Housing Insecurity, Mental Health and the Role of Clinical Psychology in the UK.
“The ache for home lives in all of us. The safe place where we can go as we are and not be questioned” (Angelou, 1987)
Adequate and secure housing has long been considered integral to people’s mental health and wellbeing. Thomas Hobbes the English political philosopher in his treatise Leviathan (1651), suggested the fundamental duty of the state is to protect its citizens, including the right to public welfare. The Universal Declaration of Human rights (United Nations General Assembly, 1948) Article 25 states, “Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.” However, though adequate housing is recognised as one of the most basic of human rights and needs, the UK is a profoundly unequal society (Marmot et al., 2010, 2020) and housing insecurity is a significant and growing problem (Hohmann, 2015; Just Fair UK, 2017) with detrimental effects on people’s physiological, psychological and relational wellbeing. (The Children’s Society, 2020).
Defining Housing Insecurity
Housing insecurity is a multidimensional, complex concept, that has been defined in a number of different ways. Currently there is no overarching framework or unified standardised measure, rather it seems to be understood as a set of discrete yet overlapping domains. Hulse & Saugeres (2008) identified the dimensions of housing insecurity as a lack of belonging, feeling unsafe, lack of privacy, housing mobility, instability and lack of physical comfort; whereas Leopold et al., (2016) Identified the dimensions as housing quality, housing cost burden, homelessness, residential instability, and neighbourhood quality and overcrowding. In their paper, “a road map to a unified measure of housing insecurity’ (Cox et al., 2019) gave this definition of housing insecurity:
‘limited or uncertain access to stable, safe, adequate, and affordable housing and neighbourhoods; or the inability to acquire stable, safe, adequate, and affordable housing and neighbourhoods in socially acceptable ways’.
What seems common to all these definitions is the concept of housing security having within it multiple psychological, social, financial and environmental stressors.
Using evidence from psychological research and housing literature, I argue that Clinical Psychology as a profession should be involved in a wide range of activities in regards to mental health, wellbeing and housing insecurity. Moving beyond the more traditional individualistic therapeutic work in clinical settings, the profession should be engaged at many levels in a both ‘top down and bottom up way’, within and without the NHS. Clinical Psychologists should be working in partnership with communities and stakeholders in various political, governmental, social, environmental, statutory and third sector spheres related to housing insecurity; along with participating in wider systemic interventions and contributing to the public discourse at local, regional, and national levels.
United Kingdom (UK) Housing Context
Robertson’s (2010) paper, ‘The Great British Housing Crisis’, lays out the roots of the current housing difficulties in the UK. After the second world war the UK embarked on an ambitious programme of building social housing. However, since the 1980’s and the shift to a neoliberal free market economy, there has been a dearth of housing stock, and huge rise in housing insecurity. This has been driven by policies such as right to buy, gentrification, and the introduction of austerity measures leading to welfare reforms such as the Localism Act (2011), along with the Local Housing Allowance which introduced housing benefit caps, as well as the bedroom tax (Morris et al., 2015). All of which have affected people’s ability to access affordable, secure and suitable housing. The term ‘housing insecure’ encompasses those who are rough sleeping and statutory homeless, those in temporary accommodation, the hidden homeless (people who are ‘sofa surfing’), those in overcrowded accommodation, people with insecure tenancies, high rents and high housing costs, and those with poor quality and unhealthy housing in deprived areas (Cox et al., 2019; Leifheit et al., 2020; Preece & Bimpson, 2019; Routhier, 2019).
Housing Insecurity, Mental Health and Wellbeing
The World Health Organisation defines mental health as “a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her community” (Galderisi et al., 2015). As this definition suggests, mental health is not merely the absence of mental illness, but also a state of wellbeing. Ryff & Singer, (1996) suggested a theoretical model of wellbeing with six dimensions, autonomy, environmental mastery, personal growth, positive relations with others, purpose in life and self-acceptance. If we consider these dimensions, it is easy to see how each of them could be negatively affected by the experience of housing insecurity.
Housing is viewed as a social determinant of health, influencing psychological wellbeing and resilience (Bates et al., 2019). The Rainbow Model (Dahlgren & Whitehead, 1991) is widely used to understand the effects of social determinants on health. This model of health inequality maps the relationships between individuals, health and the environment (including housing), with health problems linked socio economic status. It suggests that the risk of getting ill, access to treatment and the ability to prevent illness can be determined by social, economic and environmental factors. Given the previously stated dimensions of housing insecurity, it is clear to see how this might negatively impact people’s mental health and well-being, and their ability to recover from any difficulties and maintain good mental health (Mental Health Network, 2011).
There are issues around power, privilege and oppression in relation to housing insecurity and mental health, alongside ideas around social norms and who gets to control both the discourse and to frame the narrative around these problems (Jacobs et al., 2003). Evidence shows the link between an individual’s distress and social oppression (Timander et al., 2017), and housing insecurity disproportionality affects the most socially excluded and disempowered in our society (Mathieson et al., 2008). It is inherently linked to poverty and inequality and often experienced by vulnerable people at the margins of society. These people tend to be less visible to the public, and therefore not part of the general discourse or included in decision making processes to do with housing (Solomon et al., 2019; Trochmann, 2019).
Housing insecurity is negatively related to social norms in UK society, specifically the idea of home ownership as a desirable norm - much attention has been devoted to examining the benefits of home-ownership (Foye et al., 2018). Norms in society are socially constructed, and controlled by dominant discourses and narratives built over generations, existing in a historical and cultural context (Hetcher & Opp, 2001). In a white western patriarchal society such as the UK’s, not being able to adhere to ‘norms’ such as house ownership can be related to aspects of difference and diversity, including class, race, gender, geography, ability, sexuality, ethnicity (to name a few), and this can lead to social exclusion (Burnham, 2018; Gordon et al., 2000). Social exclusion makes achieving housing security more difficult, affecting peoples sense of self and agency (Mathieson et al., 2008), along with reinforcing wider society’s negative attitudes towards those experiencing it. The level of inequality people experience directly impacts on their mental health and wellbeing and in inequalities in access, experience and outcomes with services (NHS England, 2020). These inequalities can be interrelated, acting on individuals and communities lived experiences, housing and material environments and mental health in an intersectional way (Crenshaw, 2017). This in turn can lead to greater discrimination, pervasive ideas around ‘deservedness’ and the social construction of ‘otherness’ (Trochmann, 2019); furthering inequality, perpetuating housing insecurity and other structural and systemic inequalities, both causing and increasing mental distress (Solomon et al., 2019; Trochmann, 2019).
Children are particularly affected by housing insecurity (Harker, 2006; The Children’s Society, 2020b), with children in the poorest households being four times more likely to develop psychological problems than those in the richest (Hatem et al., 2020). Housing insecurity can have lifelong consequences for children’s mental health and wellbeing (Murphy & Fonagy, 2012). Carers, the disabled, those with comorbid long-term conditions, poorer families and single parents, migrants and refugees, women, the homeless, and BAME communities all suffer higher rates of housing insecurity and related mental health difficulties (Carers UK, 2020; Clair, 2019; Croft et al., 2020; Hardy & Gillespie, 2016; Jankowski et al., 2020; Meadows-Oliver, 2009). With housing insecurity not only affecting people materially through overcrowding, poor property conditions, and affordability; but also affecting their identity, sense of belonging, self-esteem, connectedness and both their physical and psychological sense of safety along with their ability to thrive (Mcgrath et al., 2015; Preece & Bimpson, 2019).
The depth of this ongoing inequity and its relationship to mental health have been thrown into stark relief by the COVID-19 pandemic, exacerbating problems already present and creating new problems for those least equipped to deal with them. The UK’s housing crisis has been highlighted, accentuating inequalities in relation to housing. Lockdowns have been especially difficult for the homeless and those with young children living in overcrowded homes with no outdoor spaces (Atkinson R & Jacobs K, 2020; Hinsliff, 2020). There have been increasing evictions and increasing fear of eviction for private renters due to the economic downturn and job insecurity, along with increased homelessness; with the homeless left with inadequate access to support (Atkinson & Jacobs, 2020). This shows the importance of clinical psychology as a profession considering the social determinants of health not only at an individual clinical level, but also using a whole systems approach.
The Role of Clinical Psychology
The work of clinical psychologists is concerned with mental health and wellbeing. Clinical psychologists have been described as ‘reflective scientist practitioners’, they work with people to try and increase wellbeing and reduce distress (Randall, 2020), along with working towards a psychologically healthier society (Psychologists for Social change, 2018; The NHS Long Term Plan, 2019).
Clinical Psychologists work in a broad range of settings, including the NHS, social care, the third sector and in education. Any organisation in these fields will deal with a proportion of clients impacted either directly or indirectly by the social determinants of health, structural inequalities and concomitant issues arising from housing insecurity. Clinical psychologists work with individuals of any age, with couples, families, groups and organisations both private and public, as well as at a community level; they are also engaged in research and its dissemination, and work in academic settings. This gives researchers the opportunity to add to the evidence base around the psychological effects of housing insecurity and to introduce ideas around its importance with regards to wellbeing in both the academic and public spheres.
Clinical psychology as a profession is underpinned by four key ethical values, respect, competence, responsibility and integrity, and five core skills, assessment, formulation, intervention, evaluation and communication (BPS Practice Guidelines (Third Edition), 2017). In accordance with the Equality Act (Equality Act, 2010), BPS practice guidelines also state that psychologists should, ‘seek to encourage and influence others in ensuring that equality of opportunity is embedded in all thinking and all practice relating to access to services’, and that, ‘Psychologists have a duty of care to both their clients and the public’. One of the four ethical principles of the BPS Division of Clinical Psychology is, ‘professional and scientific responsibilities to society’. Whilst the BPS Clinical Psychology Leadership Development Framework (Division of Clinical Psychology, 2007), explicitly states that experienced clinical psychologists have the skills and attributes to influence professional practice at national policy level and implement psychological ideas and thinking politically, with commissioners and at health economy wide levels.
The NHS long term plan (The NHS Long Term Plan, 2019) and the Five Year Forward View for Mental Health (Mental Health Taskforce, 2016), emphasise the need for development of multidisciplinary, integrated community and primary care services. With service’s delivered in a place based way, based on population needs, it is suggested there should be further emphasis on upstream prevention and reducing health inequalities, with a view to supporting people to live well in their communities. In order for people to live well in their communities, adequate housing is fundamental. As housing is viewed as a social determinant of health influencing psychological wellbeing and resilience, it follows that clinical psychologists should be involved not just at treatment level, but also in wider population health and preventative initiatives to reduce health inequalities resulting from housing insecurity.
A caveat to this however is that practitioners are instructed to work within the limits and scope of their knowledge and skills, as laid out in the standards of conduct, performance and ethics guidelines by the Health Care and Professions Council (Health Care and Professions Council, 2016). Further to this, given that many clinical psychology services are currently stretched, with many practitioners with already overly large caseloads and long waiting lists, it is debatable as to whether it is possible for clinical psychology as a profession to currently fulfil this broad remit. However, this has been recently recognised by the government and is reflected in the increased funding that has been made available for Clinical Psychology training.
Traditionally, the focus of the work of clinical psychologists has been confined to clinical populations, and is more likely to take place in a service or clinic. Practitioners are more likely to work with individuals, working on symptomatic change, using individually focused therapies which are time limited and short term. Framed within a disease and deficit model, this westernised individualist understanding of the problem being within the person, rather than as a product of society can be very shaming for individuals. The standard classification of psychological disorders and their various diagnostic criteria come from the Diagnostic and Statistical manual of Mental Health Disorders (DSM-5), (American Psychiatric Association, 2013) and the International Classification of Diseases and Related Health Problems (ICD-10) (World Health Organisation, 2014); with pathways, interventions and measurements prescribed by clinical guidelines from the National Institute for health and Care Excellence (Common Mental Health Problems: Identification and Pathways to Care, 2011). This top down approach to the understanding and treatment of mental health difficulties can at times be culturally insensitive, and not reflective of the needs of the populations psychologists are based in. The over medicalisation of distress is reductionist and unhelpful in terms of outcomes, being a bar to a more holistic understanding of difficulties. Furthermore the ‘label’ of a diagnosis can take on a ‘master status’ (Deegan, 2001), engendering not only self-stigma and disempowerment in the individual, but also stigma and discrimination from others, due to negative cultural and behavioural stereotypes around mental health diagnoses. This in turn can lead to difficulties in the treatment of people with mental health difficulties by housing organisations and inhibit individuals access to help, so further increasing levels of housing insecurity (Ali, 2020; Carey, 2019).
In his BPS article ‘Beyond Individual Therapy’ (Harper, 2016), questioned how ethical it is for clinical psychologists to focus solely on traditional individualistic therapeutic work, without also working preventatively at the level of community and society. He suggested advocating for the recognition of distress caused by policy and structural and systemic norms. He believes psychologists should be working with, ‘the causes of the causes’, of mental health problems, in order to address those problems before they become chronic. With this in mind, it is clear that psychologists could also engage with housing insecurity strategies and with policymakers directly though consultation and indirectly through contributions to the public discourse and debate, through all types of media and the wider dissemination of research.
More recently in the profession, there has been a move away from asking people, ‘what is wrong with you’, towards asking the question, ‘what has happened to you’, (Johnstone et al., 2018). In light of the difficulties caused by housing insecurity, this is a very important question for clinical psychologists to be asking. The biopsychosocial model of mental health (Engel, 1977), explains that a person’s biology is in constant interrelationship not only with other people, but also their environment. This model indicates that mental health processes arise from these interactions, and that the environment (in this case housing), can play a causal role in Mental health difficulties (Johnstone & Dallos, 2013).
However in practice, considerations of ‘the social’ aspects of the biopsychosocial model, like those arising from housing insecurity have often been ignored, or given less weight. Considering mental distress in its wider context allows for clinicians to generate richer and more holistic formulations of difficulties at an individual, community and societal level. This in turn provides opportunities for them to engage in interventions in a range of different contexts in new and novel ways, outside of the ‘traditional clinical psychologist’ role. This can be done both directly and indirectly (Hardy & Gillespie, 2016); by integrating critical and community psychology principles (Kagan et al., 2019; Mareck & Hare-Mustin, 2009), in tandem with the NHS Long Term Plan and Five year Forward View, psychologists should be considering social, cultural and political factors in relation to housing difficulties and distress. We should be placing the difficulties in the public realm and challenging and engaging the wider systems and structures that impact on wellbeing.
Our Eurocentric individualist culture, which is reflected in traditional working practices, often places ‘blame’ on individuals for what are not individual failings. When we focus on the individual, it can make wider systems invisible, and power imbalances are maintained. There are a whole set of structural and policy choices that advantage certain people over others, shaping availability to decent housing. Notably in the UK over the past 10yrs, there has been systematic disinvestment in poorer more marginalised areas and communities (Aston, 2019; Michael Marmot et al., 2020)
Again, integrating ideas from community and critical psychology (Kagan et al., 2019; Mareck & Hare-Mustin, 2009), clinical psychologists should be working with ideas of social justice, oppression and marginalisation when considering their role. Clinical psychology as a profession has power in terms of the respect and status afforded to it as a health care profession. As psychologists we have the ability to mobilise people, as scientist practitioners we have the ability to generate new epistemologies based on new evidence and develop novel interventions. Given the respect offered to us because of our professional status, we also have the ability to change social attitudes and norms about what is acceptable. Clinical psychologists should be highlighting issues of power and epistemic injustice at individual, group and systemic levels. As a profession we should be facilitating and empowering people, fostering a sense of belonging and inclusion. By inviting people into conversations and decision-making processes we can change and challenge what is possible. This can be done in many ways, including by promoting collective and community activism, through service user led research, participatory action research and coproduction with all stakeholders to make sure that we are designing and delivering services, policies and strategies based on what matters and is useful and meaningful to the people we serve (Kagan et al., 2019).
Clinical psychologists have a unique set of skills and already work in many different settings and contexts, with many different populations, so are well placed to engage in wider work outside of the clinical environment. I am aware that this is a big ask, and a challenge to the traditionally ‘objective, positivist, neutral’ position clinical psychologists have taken in regards to their practice (Fox, D et al., 2009). However, the directives from BPS code of practice along with the NHS long term plan’s emphasis on population health, suggest that as a profession we should be working beyond clinical settings; it is time we stepped into different arenas to help introduce psychological thinking, theory, evidence and practice into the wider discourse and systems. Arguably, we have an ethical duty to promote greater understanding of peoples difficulties, including those arising from housing insecurity, at all levels in upstream preventative ways, as well as continuing with treatment as usual, in order to better serve both the public at large and the people and populations we work with.
