by Dr Rachel Manning
As a little girl I remember seeing an ornament in my grandfather’s house with ‘Níl aon tinteán mar do thinteán féin’ printed on it. He explained it means ‘there’s no home like your own’. Perhaps this resonated with me. I have long thought home is a funny concept. Homes come in all shapes and sizes and exist in every corner of the globe. Homes are more than physical shelter; they are melting pots of human emotion and experience. Realising this, it is difficult not to wonder what it means to be without a home– that is, to be homeless.
In the last years I have been researching Ireland’s homeless. People ask ‘what causes homelessness?’ and I think of the young boy who ‘slipped into drugs’, the woman with depression, the girl abused at home, and the businessman who lost it all, among the many people I have met in my work. The only common thread through them is they are without homes and so that must be my answer.
In my work I also saw how unwell the homeless are. One of the few studies of health and homeless in Ireland  reported that 48% had psychiatric symptoms, while 76% had substance use problems. Physical illness was reported by up to 90% of participants, ranging across arthritis, back problems, pain, and tuberculosis. The human face of these numbers is that I was often unsure if someone I saw that day would survive to the end of the week.
It is easy to imagine how rough sleeping impacts health – verbal and physical abuse are always possible. Many I met had been urinated on by drunken passers-by. The cold from city footpaths or country ditches causes sickness. Hygiene and medication management is almost impossible and access to healthcare is complicated without an address. But most of Ireland’s homeless reside in services, and often the ways in which these are provided limits health too.
Most homeless services operate a staircase model where ‘emergency’ time-limited (up to 2-years) shelter is offered first. This shelter is congregate ranging from 5- to 75-beds. Facilities (e.g. dining rooms, bedroom, bathrooms) are shared. The chaos of these spaces means rules on curfews, gender segregation, and set meal times are used. Most are also ‘treatment first’ so that shelter is leveraged against compliance with health advice (e.g. medication obedience, sobriety). If rules are obeyed, service users may move up a step toward independent housing.
Although intended to promote health and housing, the reality is that very few get past the ‘emergency’ step in these services – in 2013 around 37% had been in these services for longer than five years . For some service users there is simply nowhere to go after services, but for others their inability or unwillingness to follow rules means they are evicted and circle between the streets, hospitals, and prisons, until they are taken back to homeless services to begin their staircase journey again.
The main problem of providing services in this way is that it undermines ‘self-determination’. Self-determination is an individual’s sense of choice and control over themselves. It has shown for positive behavioural change but if it is thwarted or restricted – as it is in services that enforce rules and operate treatment first philosphies –disengagement is likely. Self-determination has shown to promote better physical health  and health related to substance use  and psychiatic health .
An obvious way to enhance self-determination in homelessness is to provide homes. A home means individuals do not have to abide by rules. They are free to exercise the choice that you and I take for granted. I am not the first argue this point. Housing First is one example of homeless service provision where homes are provided from the offset. Support workers engage with the individual in their home 365 days a year for as long as necessary. Importantly, studies in America, Canada and Europe show better health outcomes among Housing First service users than those who receive care as usual. This type of care also costs less because individuals spend more time housed and less time in hospital, treatment facilities, and prison (See http://www.theguardian.com/cities/2014/oct/20/housing-first-the-counterintuitive-method-for-solving-urban-homelessness for an accessible summary). While in its early stages, there is also a pilot Housing first project in Dublin that is showing promise.
Slow but steady changes to homeless service provision shows that ‘tintean fein’ message is slowly infiltrating public and political will. The research shows that there really is no home like your own and it is possible that in the next years the potential of home to bolster health will be more fully realised. It is my view that aligning services with needs for self-determination is key to promoting health among Ireland’s most vulnerable people.
- Lawless, M. and C. Corr, Drug use among the homeless population in Ireland. A report for the National Advisory Committee on Drugs. Dublin: Merchants Quay Project, 2005.
- Manning, R.M., An ecological perspective on recovery in homelessness: the influence of key worker values on consumer self-determination. 2014.
- Williams, G.C., Z.R. Freedman, and E.L. Deci, Supporting autonomy to motivate patients with diabetes for glucose control. Diabetes care, 1998. 21(10): p. 1644-1651.
- Wormington, S.V., K.G. Anderson, and J.H. Corpus, The role of academic motivation in high school students’ current and lifetime alcohol consumption: adopting a self-determination theory perspective. Journal of studies on alcohol and drugs, 2011. 72(6): p. 965.