Homelessness: A Health and Social Crisis

Homelessness is an issue across the world with countries of all economies having numbers of homeless people. Globally, in 2020 it was estimated that more than 1.6 billion people were homeless (McWilliams et al. 2022). Australian census data indicate an increase in homelessness in Australia, especially among women, with recent estimates reporting 44.1% of homeless people in Australia were women (Australian Bureau of Statistics 2018). According to the Australian Bureau of Statistics (2018), Indigenous Australians comprise 20% of people who are homeless in Australia. International literature suggests that homeless populations are ageing, with more and more older people unable to find and afford suitable housing (Hargrave et al. 2022).

The path to homelessness is often complex but is associated with several factors including economic hardship and a lack of affordable housing. People with chronic and complex mental health issues, substance use issues (AIHW 2024), and those fleeing from domestic and family violence are at higher risk of being unhoused (AIHW 2023). Because of the meaning of home and its importance to health and social wellbeing, the issue of homelessness is of central importance to mental health nurses. In this call to action, we consider the issue of homelessness, and the role of mental health nurses in ensuring access to health and social services for unhoused people, and as advocates for safe and affordable housing for all and especially for those with complex mental health issues.

The word ‘home’ holds profound existential meaning. Ideally, home represents a place of shelter, safety and comfort, as well as a site for storage of essential items such as food, clothing, medications and treasured personal items. In addition to the physical dimensions, home implies a sanctuary, where a person can be their true self, let their guard down and relax. Home should also be a place of belonging, providing a means of connection with family and friends; and continuity, with links to the past and hopes for the future. Home can represent security and a focus of identity; and is often a strong thread in the narratives people weave of their lives.

However, for many people, ‘home’ is not a safe space, with domestic and family violence being a leading cause of homelessness in Australia and internationally. Furthermore, Australia is currently in the grip of a severe housing crisis with both home rental and home ownership becoming increasingly difficult and unaffordable for many people. There are no indications that this crisis is short term, and as it continues, it is likely to result in even more people experiencing homelessness. Furthermore, with the current rental crisis and ensuing competition for rental properties, people with mental health issues will find it even more difficult to compete for the few properties that are available.

Homelessness is a term to describe situations where people are experiencing housing insecurity and has been classified as primary, secondary, tertiary and marginal (Seastres et al. 2020). These classifications cover people sheltering in various settings including vehicles, abandoned buildings, streets or parks and couch surfing or in temporary shelter such as motels.

The difficulties associated with homelessness go beyond the lack of shelter. The absence of a stable dwelling means that people are deprived not only of a physical space to house themselves and their belongings, but also of a vital component of their sense of self. People who are unhoused face stigma, marginalisation and isolation. They are propelled into a state of transience and impermanence, deprived of the basic human need for shelter, connection, security and belonging.

Homelessness involves a complex web of intersecting issues, meaning that unhoused people find themselves in uncertain and deprived situations in which previously taken-for-granted essential life activities such as food storage and preparation, access to health and social support and facilities for personal hygiene become problematic. They also experience serious health inequities as researchers have previously found that people who sleep rough experience 30 years less than the national average life expectancy (Rosa 2014). Homelessness is associated with intergenerational trauma, which has a known association with mental health and well-being and this association makes it difficult for people to effectively exit homelessness (Hargrave et al. 2022).

While there is a body of scholarly and scientific literature that focusses on the health and social care needs of people who are homeless, there is rather less scholarly or scientific literature that captures the voices, or the firsthand accounts of what it is to be homeless. However, reading the poetry of people who are homeless provides a rich and authentic source through which their lived experience can be revealed. Through their work, these poets reveal their solitude, their awareness of being unseen, their sense of marginalisation, the sense they are apart from and worthless compared to others, their physical and emotional pain, their sense that others do not see or care about their suffering, and the crushing weight of hopelessness and blame. In his poignant portrayal of life on the streets, Boston (2021) refers to ‘an abyss of loneliness’ and ‘streets not paved in gold, but misery mountains that I scale everyday’. Loneliness also echoes through Folgers work as he questions his existence and the meaning of his life: ‘The isolation, the loneliness, am I not even of this earth? Will my life ever have meaning? What will it ever be worth?’ (Folger 2011a). Through their poems, these writers illuminate the uncertainty that shrouds their existence; ‘I'm still walking alone. I don't have any idea where to go … what do I do now? Where do I go?’ (wizmorrison 2021). Their works reveal the pain and truth of their invisibility and the absence of acknowledgement or connection with others: ‘it is though I am not even here, No one will say hello’ (Folger 2011b).

In Australia, the 2021 census revealed that 122 494 people were homeless (an increase of 5.2%), and of these 17 646 were children (Australian Bureau of Statistics 2018). Homelessness is a very real issue for people leaving situations of domestic and family violence. Australian data reveal a profound narrative of existential upheaval, with domestic and family violence listed as the foremost cause for women and children leaving their homes and 42% of clients presenting to specialist homeless services reporting they were escaping from violent situations (AHURI 2022). Significant numbers of both women (and their children) and men leaving violence situations experience homelessness and report sheltering in the street, vehicles, tents or abandoned buildings (AHURI 2022). This is in keeping with findings from the United States, where it is estimated that 80% of domestic and family violence survivors experience homelessness (Jagasia, Lee, and Wilson 2023).

Women experiencing homelessness are a highly vulnerable population (Milaney et al. 2020) because of their lack of services, vulnerability to violence, exploitation and marginalisation, and poverty (Calgary Homeless Foundation 2011). Research by Milaney et al. (2020) indicates that women in their study experienced higher rates of suicidal ideation and suicide attempts, childhood trauma, and stays in psychiatric hospitals when compared to male respondents.

The literature tells us that poor health can be both a cause and an outcome of homelessness. People who experience homelessness experience poorer health than the general population, have higher rates of mortality and morbidity and a reduced life expectancy when compared to housed people (McWilliams et al. 2022; Jagasia, Lee, and Wilson 2023; Seastres et al. 2020). They experience higher percentages of preventable medical problems, both acute and chronic, assaults and other traumatic injuries, disability, psychiatric illnesses and mental health problems (Seastres et al. 2020). Even though having poor health, people experiencing homelessness can be further compromised because of difficulties accessing health services (McWilliams et al. 2022). These difficulties can be associated with a range of factors, including the transient nature of being homeless, that can also make it challenging for health services to follow up with people experiencing homelessness. Furthermore, it can be more difficult for unhoused people to manage their health and those with chronic health conditions find it difficult to adhere to treatment plans as they lack safe storage facilities for food and essential medications.

Literature shows heightened mortality rate in homeless individuals, that is particularly evident among younger age groups. Accidental causes or substance abuse often cause deaths in younger homeless people, while cardiovascular disease and cancer are more prevalent causes of mortality in older people experiencing homelessness (Seastres et al. 2020). It is estimated that approximately one-third of these deaths could potentially be prevented through timely healthcare interventions (Seastres et al. 2020). Limited research on mortality among homeless individuals in Australia highlights elevated suicide rates and increased mortality among those with schizophrenia, though these studies focus on specific subsets rather than offering a comprehensive analysis of mortality outcomes across the entire homeless population (Seastres et al. 2020).

Seastres et al. (2020) found that people attending emergency departments who had an episode of homelessness within a 2-year period had around twice the risk of mortality when compared to those who were housed. The risk was evident after accounting for variables such as age, ethnicity, etc. In addition, these authors found that people who were homeless died nearly 12 years earlier than housed people, and this disparity is also the case in the United States (Lee, Jagasia, and Wilson 2023). Findings by Seastres et al. (2020) found that: once-off placement in crisis accommodation, couch surfing, or rough sleeping confers an increased risk of mortality to an individual no matter if they were homeless or housed previously (Seastres et al. 2020).

Trauma and violence often result in chronic disease, addictions and other risky behaviours; it is important that clinicians are aware that fear of critical attitudes in services turns people away for fear of being judged because of their lifestyle, homelessness, addictions, gender identity, age, race and sexual orientation (Dowdell and Speck 2022). Trauma informed care, informed by Trauma Theory, is based on the ‘do no harm principle’ and acknowledges the need to understand a person's life experiences to provide any type of service delivery. It needs a compassionate approach that is devoid of blame; which is very important when working with homeless persons who may be experiencing fear, powerlessness and/or worthlessness depending on the trauma to which they have been exposed (Yatchmenoff, Sundborg, and Davis 2017). Hence the key principles of trauma informed care, safety (emotional as well as physical), trust, choice, collaboration, empowerment and respect for diversity (Menscher and Maul 2016), are appropriate for people experiencing homelessness. Importantly, the goal of trauma informed care needs to meet the unique needs of trauma survivors (Rosenberg 2011).

Trauma-informed approaches, when operationalised correctly, have the potential to lead to fundamental shifts in service delivery that better meets the needs of service providers and service users (Dawson et al. 2014; Sweeney and Taggart 2018). Importantly, trauma-informed approaches can assist service providers to engage more effectively with their clients and provide more appropriate care. Furthermore, it is essential to recognise that health services can unintentionally re-traumatise people, especially those previously impacted by histories of medical practices that propagate medical traumas (Grossman et al. 2021). Therefore, it is essential that we recognise the potential that trauma impacts all individuals and further, that trauma has the potential for ongoing health impact for some individuals; hence the need to recognise the potential for further trauma (Grossman et al. 2021).

A recent review of nurse-led services for people experiencing homelessness revealed the range of services and initiatives led by nurses to support people experiencing homelessness (McWilliams et al. 2022). Further, these authors found that nurse-led services enhanced access to services for people experiencing homelessness, and identified nursing had a broad scope of practice in relation to providing services to this population. They highlighted key attributes including the importance of establishing trusted relationships and using trauma-informed approaches in service delivery.

Mental health nurses are well placed to provide trauma informed care. The provision of services that are trauma-informed can help improve positive health outcomes for people who have experienced trauma. The most fundamental need of a traumatised person is the development of a secure relationship with a trusted person. Mental health nurses are well-placed to provide this care and are also well prepared for the delivery of collaborative and culturally appropriate care that promotes empowerment and choice.

People experiencing homelessness are often also live with stress from multiple sources, including adverse child experiences (ACE), or traumatic events occurring while unsheltered. Evidence indicates that people experiencing homelessness may also have multiple traumatic experiences such as racism, oppression and marginalisation (Wiewel and Hernandez 2021). Together, these experiences indicate the gap in quantitative outcomes research that directs practitioners to design programmes and therapeutic services. Future research needs to focus on measurement to improve knowledge about systems which assist clients with high levels of traumatic stress and histories of homelessness.

As mental health nurses, it is also important to critically reflect on current and routine health practices and consider if they support or further marginalise unhoused people. There is shame and stigma associated with being unhoused and so it may be that people will attempt to conceal their status as an unhoused person, meaning that they will not get access to supportive services they may need. Through practices such as assuming everyone has an address, and asking for this information in ways that make it difficult for a person to disclose their true situation, we may inadvertently contribute to the silencing and the invisibility of issues of homelessness in clinical practice.

The creation of safer environments, a critical component of trauma informed care, provides opportunities for unhoused people to access services and engage authentically with health professionals and with health systems. Mental health nurses can help facilitate safer environments by respecting the needs of the person and seeking to understand their experiences and offering advocacy when appropriate or requested (Dowdell and Speck 2022). Furthermore, it is important to allow people the space and opportunity to disclose their situation as an unhoused person, and that we create spaces for that to occur.

Homelessness is a serious contemporary social issue; it causes major health and social inequities as well as contributing to long-standing risks such as intergenerational trauma. In the current context, with increasing homelessness, particularly among people with complex mental health issues, it is crucial that mental health nurses respond effectively to support unhoused people and the issue of homelessness in general. There is a need to respond at the individual level, the community level and at the political level to advocate for affordable housing, particularly for vulnerable populations such as people leaving situations of family violence and people with complex mental health issues. It is only through clinical practice change and political advocacy that we can minimise intergenerational trauma and look ahead to a future where unhoused people can easily access the health and social care they need, and that we can contemplate a future in which all people have a safe and secure home.

Professor Kim Usher is the EIC of the IJMHN, and Professor Debra Jackson is a member of the Editorial Board. Neither had any involvement in the review of this paper.