Carolin Hess is a PhD student in the NIHR Policy Research Unit in Health and Social Care Workforce who has been awarded Doctoral funding from the NIHR School for Social Care Research, commencing February 2023. (896 words)
In the latest webinar in the HSCWRU Homelessness series, 225 participants joined Ellie Atkins, a senior social worker and Safeguarding lead, for a presentation which asked, What does research and expert practice tell us about the importance of executive functioning assessments? The topic builds on themes from last month’s webinar, exploring mechanisms of agency and choice, and how self-neglect among homeless populations can be addressed by strengthening safeguarding responses.
The presentation opened with the question of why the Everyone In Initiative, a £3.2 million emergency fund set up during the COVID-19 pandemic to house people in the UK who were rough sleeping, did not end rough sleeping for all individuals. The scheme was widely hailed as a success, with organisations praising the unprecedented effort and rapid response to homelessness through increased partnership working and communication, which supported over 30,000 people into accessing accommodation.
Despite these successes, not everyone was accommodated or felt comfortable to be housed. The presentation explored the reasons for this and what services and policymakers can do differently. Using the case study of ‘Beryl’, a woman who experienced homelessness and complex needs, Ellie investigated why ‘her behaviour was making it difficult to house her’ and what it might tell us about the relevance of executive functioning assessments to work with people who experience homelessness and complex needs due to their ‘hidden disabilities and differences’.
‘Executive functions’ are ‘higher-order cognitive processes’ (see Figure 1). There is growing evidence that they can be indicative of someone’s trajectory in and out of homelessness. Learning disabilities, traumatic brain injuries, neurodivergence, mental ill health and intense stress – factors likely to affect a higher percentage of the homeless population – can cause executive dysfunction. Executive dysfunction often manifests as difficult or ‘non-compliant’ behaviour and therefore impacts someone’s access to housing and other support. In Beryl’s case, a combination of trauma-induced PTSD, ADHD and a brain injury, may have compromised her executive functioning to communicate, perform self-care and organise herself, and resulted in a lack of capacity to engage with services and maintain accommodation. However, due to her history of self-medicating with alcohol, these dysfunctions became ‘hard to spot’, and services failed to engage successfully with her.
Figure 1 – click on image to see enlarged version
While diagnoses can increase the risk of discrimination and stigmatisation, for Beryl the diagnosis of PTSD and ADHD helped her to understand her own behaviour, and triggered an assessment under the Mental Capacity Act 2005. This provided a framework for practitioners to work more effectively, supporting Beryl without undermining her rights, which resulted in her being eventually housed in supported accommodation.
Ellie Atkins emphasised the importance of considering executive functioning as part of mental capacity assessments, and how legal avenues such as the Mental Capacity Act 2005 and Care Act 2014 can provide an opportunity to ‘open the door to people’ and trigger more holistic support.
The subsequent discussion included voices from health, social care, probation, and homelessness services, sharing insights on how services can provide appropriate support when considering ‘hidden disabilities’. It was mentioned that practitioners were often unsure of how to use legal frameworks, so discussants shared links to a guide that helps practitioners to apply legal frameworks to highly vulnerable and dependent drinkers to improve their wellbeing and safety; and an organisation that can help people in or leaving care to navigate the legal aspects.
Discussants also gave accounts of how multi-agency working, bringing different professional perspectives and services together to work collaboratively to build trust and engagement, has proven effective to overcome barriers in support. While examples of this were shared, discussants also mentioned cases where constraints of service providers and legal barriers, such as No Recourse to Public Funds, have led to neglected care needs. Despite neurodivergence being overrepresented in the homeless population, a lack of access to neurodiverse diagnostic services and long waiting lists, often meant that disabilities remained hidden. As one discussant mentioned: “There are just so many Beryls out there who are tragically misunderstood and left at risk and unsafe and in pain.”
The webinar challenged us not to see homelessness and complex needs as the result of ‘intentional’ individual decisions, and to prioritise humane interventions which support an individual’s wellbeing, as opposed to an ‘illusion of autonomy’. We need to move away from the idea that homelessness is random or a life style choice. Poverty, adverse childhood experiences, and lack of social networks are some of the greatest predictors of homelessness. Many people who have experience of homelessness and complex needs experienced brain injuries before becoming homelessness. Mental capacity assessments should therefore consider the impact of someone’s childhood experiences, trauma, and executive capacity.
Schemes such as Everyone In can offer significant access to housing stability while they last, but policymakers and practitioners trying to end homelessness will have to consider the option that people in vulnerable situations may have reduced capacity to act autonomously in their decision (not) to engage. Practitioners and services will need to listen carefully to why people may not want to – or cannot – engage, and support people in their decisions about care and treatment without closing doors behind them.
Ellie has also posted a short YouTube film of her presentation.
Mental Capacity Act approaches to multiple exclusion homelessness and the ways in which the default assumption of capacity can currently hinder assessments and inquiry, are being explored in an NIHR School for Social Care Research (SSCR) funded HSCWRU project, led by Stephen Martineau.
Carolin Hess is a PhD student at the NIHR Policy Research Unit in Health and Social Care Workforce, King’s College London.