A UK perspective on transitions through homelessness among dual diagnosed individuals – the potential role of housing first

Objective Despite an extensive body of US and UK research on the intersection of homelessness with mental illness, substance use and poverty (Fitzpatrick & Christian, 2006) there has been little qualitative research on individuals with such experiences as they attempt to regain housing over a sustained period of time. This has led to a significant lacuna in adequately documented and analysed transitions through and out of homelessness among individuals with dual diagnosis. Without this, the identification of key factors that impact upon outcomes from a consumer perspective has also been lacking. Findings from one of the first qualitative tracking studies to be conducted in the UK are presented in this symposium paper. These provide a cross-national perspective on the significance of housing first approaches in meeting the needs of homeless mentally ill consumers. This study also addresses additional barriers to mental health recovery and well being among individuals with dual diagnoses once they are housed.

Methods. 28 homeless people recruited from a non-profit homelessness agency in the UK (all with histories of substance use or mental illness, and in most cases with a dual diagnosis) were followed over an 18 month period. Each participant completed a life history interview at the outset and then was interviewed at six-month intervals for the duration of the study. Interviews included exploration of current housing and pathways to attaining it, social support, service use, health, income, substance use, daily activities, and future plans/aspirations. Data were analysed using a dual system of developing case studies and operationalizing the ‘framework' approach (Richie & Spencer, 1994) to qualitative analysis. Individual trajectories were recorded to identify key turning points and their contexts.

Results. On concluding data collection, 10 of the participants remained homeless and 18 had found housing in their own legal tenancy. Among those who remained homeless, all had been evicted from treatment or supportive housing due to their non-adherence with the regulations in these settings. While the still-homeless grappled with unstable lives, the health and social circumstances of those in housing did not always markedly improve (and in some cases deteriorated) in the ensuing months. These individuals cited their ongoing mental ill health, intense isolation, and a lack of support services as the reasons for their lack of progress toward recovery.

Conclusions/Implications. The participants' lives continued to be marred by the intense difficulties of recovery, marginality, isolation and poverty. Housing, when obtained, did provide improved material circumstances, but problems remained that presented barriers to recovery. These problems, while manifested in individuals, are linked to broader societal factors that have implications for ‘what works'. Thus, recovery can stall when poverty and social isolation remain characteristics of people's lives. Cross-national implications for practice and policy are discussed as providers in both the U.S. and the U.K. seek to reduce homelessness and promote mental health recovery.