Cost of living crisis: “Understanding brain injury in homeless people could help us do much more”

More than 66,000 people in the UK will be pushed into homelessness by 2024. NR Times reports on the hidden consequences of brain injury in society’s most vulnerable people.

As councils warn of a “tidal wave” of need caused by benefits freezes, soaring food and energy bills, thousands of people will be left on the brink of poverty.

According to the charity Crisis, the cost of living crisis is likely to push 1.7 million UK households into homelessness this winter, putting them at high risk of neurological disease and cognitive dysfunction.

Traumatic brain injury could be either a cause or a consequence of homelessness.

Researchers from the British Columbia Mental Health and Substance Use Services have found that half of all homeless and marginally housed individuals may have suffered a traumatic brain injury at some point in their life, two to four times the rate for the population as a whole.

“It is a complicated picture,” says Professor Tom McMillan from the University of Glasgow.

While some may have a history of brain injury before they become homeless, others may be on the trajectory towards homelessness for a range of different reasons such as mental health problems and drug and alcohol abuse, increasing the risk of being assaulted and suffering a brain injury.

Dr Lucia Li, NIHR clinical lecturer in neurology at Imperial College London says this can turn into a vicious cycle where homelessness increases the risk of TBI and TBI increases the risk of ongoing homelessness.

“For this group of people, the risk of getting caught up in violence is very high,” Li explains.

“They are extremely vulnerable to many negative health and social consequences including falls, sexual violence, infections as well as decline in existing medical conditions.

“This isn’t only because of their lack of safe home but also the other factors which led to that situation such as poor mental health or drug and alcohol use.”

Brain injuries in homeless people have wide-ranging, long-term implications and yet the opportunity to help them once they are within the NHS is missed.

Health professionals would tend to deal with the issues that are most obvious and pressing at the time and they are not going too much further into the background” says Professor McMillan.

Invisible impairments make it almost impossible for these individuals to access services and benefit from them, says Dr Mark Holloway, senior brain injury case manager at Head First.

“If we think about the interrelationships between cognitive and executive difficulties, cognitive communication disorders, emotional and behavioural challenges, substance use, prior experience of/lack of experience of service use and, potentially, feelings of low self-efficacy, then [the lack of care] is perhaps unsurprising.

“In the absence of insight into your own needs in a system that fails to provide neuro-rehabilitation and lacks the knowledge of your needs, it is easy to conceptualise how people fail to engage successfully with the services that are available.

“But rather than see this as a personal falling, I question how much people are corralled into this position, squeezed into that liminal space at the edge of the world and society where even the very services that are supposed to pick up and support those with the fewest resources are in fact a barrier to life.

“I think it is less that these are ‘hard-to-reach service users’ and more that the services are hard to reach.”

Adequate care for homeless brain injured people requires an all-encompassing approach to assess their needs and help them move forward.

“Homelessness is the epitome of complex medical and social problems that can’t be tackled by one type of intervention or another,” says Professor Andrew Worthington, ​director and consultant in neuropsychology and rehabilitation at Headwise.

“Even if the brain injury was a factor in them becoming homeless, this is often not the most pressing problem that these people have. There are multiple complex needs these people have which means that in order to help them we need a joined-up service provision.

“Currently, there are lots of barriers homeless people face in getting service provision – structural ones like not having an address or barriers related to a rather chaotic lifestyle and difficulty in trusting professionals.

“You have to meet people on their own territory, literally, but also, metaphorically,” Professor Worthington argues.

“These people are not necessarily going to turn up at a clinic for a set appointment. So, there has to be more of an outreach approach that involves working with people in homeless shelters and charities, rather than staying within the confines of clinics.”

A strong and adequately funded social sector is a good place to start, says Thea Arch, policy officer working on brain injury, domestic abuse and the criminal justice system at The Disabilities Trust.

“The picture is very complex. Robust care in the community programmes and accessible services, such as drop-in clinics, are helpful in treating injuries before they become worse.

“We also need to see appropriate discharge plans that involve active reaching out and persistent follow-ups because those with a brain injury find it particularly difficult to remember and attend appointments.

In concluding our own research at The Disabilities Trust, we found that the persisting cognitive and emotional effects of the brain injury may have an impact on a person’s lifestyle. So, much more needs to be done to encourage engagement.”

Education could play an important role in understanding and minimising brain injury risks in the homeless population. However, this remains a topic very little-explored.

“It’s quite striking that it isn’t given more attention,” says Professor Worthington. “The focus has been mostly on alcohol and drug misuse, past traumas and the mental health problems, but suffering a brain injury can make dealing with those factors much more difficult. Raising awareness remains a major mission.”

But spreading awareness should go beyond medical professionals. Homeless people do not have any real understanding of the long-term impacts of head and brain injuries and therefore, establishing a history of past experiences becomes an impossible task.

“What we’ve found is that there isn’t really an awareness that having repeated head injuries might cause concussion or short periods of loss of consciousness,” says Professor McMillan of University of Glasgow.

“People who grow homeless might understand [the consequences] if they’ve had a brain injury, and they’ve been hospitalised, but when they get knocked in the head repeatedly, sometimes in the context of domestic abuse, they fail to understand the cumulative and long-term effects.”

Additionally, increasing awareness of brain injuries could play an important role in reducing fear and stigma particularly in the homeless community.

Jane Jardine, information and advice officer at The Brain Charity, says there are still huge barriers for these people to overcome and more practical support is needed to make them aware of their rights, eligibility and who to contact if they need help.

“Raising awareness is vital in tackling discrimination and increasing the support available,” she adds.

“A good understanding of how brain injuries can affect these individuals is equally important for staff working within local authority housing option teams, the criminal justice system, housing associations and housing support agencies.”

In the light of a looming cost of living crisis, experts argue that support for low-income families is crucial to prevent more people going homeless.

“Once you are homeless, it’s very difficult to get back off that,” says Professor Worthington. “Homelessness itself is a risk for other health problems, so it’s much better to stop people becoming homeless than to try and deal with the problem afterwards.

“The most cost-effective way to help in the current crisis is to bolster people as much as they can financially rather than wait until they become homeless.”

The estimated 227,000 experiencing the worst forms of homelessness are heading into uncharted territory.

The Salvation Army has warned that measures need to be put in place to make sure that the cost of living crisis does not lead to a rough sleeping and homelessness crisis, but the government has not as yet confirmed additional support.

“Head injury remains a hidden disability and not a major focus for governments,” says Professor McMillan. “But although brain injuries don’t achieve the eminence and focus of other conditions, more support is needed.”