Homelessness, Addiction and Childhood Trauma: a change in perspective.
Over the last 2 years, I have been involved in running medical clinics for service users at Helping Hands Community Project in Leamington Spa. As a local General Practitioner (GP), getting the opportunity to better engage with some of the area’s most vulnerable patients has been a privilege. The twice-monthly clinics aim to improve access to healthcare services for a population that is often overlooked and stigmatized. My team works with a wide range of patients including people experiencing homelessness, sex workers, victims of domestic violence or human trafficking and many suffering current or past addictions and substance misuse.
People experiencing homelessness have a life expectancy that is over 30 years lower than the general population. They have higher rates of physical and mental health issues and the main barrier to accessing healthcare is simply that they have no fixed abode. Unfortunately, most of these early deaths come from suicide, drug overdose or alcohol-related deaths (1).
When examining the causes of these deaths it would be easy to take a viewpoint that they are all things people “do to themselves”. If homeless people want to get their lives back on track and get off the street, perhaps they should stop drinking or taking drugs? Better still go get a job and re-engage with society in a meaningful way, that may even improve their mental health. I’m afraid before arriving at this conclusion we need to understand the root cause behind these deaths.
For a large majority this lies in a background of adverse childhood experiences (ACE’s) and addiction. ACEs refer to specific exposures that a child has in the first 17 years of life including physical, sexual or emotional abuse. It also encompasses living in a household where family members experience domestic violence, severe mental illness, incarceration or substance misuse. Many studies use an ACE score out of 10 to quantify exposure in patient groups. Only about 4% of the general population have been exposed to four or more ACEs. In people experiencing homelessness, this figure is over 50% (2). In our Leamington clinic, the average score is 6 out of 10 and 52% of our patients had a score of 8,9 or 10. Understanding this background of trauma is key to understanding the road to addiction.
Many addicts I speak to have a background of horrific childhood trauma that led to adversity and further challenges in adulthood. Most patients I work with began using substances to escape either current or past trauma. I recall a young man who turned to drugs to manage his mental health after his sister was sexually assaulted whilst they were both in foster care; he also experienced physical and emotional abuse. He felt personally responsible but was in no way to blame. The day-to-day anger, frustration, guilt and responsibility he felt that he couldn’t prevent this assault was so overwhelming that the dissociative experience of taking drugs was an escape from his now severe PTSD, depression and anxiety. Another patient I met turned to drugs after years of domestic violence and sexual abuse. She felt trapped in the relationship (as many victims of domestic violence do) and worried about what would happen to their child if she left. She began using heroin, which her partner was addicted to, to get a brief reprieve from her terrible day-to-day reality. This pattern of escaping trauma through substance misuse is a common thread seen in many addicts.
The problem with any addictive substance is that once you have started, it’s incredibly difficult to stop. The damage from addiction often then comes from the surrounding circumstances of financial difficulty, isolation, loss of employment and family breakdown. The probability of becoming homeless from addiction is largely related to your level of financial resilience or family support. If you don’t have this, you quickly struggle to support yourself and it’s downwards from there. It’s worth noting the vested interest of organized crime groups involved in drug distribution to target vulnerable people, encourage addiction and keep them addicted for as long as possible. Both aforementioned patients ended up homeless due to addiction. The young man died of an overdose in his twenties and the woman lost guardianship of her child.
It is therefore very likely that the homeless person you pass on the street has a history of severe childhood trauma that in many ways shaped the rest of their life before they were even old enough to buy the substances they now abuse. It’s also worth noting that simply taking a homeless person off the street and into temporary accommodation doesn’t fix decades of trauma. Housing is an important, yet still small part of the whole picture of rehabilitation, alongside drug and alcohol support and mental health input. As a society we need to change the way we stigmatize this group and change the focus from “what they are doing to themselves” to “what have others done to them”. This provides room for empathy and understanding instead of pity or judgement. In this context it seems even more perverse that the victimized children of previous decades grow up to be ignored, discriminated against and sidelined by the public as well as by healthcare systems.
But the good news is that we can try to push for change. Supporting local homelessness charities or organizations associated with mental health and addiction can help improve local services. I would also hope that by understanding more about this group of people, we can change our own perspective to look at more supportive and solution-focused approach to the wider issue of homelessness, addiction and adverse childhood experiences.
Dr David Maud
MRCGP MBChB BSc (hons)
General Practitioner – Clarendon Lodge Medical Practice
Clinical Outreach Lead – Leamington Primary Care Network
