many facets of care or is still too dependent on alternatives to hospital accommodation but the severely disabled person having the personal what little already existed may well have been resources to keep the string of appointments inadvertently lost. In the decade preceding with separate service providers. A better model 1991, there was a net loss of 75% of direct may involve specialist multi-disciplinary teams access hostel spaces. These old direct access that provide all the necessary housing, social hostels housed many chronically ill people, and medical care from one location and which largely out of contact with psychiatric services. are available for extended hours and at week Unlike the residents of the old psychiatric ends. The best evidence for the efficacy of such hospitals, these patients were moved on with an approach comes from North America where out any recognition of their resettlement needs there have been several attempts to modify the in terms of psychiatric treatment or specialised assertive community treatment model of case support (Craig & Timms, 1992). management with some quite impressive results, Despite these gloomy observations, there is including reductions in the length of time spent evidence that services can be arranged and in homeless accommodation, improvements in provided in ways that make a difference. The psychiatric symptoms and in social functioning Rough Sleepers Initiative, launched by the (Lipton et al, 1988: Morse et al, 1992). Department of the Environment in 1990 and While there is likely to be a continued need for aimed at boosting resettlement services to young specialist services for homeless mentally ill people sleeping rough in central London, has people for many years to come, the fact remains been credited with a substantial success, the that homelessness among those with mental increased provision of temporary and permanent illness is a preventable adverse outcome that accommodation under this initiative being ought to be addressed by mainstream services. matched by a steady fall in the numbers of rough Proactive working with in-patients who are sleepers since the initiative was launched (Ran homeless or lose their accommodation during dall & Brown, 1996). At the same time, the an admission, proactive work with landlords of Department of Health and the Mental Health patients whose tenure is precarious and the Foundation jointly funded the Homeless Men effective implementation of prison and court tally 111Initiative, which succeeded in bringing diversion schemes ought to be a good place to specialist services to severely mentally ill home start. less people who had fallen through the net of community care with modest social and clinical benefit (Craig et al, 1995). The initiative spawned a number of other projects nationally with broadly comparable results (e.g. Commander et References al 1997). BACHRACH,L. (1984) The homeless mentally ill and the Although these initiatives have been broadly mental health services. In The Homeless Mentally III(ed. successful, there are several aspects of clinical H. R Lamb), pp. 11-54. Washington, DC: American practice that remain to be resolved. First, it Psychiatric Association. seems clear that lengthy and labour intensive CENTRALSTATISTICALOFFICE(1991) Social Trends. London: HMSO. efforts are required to engage the homeless COHEN.C. I. «¡THOMPSON,K.S. (1992) Homeless mentally ill person in treatment which often only proceeds or mentally ill homeless? American Journal of once the basic necessities of food and shelter Psychiatry. 149. 816-823.

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COMMANDER.M., ODELL, S. & SASHIDHARAN,S. (1997) MOORE.J.. CANTER.D., STOCKLEY.D..et al (1995) The Faces Birmingham community mental health team for the of Homelessness in London. Aldershot: Dartmouth. homeless. Psychiatric Bulletin. 21. 74-76. MORSE. G. A., CALSYN. R. J., ALLEN. G.. et al (1992) COWAN.C. & MAcMiLLAN.F. (1996) No fixed abode - Its Experimental comparison of the effects of three definition in clinical practice. Journal of Mental Health. treatment programs for homeless mentally ill people. 5. 161-166. Hospital and Community Psychiatry. 43. 1005-1010. CRAIG, T. K. J., BAYLISS,E.. KLEIN. O., et al (1995) The OFFICE OF POPULATIONCENSUSESAND SURVEYS(1991) The Homeless Mentally III Initiative: An Evaluation of Four 1991 Census. Preliminary Report for England and Clinical Teams. London: Department of Health. Wales. Supplementary Monitor on People Sleeping —¿.HODSON,S.. WOODWARD.S.. et al (1996) Off to a Bad Rough. London: HMSO. Start: A Longitudinal study of Homeless Young People in RANDALL,G. & BROWN.S. (1996) From Street to Home: An London. Final Report to the Mental Health Foundation. Evaluation of Phase 2 of the Rough Sleepers Initiative. London: Mental Health Foundation. London: Department of the Environment. —¿& TlMMS, P. W. (1992) Out of the wards and onto the SHAFFER. D. & CATÓN,C. L. M. (1984) Runaway and streets? Deinstitutionalisation and homelessness in Homeless Youth in New York City: A Report to the Britain. Journal of Mental Health. 1. 265-275. Ittleston Foundation. New York: New York State FISCHER.P. J.. SHAPIRO.S. & BREAKEY,W.R. (1986) Mental Psychiatric Institute and Columbia University College health and social characteristics of the homeless: a of Physicians and Surgeons. survey of mission users. American Journal of Public Health. 76. 519-523. GREVE. J. (1991) Homelessness in Briiain. York: Joseph Rowntree Foundation. LEFF,J. (1991 ) Evaluation of the closure of mental hospitals. In The Closure of Mental Hospitals (eds P. Hall & I. F. B. Tom Craig, Professor of Community Psychiatry. Brockington). pp. 25-32. London: Gaskell. United Medical and Dental Schools, Honorary LIPTON.F. R.. NUTT. S. & SABATINI.A. (1988) Housing the Consultant. Lambeth Healthcare NHS Trust. St homeless mentally 111: a longitudinal study of a Thomas' Hospital. Lambeth Palace Road, London treatment approach. Hospital and Community Psychiatry. 39, 40-45. SEI 7EH

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Homelessness and mental health 197