Psychologically Informed Care in Homeless Hostels

My name is Jake Camp and I’m a Trainee Clinical Psychologist working within the South London and Maudsley NHS Foundation Trust, Psychology in Hostels Project (Westminster). The service is an innovative project that delivers psychologically informed care within homeless hostels across different London boroughs. In Westminster, we are a small team: ­ one Highly Specialist Clinical Psychologist, one Trainee Clinical Psychologist, and one Honorary Assistant Psychologist. I’m going to provide an insight into my time with the project and the degree of complex psychological difficulties within the homeless population.

Nine in the morning, I enter the homeless hostel to find a resident heavily intoxicated after another night trying to block out the horrendous experiences of their past. The resident, desperate to feel cared for and supported, is trying to communicate their needs to the support staff in the only way they know how – by shouting and screaming. Before I finish my morning coffee, I’m already supporting the resident to cope with their intense feelings of fear and shame, and helping them get their needs met in a more optimal way.

This is not an uncommon experience within homeless hostels; people who are homeless have over-represented histories of neglect, abuse, and traumatic life events. It is therefore unsurprising that up to 70% of homeless people experience significant mental health difficulties accompanied by high levels of substance misuse, self-harm, and suicidality. Up to 75% also have forensic histories and 70% would meet diagnostic criteria for a “personality disorder”[1]. Sadly, homeless people have a life expectancy of only 47 years[2], compared to 79-83 years for the wider UK population[3].

The complex needs and difficulties experienced within the homeless population feel largely unmet by mainstream health and social care providers. The degree of complex trauma, substance use, and difficulties with trust and relationships with caregivers – as well as severe material deprivation and under-privilege – make it very difficult for homeless people to access mainstream support. Many individuals I have worked with report experiencing mainstream services as rejecting and lacking empathy for their experiences. This leaves needs unmet and adds to experiences of social injustice and exclusion.

The Psychology in Hostels Project aims to identify and meet these needs by supporting the development of psychologically informed environments within homeless hostels. The psychology team is embedded within hostels to offer trauma-informed support based on an attachment-based model (Mentalization Based Therapy). This is done by providing flexible and multifaceted support to hostel residents and hostel staff.

Some residents engage in formal therapeutic work – but many can barely tolerate a quick chat in a corridor and thus are supported through more informal activities, such as cooking, heading out for a walk, or going for a coffee. Some of the most useful and rewarding sessions I have had with residents have been while supporting them to learn how to cook their favourite meal or taking them to play their favourite sport. This allows residents to slowly build a more positive relationship with care providers and feel more comfortable to talk about their difficulties. Many eventually work towards sitting in a room with a psychologist to discover coping skills and reprocess their traumatic past experiences.

Residents are not expected to do this alone; hostel staff members are offered training, support, and consultation in how to work with residents’ complex needs. They are supported to build a trauma-informed understanding of the residents’ difficulties, deliver planned support, and manage risk. Further work is completed with external health and social care providers to facilitate access to mainstream services. Hostel staff can have a very difficult time providing the support required for complex needs in a high pace and pressured environment; as such, it has been a pleasure to see them benefit from feeling more equipped and supported to care for the residents and for themselves.

It has been a real privilege to provide residents with a different experience of care and see the difference that can be made by using a flexible approach to delivering psychological interventions. Hostel residents and staff have frequently reported really valuing the empathetic understanding and compassionate approach that the psychology team brings. It is unsurprising therefore that the psychology in hostels project has high levels of attendance to sessions by residents (78%; noteworthy for populations with complex needs) and results in meaningful improvements to their mental health and well-being, as well as a significant reduction in A&E attendance (58%), prison stays and criminal justice contact (87%), and rough sleeping (82%)[4].

On a more personal level, I have experienced residents begin to make sense of their complex histories and current difficulties, build their strength and skills to cope, and start to rebuild their life. This is a testament to the value of this approach and its ability to enhance engagement and interventions for the complex level of difficulties experienced by many of the homeless population.

Jake Camp

Trainee Clinical Psychologist

[1] MH Network NHS Confederation (2012). Mental health and homelessness: planning and delivering mental health services for homeless people.

[2] Crisis (2011). Homelessness Silent Killer.

[3] Office of National Statistics (2018). National life tables, UK: 2015 to 2017.

[4] Psychology in Hostels Lambeth, Evaluation (2015-2018).

Photo by Jeremy Yap on Unsplash.