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.
‘Don’t be alone, don’t be too proud to reach out for help’
After Vasili Kalisperas was born a healthy baby, his jaundice was left undetected by midwives and led to him being left with cerebral palsy and needing round-the-clock care. Here, his mum Elena discusses the huge mental health challenges of being a parent in such a position and how she learned to admit it’s OK not to be OK
I’ve always been a very optimistic and positive person, which I do think helps during such traumatic times, but that’s definitely not to say it hasn’t been a struggle. As equipped as you might be in terms of your outlook on life to deal with challenges, when something so traumatic happens to you, it is of course going to be a struggle to come to terms with that.
No-one tells you how to cope, you can never prepare yourself for something like this. There is no right or wrong way to do things and you can only get through it as best you can.
My husband and I dealt with things so differently in the early days. He found comfort in talking about what had happened to Vasili, by sharing a lot of information on social media, whereas for me I was more introvert, I didn’t want to do that.
I was diagnosed with PTSD, which stemmed from the fact our situation was so completely preventable. I became fixated with Vasili still being in the womb, when things were still fine, and I so desperately wanted to find a way to turn back time. I had a water birth with Vasili, and every time I had a bath I’d be in there for hours crying, reliving the whole experience of giving birth to him, feeling the exact pains I felt.
My husband made sure I was cared for and was OK, but finding help was hard. I did try and get medical help but the waiting list was huge. I waited for over a year to see a therapist but I didn’t find it helpful – she wasn’t trained in my needs and was a general counsellor, so I didn’t get anywhere. I was then referred somewhere else, but that was in the same place I had my check ups when I was expecting Vasili, and that in itself was too traumatic.
After being bounced around for a couple of years, eventually, I went privately and found an amazing therapist. It does take a huge amount of time and energy to relive the experience, but I found that opening up and talking about how I felt was so important. I also discovered EMDR therapy through these sessions, which was fantastic and really helped me so much. I realised how far I had come through taking that decision to open up and look for support.
If you have a support network around you, then that can be vital in times of trauma. Even if friends don’t know quite what to say, the fact that they’ll listen can be so valuable. My mum and sister were always there, anytime I needed anything. There were times when no-one could say the right thing, no-one could fix what had happened, but just being able to talk and cry and share what I was going through helped me so much. You need to allow yourself time to grieve, as it really is a grieving process.
In society, while things have thankfully changed massively in recent years, there is still a feeling for many people that showing emotions is a sign of weakness. There is still a stigma in admitting you’re struggling with your mental health, but I see that it’s like your physical health – you’re never going to breeze through life without any problems at all, it’s going to happen to us all at some point. No-one should ever be afraid to admit they’re struggling and they need support.
Lockdown has been difficult for us all, and seeing the impact on the children and my oldest daughter in particular, has been awful. She is in high school and not being able to leave the house has had a big impact on her mental health. But as a family, we share our feelings and talk about it, and I teach my children the importance of positivity and an optimistic outlook to help them cope with challenges.
In learning to deal with what you face and move on with your life, you need to accept it and forgive yourself by recognising it isn’t your fault. It has been a long journey for me – Vasili will be nine in May – but we’ve made so much progress.
While Vasili and our other children are of course our priority, I’ve learnt the importance of making time for self love and care. Without making time for that, you’ll run yourself into the ground. For the last two-and-a-half years, the children have been at school every day, which has meant I’ve had time to take control of my mental and physical health. I started doing daily exercise, which began by making sure I got out to walk every day, and I now regularly go to the gym. It’s a big release for me.
I’ve also reached a place where I’m able to look to the future and I’ve started my own business as a hairdresser, working from home in a salon we’ve created in an outbuilding. Being a hairdresser gives me a chance to help other people to open up and discuss anything that’s on their mind, which for many people may be the only chance they have to do that. And also, I’m training to be a personal trainer – I’m already a mental health first aider, and I’ve seen for myself the impact that exercise can have during the most trying times, so I think the combination of mental and physical wellbeing support is so important and I’d love to help people with those.
For me, in being able to find acceptance of our situation, I’ve been able to move on and find time for myself and what I want to do with my life. I’ve definitely found my purpose, both as a mum and as a woman, and I’m in a much better place now. But without having the strength to open up, to reach out and admit I needed some help, I don’t think I’d have reached this point in my journey.
The one thing I’d say to people who are struggling, whatever their situation or circumstances, is to talk. Don’t be alone, don’t be too proud, and reach out to someone. I’m so pleased I did.
‘I’m a rehab professional attempting to rehab myself’
Having contracted COVID-19, which has now become Long COVID, assistant neuropsychologist Alarna continues to battle a number of effects, including fatigue. Here, she shares her reflections on her experience, which has enabled her to gain a greater understanding of her patients’ wish to return to their ‘normal selves’
My name is Alarna, and I am an assistant neuropsychologist at a specialist private neuro rehab hospital. I have worked in both supported living and rehabilitation settings for the past 14 years, with various mental health conditions, psychologically rooted illnesses, degenerative diseases, and rare neurological presentations.
Today in discussion with our company director responding to the question of “How are you?” I found that I had reached a new level of understanding for every patient that I had worked with. I found on some level I could identify with their journey as I am attempting to rehab myself. I answered, “I just want to get back to my normal self”.
In December 2020, I tested positive for the coronavirus and was severely unwell for a period of 2-3 weeks. I initially was unaware that what I was experiencing was anything other than being run down or having a common cold. It was not until day four when I woke up feeling as though someone was sitting on my chest, each time I moved I had to take shallow rapid breaths to remain upright and when I coughed it felt as though I was being punched with weighted gloves from all angles.
This was unlike anything I had experienced in my life. Being someone who would be over a cold within 3-4 days (and very ironically did not know how to properly rest) the situation was entirely foreign to me.
Having thankfully recovered some weeks later I began to find myself falling asleep involuntarily every 2-3 hours, I was still breathless on exertion (from walking up a flight of stairs to carrying a handbag) and generally feeling weak. After seeking advice from NHS 111 I was reassured that this was to be expected following a virus and should subside in a week or so.
Throughout this period, I had regular contact with my supervisors at work who were (and still are) extremely supportive, reassuring, and understanding. It was not until several weeks later that we discussed an action plan to help me ease my way back in to work.
This brings me back to today, four months after having COVID-19 and still suffering with chronic fatigue, occasional breathlessness, and migraines. I am unable to complete a full day at work and once I get home at approximately 3:30pm I have no choice but to stop everything and sleep.
Just a key point I would like to throw in here. Fatigue is not the same as being tired!!
I have been burnt out before, I have been exhausted, and I have been tired, but this unexplainable experience is not like any of the aforementioned. It is like an involuntary shut down. People who mean well advise me to just rest or sleep more not realising that I am sleeping up to 14 hours most days and still waking up feeling exhausted.
In my attempts to help the process along I have completely changed my diet, dropped 20lbs of excess fat, complied with resting when my body tells me to, and my energy levels remain poor. Some days it feels as though my speech is unnaturally slow and slurry, though when asking my colleagues, it is not so for the listener. In summary I cannot function without having a 2–3-hour nap in the early afternoon as well as a full night of sleep.
Though there are so many unknowns with this virus, from my experience I have learnt the following:
– The importance of self-care and rest. Sometimes in the busyness of life what we think we are doing to take care of ourselves really is not self-care.
– To appreciate the stillness and tranquillity of silence
– Spending time alone and reflecting is so peaceful.
– Your health is one of the most important things you have and needs to be a priority. Facts that I knew before but like so many, have taken for granted.
Personally, as a woman of faith I believe that this situation has and will work out for my good in the end, there is always a lesson or a positive to be taken from every experience. This has also fuelled my ever-burning desire to be instrumental in changing lives for the better, starting with my own.
This situation is only temporary but for many of my patients it is not and returning to their former self is a distant memory not to be realised.
I take this opportunity to thank my incredible supervisor/mentor at Renovo Care, Dr Anita Rose, and Margreet, as well as my amazing colleagues Ana, Chris, and Simone for being so caring and supportive during this difficult time.
Rest in peace to all of those who have lost their lives because of this horrible virus, including my dear Grandpa. May we find and be the solution! Stay safe.
A rehab professional attempting to rehab herself.
Taking time to look back – so the way ahead is clearer
Reflective practice within healthcare settings is widely talked about, but not always so easy to implement in the workplace. NR Times speaks to one neurological centre about how it benefits patients and staff there.
Reflective practice and discussion in healthcare settings is a professional requirement for nurses, as laid out by the Royal College of Nursing revalidation requirements as part of their continuous professional development.
It allows professionals to take time to pause and reflect, communicate and plan, which undoubtedly leads to better outcomes for patients and staff.
But in reality, reflective practice can often be left to the bottom of the pile, underneath many of the competing responsibilities facing staff who are often pressed for time.
It could be argued that this is also why reflective practice is so important – healthcare staff are facing so many pressures that it actually makes less sense to neglect the important work of individual and team reflection.
The Royal College of Nursing defines reflective practice as: A conscious effort to think about an activity or incident that allows us to consider what was positive or challenging and if appropriate
plan how it might be enhanced, improved or done differently in the future.
Staff at Elysium St Neots Neurological Centre in Cambridgeshire started doing regular, weekly reflective practices when its new hospital director, Fiona Box, came into the role a few months ago.
The nurses and healthcare assistants from a ward are invited into the meetings and in their absence the therapy staff monitor patients and provide activities.
“We thought it would be helpful for team members to give them the opportunity to think, learn, and to hear their opinions,” says charge nurse Jemima Vincent.
“If we have an incident with a patient, we discuss it in the session” she says.
Sessions are led by the management team, with added input from psychology teams on each ward.
They will talk through any strengths, weaknesses and opportunities, and work through an analysis to learn from the incident and create an action plan.
They talk about the worst-case scenario in relation to an individual situation and discuss how staff would manage that, so they’re better prepared in the event of it happening.
While they focus on one patient at a time, issues arise during conversations that bring in their wider experiences.
In an article* published in the Nursing Times in 2019, Andrea Sutcliffe, chief executive of the Nursing and Midwifery Council said: “In these challenging times for health and social care, it’s so important that collectively we do all we can to support our health and care professionals, and their employers, in devoting time to individual, reflective, personal and honest thinking.”
Fiona has received encouraging feedback from staff, who say the meetings help the staff feel much more involved in a patient’s care and allow the team to increase their knowledge and understanding resulting in a more consistent way of working.
“Healthcare workers often don’t fully understand patients’ diagnoses or why they’re reacting in a certain way, for example,” Jemima says.
“They know a patient presents with certain behaviours and may be taking medicine to help them cope but they’re not aware why the patient is showing signs of aggression and the best response to deescalate the situation,” she says.
“It’s a learning opportunity for staff, because reflective practice means that they can understand a patient’s diagnosis and why they behave how they do,” Jemima says.
“Reflective practice answers their ‘why’ questions, and gives them a more open mind.”
Jemima also benefits from the meetings; it’s a way for her to get to know staff better, especially when it comes to learning opportunities.
“I’m able to understand what level of support each member of the team requires, including training needs and if they need more knowledge on a specific topic.”
In her final year as a mental health nurse student on extended clinical placement at Elysium St. Neots, Jo took part in a reflective practice session.
She had just finished her dissertation, in which she looked at how settings can increase the opportunities and variety of reflective practices within hospital settings.
The aim of Jo’s session was to reflect on the recent deterioration in a patient’s mental state and the resulting impact on their well-being to ensure staff had a consistent approach to support the patient.
The hospital’s director Fiona asked the team about the patient’s care plan, diagnoses and needs and wishes.
Where staff were unsure of the answers to questions, Jo says Fiona gave them answers and encouraged the team to share their knowledge of the patient, problem solve and come up with an agreed plan to move forward with.
Jo found the session helpful and was impressed with how the healthcare assistants were so involved in the discussions about all aspects of the patient’s care, including the more clinical elements.
Healthcare assistants told her they found the session helpful too and that it made them feel like they had a better understanding of the patient’s changing mental state, behaviours and needs.
Jo says having the opportunity to reflect on practice is a crucial skill for all healthcare workers to help them learn from their experiences and increase self-awareness, which, in turn, can improve individual professional standards, strengthen teams and enhance patient-centred care and clinical outcomes.
For referrals to Elysium St Neots Neurological Centre or other Elysium centres visit: www.elysiumhealthcare.co.uk/neurological
Reference source: https://www.nursingtimes.net/news/ professional-regulation/nmc-highlights-importance-of-nurses- reflection-on-practice-18-06-2019/
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