Half of all homeless people may have had a traumatic brain injury (TBI) at some point in their lives, research shows.
Studies in the UK and North America over the last decade have found levels of past TBI experiences among homeless people to generally range between around 45 and 55%
Research also suggests the vast majority of TBIs happened before homelessness occurred (90% in one study in Leeds in 2012).
Such stark figures prompt serious questions about the way brain injuries cases are diagnosed and handled.
With homelessness rising sharply in recent years – by 55% in England alone between 2010 and 2015 – there is also a pressing need to better address the many TBI cases out of reach of the vital interventions they may need.
Closing the road from brain injury to homelessness requires work from every angle, including healthcare, social services and politics.
Getting the many homeless people with a past brain injury o the streets and receiving adequate care requires a similarly all-encompassing approach.
A solution to this escalating, labyrinthine challenge may well be taking shape in the West Midlands, thanks to a small band of pioneers.
“We’re not suggesting what we’re doing needs to be rolled out as it’s too premature for that,” says Dr Andrew Worthington, a neuropsychologist who runs Birmingham- based rehabilitation group Headwise.
“We are giving an example of one model and we’re going to evaluate its impact.”
Headwise has joined forces with the charity Headway Birmingham and Solihull to employ a ‘homelessness caseworker’ to assess the needs of homeless brain injured people and help them move their lives forward.
The post, funded by Headwise and based at Headway, is part of a wider research project by the partnership to explore links between brain injury and homelessness.
At the time of writing, the scheme is nearing the first six-monthly follow up with homeless people and Worthington is hopeful of some meaningful data.
“We’re primarily doing an intervention study. The idea is to provide a support and signposting service for people with a brain injury. When the needs of an individual are related to a brain injury we will provide that support.
“Where they just happen to have a brain injury, but their primary needs may be drug or alcohol abuse, domestic violence or simply that they have nowhere to sleep at all, we’ll signpost them to other services.
“We don’t necessarily think everyone’s problems are all down to the brain injury, but it’s important to have a point of reference where they can be properly assessed and provided with support.
“Previously they might have been given a leaflet and left to get on with it, with nobody following them up. We’re providing a dedicated case worker who’ll work with them.”
The main research element of the scheme is to compare the results between people accessing this new model and those receiving the usual standard of care.
“It’s very early days but hopefully we’ll have some evidence as to what works and will be able to develop a model that can be tweaked and may be rolled out elsewhere.
“It’s only the last 10 years or so that we’ve become aware of the problem of homelessness and brain injury so we’re still trying to work out the scale of the problem.”
Solutions which emerge in the future to stop TBI acting as a catalyst for homelessness will need to address several major challenges; including the disjointed nature of services which come into contact with vulnerable people.
“There’s a broader need to educate the agencies which work with the homeless, such as social services and the voluntary sector, to recognise amongst all the other problems, signs of head injury.
Although an individual may be drunk, for example, have they got behavioural difficulties because of a previous head injury? We’ve also got to give them some options for services to refer on to.
“What’s at the heart of this, and the reason why the government and local authorities have struggled to deal with it, is the fact that it cuts across boundaries.
“Homeless individuals can have multiple problems, one of which may seem more urgent than others at different times.
“Any service that comes into contact with homeless people, whether that be a shelter, dentist or GP, needs to be aware of what specialist services are available.
“Currently there is a problem in trying to provide joined-up services. If everyone is focusing only on their area, no-one is looking at the bigger picture.”
A homeless person living out of reach of regular contact with local services might reappear on the radar with a trip to A and E. In this pressured environment, with the immediate health of the individual taking priority over anything else, previous brain injuries often go undetected.
“They may have been assaulted or be drunk. Understandably the pressing problem is dealt with and they are discharged. Rather than getting to the root of the problem, they may go back to the streets. So we have this revolving door syndrome.
“Often it’s difficult to know how to help, because the problems can be very complex and usually hospital staff aren’t aware of the specialist services available for homeless people.
“On the other side of the coin, homeless services are often unable to identify the relevant medical problems.”
Furthermore, if the police or social services come into contact with a homeless person, they may also deal with the individual’s most urgent need rather than tracing the reasons for their homelessness. Finding that person a place to live is effectively treating their symptoms with a “sticking plaster”, says Worthington.
Even if past head injuries are identified, getting someone at risk of homelessness to partake in rehabilitation and engage in brain injury services can be hugely challenging.
“They might move out of the area and, if they don’t turn up for an appointment, a lot of services won’t bother to enquire why.
“Also, they often have certain problems with mental health and substance abuse disorders which then makes it difficult for them to meet the criteria to be helped by brain injury services.
“Some brain injury services have exclusion criteria which means that many people who are homeless and need the service can’t access them.”
Preventing homelessness among people with brain injuries, rather than getting them o the streets and on the road to recovery, presents an entirely different challenge.
“It’s quite likely that individuals who have had head injuries as children or adolescents may be at a greater risk of being homeless in later life, although there is no evidence of this yet.
“They might not develop normally, their education may be interrupted and they may not acquire the skills that adults to a certain degree might have. If it can’t be addressed early on or isn’t addressed quickly enough then this changes their trajectory for the rest of their life.”
There is an argument that some people who are considered risk-takers might be susceptible to both homelessness and head injuries – rather than one being a result of the other.
“Certain antisocial behavioural activities could have caused them to be on the streets, such as drug-taking, which could have also contributed to a brain injury.
“What we do know quite clearly is that having a brain injury massively increases any existing problems you might already have.”
While the Headwise/Headway project remains at an early stage, there are examples of successful models that are already improving the way homeless people with head injuries are treated.
Worthington cites the PIE (psychologically informed environment) system as one approach to learn from.
“The idea is to provide an environment, perhaps in an accommodation setting, that meets the person’s needs for shelter but also their psychological and emotional needs too.
“These have been known to reduce offending behavior among homeless people with mental health issues and could have possible implications to help people with brain injuries.”
Worthington’s long-term vision is for a system that helps, not hinders, homeless people with brain injuries.
“In North America they have collaborative models of care that cut across boundaries. We’ve struggled with that here because everyone has their own ring-fenced budgets,” he says.
“We need a coordinated system that will pick people up after discharge from hospital, which is staffed by people with knowledge of head injury who are able to undertake assessments of their social and health needs and then help them access the relevant support. We need a network of services for people that are homeless.
“Currently in hospitals, if they haven’t got a discharge destination, they are either kicked onto the streets or kept in for longer than they need to be, ultimately blocking beds.
“There needs to be a service to which these individuals must be referred. We can find them temporary accommodation and get the assessments done and refer them on to other services to give them the support they need.”
Before that ideal is realised, support in tackling the issue is needed from many sources, including charities – especially against the backdrop of austerity measures.
“The third sector is going to play a critical role in this. NHS budgets are so stretched and are skewed towards acute services. Social services budgets are also stretched.
“It would help if we could make social services more informed. But ultimately they are not going to have the resources to address these complex needs, so I think a lot of responsibility is going to fall on charities.”
If charities are to take on this burden, they will need considerable support.
“Often a charity might lack medical expertise. What’s innovative in our model is that we’ve got a partnership between my professional, medical organisation and Headway, the charity.
“The future needs to be collaborative and it’s going to be incumbent on the charities to develop or access professional support.”
For now, Worthington takes optimism from the way in which brain injuries among criminals have been handled over the last decade.
What was once a suspected link between brain injury and criminal activity, now has a vast weight of evidence behind it.
With as many as 60% of prisoners reporting a head injury, according to one study on male inmates, the issue has infiltrated politics and is beginning to influence decisions and discussions about the future of the justice system.
In October, for example, the House of Commons justice select committee mentioned the increased risk among young offenders of head injury in its report on why the under-25s should be kept out of adult prisons.
In contrast, a parliamentary report published in the same month related to the Homelessness Reduction Bill 2016/17 made no mention of TBI among its list of the causes of homelessness.
In fact, there was no mention of head or brain injury anywhere in the document.
“A few years ago we were in the same position with brain injury and criminal activity and now we have a much better understanding of it.
“So I think in 10 year’s time that’s where we’ll be with homelessness and brain injury. It’s taking a while and we remain at a very early stage, but we’ve made a good start.”
TBI and homelessness: The evidence
A 2012 study by the Disabilities Trust found that 48 of the 100 homeless people it questioned in Leeds had experienced a head injury.
Of those, 90% suffered the injury before they became homeless.
The 48% figure was more than double the proportion of head injuries reported by those in a comparator control group of non-homeless people.
Another Disabilities Trust study, in Glasgow, used hospital records of admission to assess the city’s homeless population.
It found that the frequency of admission to hospital with head injury among the homeless was five times higher than that of the city’s general population.
In Toronto in 2004/05, 601 men and 303 women at homeless shelters and meal programmes were surveyed.
Overall, 53% had experienced a TBI, with 12% reporting a moderate or severe TBI. In this study 70% of respondents sustained their injury before they were homeless.
In 2014, researchers at St Michael’s Hospital in Toronto surveyed 111 homeless men and found that 45% of them had suffered at least one TBI in their life, and 87% of those injuries occurred before they were homeless.
Among the general population, TBI rates are estimated to be 12%, according to a 2013 meta-analysis of studies from developed countries.