- Debate article
The role of compassion and ‘Tough Love’ in caring for and supporting the homeless: experiences from ‘Catching Lives’ Canterbury, UK
Journal of Compassionate Health Carevolume 2, Article number: 7 (2015)
Homelessness is a wide-spread problem which can lead to high vulnerability and social exclusion. There are many reasons why a person may become homeless, with relationship breakdown being reported as a common cause. Homeless people often encounter a number of other problems such as mental and physical health issues and problems with drugs and alcohol which might represent either a cause or an effect of homelessness. A compassionate approach towards the homeless is crucial, whether this be explicit in taking action to deal with basic needs, or implicit with more of a ‘tough love’ approach in encouraging motivation and independence to help people re-build their lives.
This paper takes recent experiences from a local homeless charity ‘Catching Lives’ in Canterbury, UK, and discusses these in the light of recent literature. Drawing on such experiences, the paper aims to draw attention to the issue of homelessness and the importance of a compassionate approach.
The paper concludes by summarizing the findings, and encouraging the importance of a compassionate approach towards addressing the needs of the homeless. With the correct support and understanding, individuals can learn to take control and re-build their lives.
The issue of homelessness is wide-spread, at an international level, and worse so in times of economic crisis. The charity organization ‘Crisis’ (http://www.crisis.org.uk/data/files/document_library/factsheets/homlessdefs_2005.pdf (Accessed December 2014)), define homelessness as ‘…the problem faced by people who lack a place to live that is supportive, affordable, decent and secure…’ They further state that a permanent address is more than a physical space, and that it represents security and well-being in a very real sense. The term ‘homelessness’ may refer to not having a roof over ones head, but potentially the concept goes much further than this, and as Seager  reminds us ‘…homelessness is more than houselessnes and goes much deeper in terms of psychosocial issues and social exclusion..’.
For a homeless person, social and emotional support, a sense of belonging, trust, assistance with daily living, help to re-build their lives, and assistance with primary/secondary/mental health care access, may all represent important issues, in addition to the importance of shelter and longer term permanent housing.
Homeless people represent a vulnerable group in society, yet according to the Lancet , ‘…we still have a 14th century-long tradition of treating them as criminals. Yet this vulnerable group are more likely to be victims of crime, rather than perpetrators. Many homeless have experienced brutal childhoods, unstable families, or domestic violence. They are more than ten times as likely to be assaulted and 50 times more likely to be robbed than those who have a home. 40 % of young homeless women have been abused sexually and many are at risk from untreated sexually transmitted diseases…’.
It can be difficult to categorize a homeless person, and in addition to the above, the reasons that a person may become homeless vary considerably, and can also include, relationship breakdown, loss of job/income, eviction, inability to cope with everyday life due to either mental, physical or environmental trauma and so on. There does seem however, to be a relationship between homelessness, mental health problems, and drug or alcohol abuse, together with an overlap with social exclusion. These are crucial issues which require understanding, support and guidance, in order for a person to re-build their life, and re-establish their important role as an individual human-being in society.
The role of ‘Compassion’ in assisting the homeless
Recently, the concept of ‘Compassionate Care’ has received much attention globally, particularly within healthcare settings, and much work is in place at a multidisciplinary level to enhance and utilize this concept [3, 4]. The role and importance of compassionate care was particularly brought to the forefront in the UK, following the release of the Francis Report which was based on an inquiry into devastating events at Mid-Staffordshire Hospital in the UK . This report gained international attention by demonstrating that for many patients the most basic elements of care were neglected.
The concept of compassion is generally thought to include a number of other virtues, such as empathy, sympathy, kindness, respect, and perhaps most importantly, actually taking some kind of ‘action’. A well used definition of compassion is: that ‘… [compassion] reflects a deep awareness of the suffering of another, coupled with the wish to relieve it’ . There is evidence to suggest that the components parts of compassion are also crucial in alleviating pain, prompting fast recovery, assisting in the management of chronic illness, and relieving anxiety. Physiological benefits of compassion have also been reported in studies which show that kindness and touch alter the heart rhythm and brain function in both the person providing compassion and the person receiving it [7, 8] (http://www.sciencedaily.com/releases/2012/12/121203145952.htm (Accessed November 2014)).
As such, a compassionate approach applies not only to the health care setting, but also to the needs of vulnerable groups such as the homeless who may have specific health and social needs.
Due to the nature of the virtues of compassion, it might be assumed that during acts of compassion, these virtues must be explicitly demonstrated. But there is also room for implicit acts of compassion, which might also be termed ‘tough love’ (i.e. we may imply the virtues of compassion, but in a given situation we may not be explicit in demonstrating them). Under such circumstances, explicit demonstrations of the virtues of compassion might be less important, whilst the implicit might be the important factor – remembering of course, that compassion implies taking ‘Action’. This is particularly essential when helping homeless people. For example, compassion may be explicit in attending to, and offering services in relation to basic needs, but more implicit in terms of encouraging independence and choices. In this sense, it would seem appropriate to apply the term ‘tough love’, whereby we may refer to a sometimes stern approach where the intention is to help the individual in the longer term - thus reflecting genuine feelings of care and concern for the individual.
The notion of tough love within the context of dealing with homeless individuals can have a strong emotional and behavioural effect. This may be because at an individual level, people who are vulnerable need to feel safe and this is less likely to be the case in an environment which it too soft and where the rules may be simple, few, and vague. There is a need for homeless individuals to move away from a chaotic lifestyle, but assistance in helping them back into a world where rules apply such as payment of bills etc., might seem frightening and unsafe to them if too soft an approach is taken. An analogy to this might be if we were to imagine crossing a dangerous river by way of an unsafe bridge – we would want someone to help us to safely reach the other side, but we would need this person to be strong.
Thus by referring to the notion of tough love within this paper, and within the context of compassion for homeless people, we may be referring to a set of creative rules intended to enable happiness and independence of the vulnerable person in the longer term. This may further include providing a sense of direction, showing the person the way and teaching them examples of being assertive but in a calm manner. We are referring to a behavior which in some ways might resemble that of a ‘fair, kind, but disciplined parent’, which is important as many homeless people have encountered a disturbed background,
In both cases (both implicit and explicit provision of care) the concept of compassion and taking action is highly relevant.
There are many worthy causes, charities, and organizations dedicated to supporting homeless people. However, in this short paper, we draw on experiences from a small but devoted centre for the homeless - ‘Catching Lives’ in Canterbury, UK (Additional file 1) (www.catchinglives.org (Last accessed February 2015)). We aim to draw attention to the important issue of homelessness, and to the importance of ‘compassion in action’, and how the concept both implicitly and explicitly can play a crucial role in assisting the homeless. We feel that it is important to share this experience, and to encourage others to publish work in this field.
With the above in mind, this paper will incorporate extracts and data (as boxed text), from a recent report compiled by Limebury  on behalf of ‘Catching Lives’.
‘Catching Lives’ is an independent local charity, which is dedicated to supporting the homeless and vulnerably housed in and around Canterbury, UK. The charity has operated in Canterbury and East Kent for over 20 years and represents a community effort to raise awareness and help people to get off from the streets and to change their lives. The charity seeks to change attitudes regarding the issue of homelessness, and works closely with the community by engaging in school talks, talks to church groups, study placements, training events, and training different types of volunteers.
The charity has a vision of ‘…a society where all are included and all, no matter how disadvantaged, can make a contribution… ‘. The charity also works with their clients ‘…to help them to tackle any issues that they may have, get access to suitable accommodation and find the motivation to take steps towards personal recovery and independent living…’ (www.catchinglives.org).
A number of services and attention to basic needs are offered by the charity, including: food; laundry facilities; toilets and showers; storage; telephone and postal address usage; IT access; mental health services; structured activities etc. In addition, the charity offers advocacy and advice, including specialist advice to encourage independence.
Finding shelter for the homeless
Becoming homeless is likely to be one of the most stressful and frightening events that can happen to a person, and finding shelter or knowing who to approach to assist with this, might be difficult. In assisting with finding shelter for the homeless in and around Canterbury, the Rolling Shelter model is utilized which was first piloted in London in 2000. Rolling Shelters offer overnight accommodation to the homeless which ‘roll’ between different locations. Rolling Shelters initially replaced Cold Weather Shelters and were open all year round for four monthly periods in different locations in inner London . The concept of Rolling Shelters presents a good solution to the problem regarding provision of overnight accommodation. Because of the laws surrounding provision of accommodation, one location/church cannot be utilised as a full-time shelter. For this reason, the impact on the community is minimal, allowing the venues to still operate and offer the services that they would normally offer. Utilising the Rolling Shelter model, whereby each venue may offer accommodation for 24 hours once a week is also cost effective and minimizes the risk of mis-use. In Canterbury, this initiative is referred to as Canterbury Community Shelter, and is coordinated by ‘Catching Lives’:
|Our model uses 7 venues, one for each day of the week, with each venue having a set day of the week on which to be act as shelter and overnight accommodation for our clients. Coordination of the shelter is taken care of by Catching Lives, based at Canterbury Open Centre; this was done alongside the normal provision of food, personal storage, showers, laundry and a project team who assess and assist our clients to change their situations for the better. We work with the homeless and rough sleepers of the Canterbury area, an issue that has not reduced in the past year. The official estimate was that over 20 people were sleeping rough in the district last autumn. At Catching Lives' Canterbury Open Centre had up to 25 individual rough sleepers accessing it’s services in October and November 2013, with an average of just over 20 individuals accessing over the two months. Although recent political publicity has claimed that the economy is recovering, we continue to be in the midst of a housing crisis. Quality affordable housing and well funded, coordinated services to deal with the issues vulnerable people are lacking and local government and statutory agencies of all kinds have to find more savings and cuts to budget. The effects of this continued to show as our project progressed and will be discussed later in our Social Policy Summary. We have, however, learned a lot from previous years; and in the operation of 2013/14 Canterbury Community Shelter we took on as many of the suggestions from last year as we were able, and the incorporation of these into our service model made a major difference. (Limebury, 2014)|
The shelters consist mainly of the rotated use of local Church Halls.
Other services that have assisted with the Canterbury Community Shelter initiative include:
Porchlight Rough Sleeper Service
CatchingLives' Mental Health Outreach Team
Sanctuary Supported Living – Floating Support
Canterbury City Council Housing Team
Canterbury Housing Advice Centre
Furthermore, Winter Shelters such as Folkestone Churches Winter Shelter, Tunbridge Wells Churches Winter Shelter and Maidstone Churches Winter Shelter means that there are now four covering Kent over the winter period.
Through such assistance and action, 59 % of individuals (32/54) staying at the Canterbury Community Shelter have achieved an ultimate positive housing outcome. An analysis of this provision is as follows:
|A direct result of having the extra time, money and staff this year has been that nearly 60 % of those who stayed in the shelter moved on into other appropriate accommodation. This is the largest percentage result I have seen working in winter night shelters since my first involvement with Folkestone Churches Winter Shelter in 2009; and although this is incredibly positive we remain a little sceptical about the long term success of a significant number of these people within these housing situations. This is due not because of a major lack of belief in the willingness of individuals to succeed but the complex needs and decreasing help available for them. The high number of housing outcomes reflects our projects ability to work with the housing opportunities available but within it there are figures which highlight the tenuousness of housing for vulnerable people. For example, 10 of the successful outcomes we had were to the Hostel Plus scheme, which is another short term project only run as a “one off” until the end of March. People within this scheme then had to be found alternative accommodation by the end of that project. We do not have the statistics for that project so cannot comment on its success but as, with Canterbury Community Shelter, being a temporary measure means it is not a long term solution to the needs of homeless people. This also means that, outside of Hostel Plus, only 4 people – 5 % of the 77 referred were moved into permanent supported accommodation projects. Including Hostel Plus, 18 % of those referred to us were moved into supported accommodation. If we take the number of those people with support needs to be those with diagnosed mental health issues (40 %) and assume that they would benefit from supported accommodation, 22 % of them missed out on the help they needed. If we took the total of people with drug and alcohol problems (57 %) to have needed supported accommodation, 39 % of them missed out. People are able to access Porchlight Outreach Workers and Sanctuary Floating Support Workers whilst homeless but there are very few of these professionals left working across Kent, let alone in the Canterbury District. Further funding for these types of services are vital to provide access to longer term solutions. (Limebury, 2014)|
Mental health issues among the homeless
There has long been an association between mental health problems and homelessness, and access to appropriate support services might be difficult. As early as 1984, The American Journal of Psychiatry  suggested that shelters have perhaps become ‘alternative institutions to meet the needs of mentally ill people who are no longer cared for by departments of mental health’.
It is also reported that homeless people have considerably worse health related quality of life than the general population, with many problems in relation to anxiety and depression being reported . Such problems might contribute to the cause of homelessness, or may be a result of it.
Homeless people may have difficulties in accessing mental health care services, despite the strong body of evidence that there are significantly higher rates of mental health problems in populations of homeless adults, and that unusually high rates of psychosis are a feature . Equally, a systematic review and meta-regression analysis performed by Fazel et al.  demonstrated a high prevalence of psychotic illness and personality disorder among the homeless in Western Countries, and suggested that models of care that can best meet these needs require further investigation.
At Catching Lives, a breakdown of the mental health status of individuals using Canterbury Community Shelter revealed the following:
|Of the 54 people who described having mental health issues, 44 were either not receiving any treatment or felt they needed more. Although 14 of those not receiving treatment said they did not want help at the point of assessment, this does not always hold fast and is often as a result of negative experiences when they have tried to access help in the past. For example, as part of the Social Policy project we have been involved with, a pattern of releasing people from hospital to street homelessness has been identified – we have noted cases where people have been dropped off in taxis outside Canterbury Open Centre. Those who wanted treatment or more treatment than they were receiving placed access to a Specialist Mental Health Worker and talking therapies such as counselling at the top of their requirements, with access to practical help with day to day living as the next most popular answer. (Limebury, 2014)|
For a further breakdown, please see Table 1
Physical health problems
According to the Guardian newspaper (http://www.theguardian.com/society-professionals/2014/jul/22/homelessness-public-health-crisis (Accessed January 2015)), national data looking into the health of homeless people was published by ‘Homeless Link’ in 2010 yet since that time there has been little improvement. It is reported that not having a stable home is extremely damaging and those living in the worst conditions, experience the greatest levels of ill health. Likewise, the Queen’s Nursing Institute (QNI) (http://www.qni.org.uk/docs/Section%20B%20Module%201.pdf (Accessed February 2015)) report that individuals who sleep rough have a rate of physical health problems two or three times greater than the general population. QNI further report significantly higher rates of respiratory disorders, skin and dental problems, musculoskeletal problems and sexually transmitted diseases in homeless people, and many have multiple health problems. They also refer to findings of the prevalence of chronic chest and breathing problems being twice as bad as the general population.
These findings are also reflected in the experience of Catching Lives, whereby:
|43 people referred to us declared a physical health need - 56 % of the total number of people referred to us. The national average for those with a long standing physical health issue is 29 %. 16 % of those referred to us declared a chest pain/breathing problem where the national UK average is 5 %. 14 % of those referred to us have musculo-skeletal problems – the national UK average is 10 % (Office of National Statistics, 2008). (Limebury, 2014)|
For a further breakdown, please see Table 2
As with the association of homelessness with mental health problems, there is also a strong relationship between drug and alcohol abuse and homelessness. Yet again, it might be difficult to determine whether such abuse leads to homelessness, or whether homelessness leads to substance abuse.
Addiction may be difficult to overcome for any individual, and possibly much harder for homeless persons. The National Coalition for the Homeless , draw attention to the fact that addictions should be viewed as illnesses and require a great deal of treatment, counseling, and support to overcome. They further report that although addiction disrupts relationships and causes people to lose their jobs, in many cases substance abuse is a result of homelessness rather than a cause. Thus, an effective social support network is required to help with overcoming the difficulties of recovering from an addiction.
At Catching Lives, the prevalence of drug and alcohol abuse among those utilizing the Canterbury Community Shelter initiative was as follows:
|36 people referred to us said they had a drug problem or were in recovery – 47 % of the total referred to us. The national figure for adults who have ever taken a drug is 36.5 %. 3 13 % of the referrals stated they used heroin. Although much higher than the national average of heroin use, this does represent a reduction in the number of heroin users as a whole. 6 of the 10 people, 60 % who used heroin in the past month at the point of assessment were prescribed methadone. Despite the existence of a successful needle exchange, 60 % of those who said they had used heroin in the past month also said they sometimes shared needles with others. Other drugs are now used, including the increase in use of “legal highs”, which are largely untested and unknown for short or long term effects and harm. One hospital admission was noted during the course of the shelter due, in part at least, to the use of a legal high. Alcohol remains the most widely used drug amongst those referred to us. 79 % of those referred to us said they used alcohol. It remained the main factor when dealing with challenging behaviour during the operation of the shelter. 19 people said that they had an alcohol problem or were in recovery from an alcohol problem – 25 % of those referred to us. An estimated 1.6 million people in the UK have an alcohol dependency – 2.5 % of the population. (Limebury, 2014)|
For a further breakdown, please see Table 3
Criminal behavior and return to criminal activities following release from prison are often commonly reported among homeless people. The combination of homelessness and mental health problems may both be contributing factors with regard to this problem. A systematic review performed by Roy et al.  reports that rates of criminal behavior, contacts with the criminal justice system, and victimization among homeless adults with severe mental illness are higher than among housed adults with severe mental illness.
When reporting figures on the prevalence of factors commonly associated with reoffending, the Ministry of Justice Analytical Services  revealed that 15 % of prisoners reported being homeless before custody, and 37 % stated that they would need help finding a place to live upon release. Self-reported homelessness was associated with a higher one-year reconviction rate (79 % compared with 47 % among those who did not say they were homeless prior to custody).
Proper rehabilitation services, could perhaps prevent the level of re-offending.
The breakdown from Catching Lives is as follows:
|47 of the 77 people referred to us had criminal convictions – 61 % of the total referred to us. 5 of those referred to us were currently on Probation. 14.6 % of the UK population have a criminal record. Another area of Social Policy has been highlighted here, whereby people are released from prison to “No Fixed Abode”, causing the likelihood of re-offending to be vastly increased. Charities such as Porchlight do work with the prison service in order to try and reduce this practice. The effect of this cycle of offending can be seen in the fact that between the 47 people with criminal records, the lowest estimate stands at 279 convictions. (Limebury, 2015)|
* For a further breakdown, please see Table 4
Access to services
As outlined above, many homeless people encounter mental or physical health problems, and in many cases they may encounter both. In addition, drug and alcohol abuse is also common.
However, access to the appropriate health services for these people can be difficult. According to the Royal College of General Practitioners (RCGP) (http://www.rcgp.org.uk/news/2013/december/~/media/Files/Policy/A-Z-policy/RCGP-Social-Inclusion-Commissioning-Guide.ashx (Accessed January 2015)) such difficulties may arise for a number of reasons including: more immediate needs such as food and shelter; poor staff attitudes; fear of being judged etc., and this might be particularly problematic when attempting to access general practice. To overcome such problems, RCGP draw attention to the following possibilities: Outreach services; In-reach work: Dedicated hospital pathways: Peer-education: Cultural awareness training: and Intermediate care. Because access to services is problematic for homeless people, use of Accident and Emergency (A&E) services is high among this population. According to the charity organization ‘Crisis’ http://www.crisis.org.uk/data/files/document_library/factsheets/homlessdefs_2005.pdf (Accessed December 2014), homeless people are more likely to use to A&E if they are unable to access a GP, or if an untreated problem needs immediate attention. Often, it is the one place they know that they can go to in order to receive treatment.
Catching Lives has also experienced problems with care and after-care for clients:
‘With Social Policy reporting, we have again highlighted issues regarding homeless peoples access to services regarding discharge from hospital inappropriately. A person was discharged without proper clothing or footwear in the middle of the night after being admitted with severe circulation problems in their feet…’
‘…a pattern of releasing people from hospital to street homelessness has been identified – we have noted cases where people have been dropped off in taxis outside Canterbury Open Centre…’ (Limebury, 2014)
Catching Lives is fortunate enough to have obtained GP access for its clients. In addition, it also employs mental health workers and provides mental health outreach services. However, in general the ease of access to services for homeless persons remains a crucial issue.
Our aim within this paper was to draw attention to the issue of homelessness, by utilizing experiences and data from a local homeless charity in Canterbury UK. Sharing these experiences, we hope, will inform and encourage others to share their work in this area, and we hope that our readers will appreciate our concerns about this particular societal problem. The problems identified in the extracts from the Catching Lives Report reflect the problems encountered by homeless people across the board, nationally and world-wide.
Homelessness is associated with multiple problems for the individuals who experience this unfortunate life event. Finding shelter is crucial, and as reflected by the Catching Lives experience, the Rolling Shelter Model seems to be an effective method for temporary shelter leading onto positive housing outcomes. However, there are many additional needs to consider such as mental health problems which seem to have a high association with homelessness. As identified by the literature, problems in relation to anxiety, depression, and psychosis are common [12–14]. Likewise, physical health problems represent a further issue (http://www.theguardian.com/society-professionals/2014/jul/22/homelessness-public-health-crisis (Accessed January 2015)), (http://www.qni.org.uk/docs/Section%20B%20Module%201.pdf (Accessed February 2015)) requiring additional attention. Drug and alcohol abuse may be either a cause or an effect of homelessness, but as the National Coalition for the Homeless  remind us, addictions should be viewed as illnesses and require a great deal of treatment. The issue of police involvement and re-offending, could benefit from proper rehabilitation services, to avoid a return to homelessness and offending. Finally, access to services is an important factor when considering the health needs of the homeless, and RCGP draw attention to a number of possibilities for overcoming this problem (http://www.rcgp.org.uk/news/2013/December/~/media/Files/Policy/A-Z-policy/RCGP-Social-Inclusion-Commissioning-Guide.ashx (Accessed January 2015)).
Catching Lives is fortunate in having secured GP access for its clients, together with mental health outreach services, but in general access to medical and social services remains problematic among the homeless.
Compassion and homelessness
Tending to the problems faced by homeless people requires an approach which is compassionate, and activated at a community level with the recognition of the problems, high vulnerability, and social exclusion that these people face.
Homelessness is an issue where compassion plays a major role, whether this be explicit (providing basic needs, developing trust, providing a much needed service), or implicit (encouraging independence and motivation, and offering choices).
At the heart of compassion, is the element of ‘action’, and this may sometimes involve perhaps a ‘tough love’ approach in order to encourage independence. Such an approach is based on underlying care, and a desire to help the individual succeed in life in the longer term. What is evident from the work of Catching Lives, is that ‘action’ is very much a feature, whereby taking care of basic needs is demonstrated, but help is also given to encourage independence. Thus, compassion is present both implicitly and explicitly, through the charity’s staff and volunteers, and through its important links with the local community.
In a paper by Daly et al. , it is suggested that people who have experienced homelessness can achieve a successful life with support by drawing on their considerable life experience and personal talents. Listening to homeless peoples’ own thoughts on how they could be supported might also prove crucial. At Catching Lives, clients suggested the following ways in which they could be supported:
Having a specialist mental health worker
Talking therapies such as counseling
Activities such as arts, volunteering, sport
Practical support with everyday life
Services to address dual diagnosis
A previous client of Catching Lives reported very positively that:
‘…I’m doing computer courses now; I’ve just passed the first one. A year ago I wouldn’t have imagined that I’d now be looking for a flat. If it wasn’t for Catching Lives, I’d still be on the streets…’ (Steve, www.catchinglives.org )
Whilst a previous employee of Catching Lives, upon leaving to pursue a degree in Mental Health Nursing reflected on her experience working at the centre as follows:
‘…I became disconnected from the issues that the rest of society distract themselves with like: I can’t afford to buy these shoes, my train is late, I’ve run out of milk. I can honestly say that relative poverty gained a whole new meaning, not just in a material sense, but also in the degree of social and emotion capital that most of us are fortunate have. I found joy, happiness and thankfulness in all the things I have. I valued my circumstances and existence so much more because I could see how bad things could be if I didn’t have all that I do..’.
(Holly, www.catchinglives.org )
Recommendations from Catching Lives
Finally, recommendations from Catching Lives include the followowing:
|Canterbury Community Shelter is now at a point where it can, in its’ current form, be re-run without any major changes and be a continued outstanding success… …my own shortcomings this year were with regard to effective management of the data collection and monitoring of the processes involved – this is the first year using the database in the way we have and I had underestimated what it would require of me to ensure we kept up with the recording of information on it. I had to rely heavily on volunteers and staff to help update all of our records in order to compile this report.. With this considered there are two suggestions: 1. Appointment of an administrative member of staff for data entry. 2. Appointment of a Case Manager. ….this should have an associated quality system in place to monitor the progress of individuals through the project and ensure the record keeping is maintained to a high standard. …from the statistics found within the mental health area of our assessment we can see a continued need for access to mental health professionals such as provided by the Catching Lives Mental Health Outreach Service. In addition to this, a source of talking therapies for homeless people may be of benefit – we often avoid these when people are street homeless for fear of “opening a can of worms” whilst in a more vulnerable position but a more detailed assessment of what may benefit is needed. The training of and communicating with statutory mental health services must continue in order to help prevent the discharge of patients to street homelessness must also continue as part of the Social Policy Campaign run by Catching Lives as our reporting on this still shows it is a problem. Where many of our guests have expressed a wish for help with practical day-to-day living, we can look to assess how to do this more – an area which Occupational Therapy may play a larger role in should be explored. The physical health needs of our client group have again been shown to be higher than average amongst our population. Catching Lives has previously had an in-house Nurse Practitioner but it was deemed unnecessary due to the ability of all to access local GP services. Catching Lives already works hard to advocate for homeless people to access GP services but this area may also benefit from closer analysis in order to examine whether specialist homeless primary healthcare is needed again or better access to services can be brought about via training and informing local services. We already work closely with specialist healthcare services including some specialist community nursing teams. The number of intravenous drug users sharing needles raises concern around the transfer of blood borne viruses within the homeless community. We are also concerned that we have limited ability to follow up our signposting of people to local substance misuse services. We need to further develop communication and possibly look to service level agreements to cement relationships which have been extremely beneficial in the past. A specific harm reduction programme within Catching Lives day centre may help towards developing awareness amongst people over the dangers of injecting and sharing equipment. Finally, with the offending rates amongst those referred to us as high as they are, we believe a more formal relationship needs to be made both with the Police, Prison Service and Probation Service in order to assess the causes of criminality amongst the homeless and ways of preventing both offending, re-offending and prisoners being released to street homelessness – where the risk of re-offending reaches a very high magnitude. (Limebury, 2014)|
The above recommendations are relevant to all concerned in working with the homeless, and those with an interest in assisting homeless people.
Homelessness is a wide-spread problem, and there are many reasons why a person might become homeless. Homeless people might encounter a number of problems and a compassionate approach is crucial.
Our aim within this paper was to draw on experiences from a local homeless charity, Catching Lives, in Canterbury, UK with the intention of raising awareness of the problems faced by homeless people both as identified by the charity, and in the light of recent literature. The health and social profiles, and the problems identified by Catching Lives reflect the issues faced by homeless people on a large scale. Thus, we hope to encourage discussion on this topic, and to motivate others to write about experiences in this area.
The role of compassion is an important factor, whether this be explicit or implicit. Attention to important basic needs such as food, showers, laundry, use of telephone, use of postal address, access to healthcare services all represent an important explicit act of compassion. Implicit acts of compassion such as a ‘tough love’ approach are equally important in assisting an individual to regain independence, self-worth, confidence and motivation. With the correct support and understanding, individuals can learn to take control and re-build their lives.
Certain issues of debate exist of course, in terms of whether the provision of food and other facilities should be provided to the homeless. But how can we expect these individuals to move forward in life if their basic needs are not attended to first? A non-judgement approach is required, whereby we are not ‘judging a person’s pain or distress, but simply accepting and validating their experience’ . Adopting such an approach may help us to better understand the needs of this vulnerable group, and to assist in removing the stigma that is sometimes attached to homelessness, and to ensure social inclusion.
To this end, we hope to stimulate discussion on this important societal issue to perhaps help to find answers to important questions such as: how access to healthcare services can be improved; how situations such as individuals being discharged from hospitals and left outside a homeless centre can be avoided; identifying the best methods for encouraging independence, motivation, and confidence among homeless people.
Seager M. Homelessness is more than houselessness: a psychologically-minded approach to inclusion and rough sleeping. Mental Health and Social Inclusion. 2011;15(4):183–90.
The Lancet (Editorial) . An SOS from homeless people. The Lancet. 2005;366(9501):1903.
Youngson R. Time to Care: How to love your patients and your job. New Zealand: Rebelheart Publishers; 2012.
Shea S, Wynyard R, Lionis C. Providing Compassionate Healthcare: Challenges in Policy and Practice. Oxon and New York: Routledge; 2014.
Francis, R. QC (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, House of Commons: Stationery Office (Vols 1–3).
Chochinov H. Dignity and the essence of medicine: the A, B, C, and D of dignity conserving care. BMJ. 2007;335:184.
Fogarty LA, Curbow BA, Wingard JR, McDonnell K, Somerfield MR. Can 40 seconds of compassion reduce patient anxiety? Journal of Clinical Oncology. 1999;17(1):371.
Shaltout HA, Tooze JA, Rosenberger MS, Kemper KJ. Time, Touch, and Compassion: Effects on autonomic nervouse system and well-being. Explore. 2012;8:177–84.
Limebury J. Canterbury Community Shelter Report 2013–2014. Produced on behalf of Catching Lives. UK: Canterbury; 2014.
Fountain, J., Howes, S. (2002) http://www.crisis.org.uk/data/files/publications/HomeDry.pdf (Accessed January 2015)
American Journal of Psychiatry. Is homelessness a mental health problem? The American Journal of Psychiatry. 1984;141(12):1546–50.
Sun S, Irestig R, Burstrom B, Beijer U, Burstrom K. Health-related quality of life (EQ-5D) among homeless persons compared to a general population sample in Stockholm County, 2006. Scandinavian Journal of Public Health. 2012;40(2):115–25.
The Queen’s Nursing Institute (2012) Mental Health and Homelessness: Guidance for Practitioners
Fazel S, Khosla V, Doll H, Geddes J. The prevalence of mental disorders among the homeless in Western countries: Systematic review and metaregression analysis. PLoS Med. 2008;5(12).
National Coalition for the Homeless (2009) Substance Abuse and Homelessness. Published by the National Coalition for the Homeless http://www.nationalhomeless.org/factsheets/addiction.pdf (Accessed December 2014)
Roy L, Crocker AG, Nicholls TL, Latimer EA, Ayllon AR. Criminal behavior and victimization among homeless individuals with severe mental illness: a systematic review. Psychiatr Serv. 2014;65(6):739–50.
Ministry of Justice (2013) Transforming Rehabilitation: a summary of evidence on reducing reoffending. Ministry of Justice Analytical Series
Daly A, Anderson J, O’Driscoll D, Pitt K. From home to home: homelessness during austere times. Housing, Care and Support. 2012;15(3):109–19.
Cole-King A, Gilbert P. Compassionate care: The theory and the reality. Providing Compassionate Healthcare: Challenges in policy and practice, Edited by Shea, S., Wynyard, R., Lionis, C. Routledge. London; 2014.
We wish to thank Terry Gore, James Duff, and all staff and volunteers at ‘Catching Lives’, together with supporting churches, local services and generous donators.
SS has no competing interests. JL produced the report utilized within this paper on behalf of Catching Lives.
JL prepared the report that is referred to throughout the text, and provided advice and additional commentary on the main text of the article. SS conducted background literature reviews and prepared the main text of the article. Both authors read and approved the final manuscript.