A home of your own

A home of your own

Article Type: Editorial From: Mental Health and Social Inclusion, Volume 20, Issue 3.

Our homes are far more than a roof over our heads. Home is the place where we:

[…] are nurtured, comforted and loved […] where we can dream and hope, relax and be ourselves, laugh and cry […] a safe and welcoming place […] Home transcends the domestic, physical structure encompassing cultural, symbolic and psychological significance […] extending to the neighbourhood, city, region and nation. Home is a place of personal identity and worth where the individual can exercise a degree of power and autonomy denied elsewhere […] Significant life events […] occur at home. These are the bases for our memories of home and its importance to us [giving us] a sense of permanence and continuity over time […] Home represents the interface between public and private worlds; a place where cultural and societal norms are symbolically juxtaposed with expressions of individuality (Thompson, 2007).

The detrimental impact of losing your home on mental health is well established (Mental Health Foundation, 2015) yet too many people living with significant mental health challenges have lost their home. In 2015, 32 per cent of single homeless people reported a mental health problem with depression rates over ten times higher than the general population (Mental Health Foundation, 2015). Mental health problems can be both cause and consequence of homelessness (Shaw, 2004; Koegel and Burnam, 1992) and homelessness further exacerbates the discrimination and exclusion associated with mental health challenges, erodes self-confidence and decreases the control that you have over your life. For most people with mental health challenges having a home is central to recovering a sense of self, meaning and purpose in life.

There are many people who have never had a "home" in the full sense of the word. It is not uncommon for people with significant mental health problems to have experienced home that is riven with trauma, conflict and broken relationships, to have been moved around in the care system, to have lacked the secure base necessary to grow and explore the world. This makes enabling people with mental health challenges to establish a home for themselves even more important, yet support and service systems fail to recognise the full meaning of "home" and thereby perpetuate homelessness and rootlessness.

Home is a multi-dimensional concept having at least six facets (Somerville, 1992).

Home as "abode" is anywhere a person happens to stay: "the place where you lay your head"

This could be anything from a park bench to a palace, or for those with significant mental health challenges it might be a hospital ward. An abode is rarely permanent, simply where you happen to be.

Home as "shelter" is about the physical structure: "a roof over your head"

Providing people with a roof over their heads is typically a major focus of mental health services, and most people with significant mental health challenges do have shelter, but shelter does not equal a home.

Home as "hearth" is about warmth and comfort: "a welcoming and homely atmosphere"

There are many people living with mental health problems whose accommodation could not be described as either "welcoming" or "homely". This may be a consequence of lack of resources and/or support, living in temporary accommodation or a run-down area, or living in a shared "institutional" setting such as a hostel. Even if efforts are made to ensure that staffed/sheltered accommodation is "homely" such "homeliness" is not always personalised to the individual.

Home as "roots" is about identity, meaningfulness and "ontological security": who you are in the world

Typically, in collective sheltered or staffed living situations it is staff, or collective community decisions that determine what is and is not "homely". Individual roots and meaning are lost in a kind of "corporate homeliness" that is not grounded in a wider web of personal and cultural meaning. Often individuals have lost many of the personal possessions that we all use to make our space a reflection of ourselves: photos; keep sakes of sentimental value; pictures, ornaments and books that reflect our history, personal, familial and cultural identity. These are not only important in fostering a sense of self identity, they are also central in communicating to others who we are and where we have come from.

Home as "heart" is about physical and emotional security: a happy and stable home based on supportive and affectionate relationships

Too often, people living in specialised/sheltered housing share their accommodation with people who are not of their choosing: people are clustered together not because of bonds of friendship or shared interests but because of their identity as "mental patients". Sharing your living space with people not of your choosing generates friction and conflict (as anyone who has lived in a student hall of residence will know), however, where people are struggling with a range of emotional distress, and have no other home to go to, these problems can be exacerbated. Often people are excluded from sheltered/supported living situations because relationship problems occur and they are deemed to be "disruptive" to the others in their accommodation.

Home as "privacy" refers to the power to control your boundaries: "[...] the power to exclude other persons from that territory and to prohibit surveillance of that territory by other persons" (Somerville, 1992)

For many people with significant mental health problems, access to housing is determined by the health and social care staff. They determine whether someone is "suitable" for independent living or whether they require specialist sheltered or supported accommodation (at least initially, if not indefinitely). Those deemed "suitable" for independent living have to prove they have the "daily living skills" and "ability to budget" necessary to manage a tenancy. If they are found lacking then some form of sheltered, supported or staffed accommodation is often their lot. Such accommodation does not offer them power and control over their home. The rules of the house are set by others (e.g. you must be in by 10 p.m., you must clean your room on a Wednesday, you must attend the "community meeting", you must not have people in your room – especially overnight, you cannot smoke, even in your own space […]). It is often impossible, or made very difficult, to invite friends round for coffee, sleep with your partner, or have any say about who else lives there. In such accommodation, tenure is typically determined by the staff providing support: if you break the rules you might be kicked out. There are of course some people who are deemed unsuitable for the hostels and specialist, sheltered accommodation available – often because their behaviour is deemed "inappropriate" in a communal setting.

It is this power and control to determine what you do in the privacy of your own home that most specialist, staffed/supported accommodation for people with mental health challenges denies those who live there, yet it is the thing that people say they want most. We know that control and self-determination are central to recovery (Repper and Perkins, 2003, 2012; O’Hagan, 2014) yet, too often, the housing we provide denies this.

Ogden (2014) interviewed eight older people (over 55) with a diagnosis of schizophrenia all of whom had at some time been homeless and were currently living in sheltered/supported accommodation for people with mental health problems. While all were grateful to have a roof over their heads, and saw themselves as having made significant progress in moving off the streets, one consistent theme was their sense of "waiting to go home". Although most lived in what might be described as "homely" settings, they continued to dream of having a "home" and often this meant having control over their own space. For example, one woman described how she was not allowed to smoke in her sheltered apartment. When she continued to do so, she was not permitted to bring cigarettes into the building and was told she would lose her accommodation if she smoked. Similarly she was expected, as a condition of her residence, to attend a day programme: when she failed to attend because she "found it too depressing" she was pressured to return. Although she had a "homely" apartment she still did not have a "home" as she was still answerable to institutional rules. Another male resident spoke of how the location of his sheltered accommodation took him away from the comforts and security of his former neighbourhood: his "roots" where he felt a sense of belonging. While he was "housed" he had not, therefore made the place his "home (few personal possessions, furniture provided by the institution, felt no pride in his surroundings): he too was ‘waiting to go home’".

At present, in the mental health world, there is increasing concern about the lack of "appropriate housing" for people with mental health challenges, yet such attention typically focuses on the need for "specialist housing" (e.g. van Doorn and O’Dwyer, 2016; Mental Health Provider Forum, 2016).

In the broader disability arena people with significant mobility and sensory impairments have long fought for a "home of their own". In 1979, a group of people living in Le Court Residential Cheshire Home in Hampshire formed Project 81 to campaign against the institutional living that had been forced upon them. They asserted the principles of "Independent Living" by which they meant control about the decisions about their lives, having responsibility for what was happening to them and having choices. They were successful in persuading their local authority to provide them with the money they needed to employ "personal assistants" to provide the support they required in their own homes (Evans, 2003). It is important to emphasise that "independent living" in this context did not mean "living without support" but having access to the support they needed, and having control over the support they received, in order to have a home of their own. The Disability Rights Commission (2002) have defined "independent living" as referring to:

[…] all disabled people having the same choice, control and freedom as any other citizen – at home, at work, and as members of the community. This does not necessarily mean disabled people "doing everything for themselves" but it does mean that any practical assistance people need should be based on their own choices and aspirations.

The success of these, and similar, initiatives within the disabled people’s movement means that, today, people with significant physical impairments can enjoy life in real "homes of their own", with support from people of their choosing up to 24 hours per day, funded by direct payments and personal budgets. Although people with mental health problems are included in such disability policies and initiatives, in practice they have been left behind. The focus remains on "specialist housing" and, unlike their counterparts with physical and sensory impairments, those living with mental health challenges are only deemed capable of "independent" accommodation if they are able to manage without a high level of support. This is quite a different understanding of the term "independence" which deprives many of a "home" in the full sense of the word.

The reality for many people with mental health problems who have high support needs is that "institutional living", albeit in community based hostels and staffed accommodation (akin to the Le Court Cheshire Home), is the only option open to them. In such accommodation a set of "house rules" deprive them of the privacy and control of the "hearth", "heart", "privacy" and "roots" of home. Often the duration of their tenure is specified ("you can stay here for up to two years") on the assumption that people will acquire the skills of living without support […] and those who do not progress lack secure tenancies and so often get moved from one sheltered/staffed setting to another.

Those who do "make the progress" expected of them are faced with the challenge of moving to less sheltered settings and eventually into a tenancy of their own: it is not the level of support is changed, but the individual who must move. This means that their "reward" for making "progress" is moving house, which for anyone is a major stressful life event that can cause (or exacerbate) mental health problems (Holmes and Rahe, 1967).

Like everyone, people with significant mental health challenges need the hearth, heart privacy and roots that constitute a home, not just the shelter. People facing such challenges do not need insecure "specialist housing" but, like those with physical impairments, they have a right to the same secure tenancies that other citizens expect, no matter how serious the challenges they face.

Like those with physical impairments, they may need additional support in such a tenancy, but this support should be based on their own "choices and aspirations" (Disability Rights Commission, 2002). For some this may mean support 24/7, for most it will be less than this. For some the support they need may be temporary (in order to enable them to develop their own confidence and skills), for some it will be intermittent (many mental health challenges fluctuate), for some it will be indefinite. Some mental health challenges are continuous and long term, but this should not deny people the right to a home of their own. It is true that some people do not want to live alone, but there are few (if any) who wish to be lumped together with people not of their choosing. For those who do wish to live with someone else, shared tenancies (flat-mates) are a possibility, just as they are for any other citizen.

References

Disability Rights Commission (2002), Policy Statement on Social Care and Independent Living, Disability Rights Commission, London

Evans, J. (2003), "The independent living movement in the UK", Independent Living Institute, Stockholm, available at: www.independentliving.org (accessed 28 May 2016)

Holmes, T.H. and Rahe, R.H. (1967), "The social readjustment rating scale", Journal of Psychosomatic Research, Vol. 11 No. 2, pp. 213-21

Koegel, P. and Burnam, M.A. (1992), "Problems in the assessment of mental illness among the homeless", in Robertson, M. and Greenblatt, M. (Eds), Homelessness: A National Perspective, Plenum, New York, NY, pp. 77-99

Mental Health Foundation (2015), "Homelessness and mental health", Mental Health Foundation, London, available at: www.mentalhealth.org.uk/blog/homelessness-and-mental-health (accessed 28 May 2016)

Mental Health Provider Forum (2016), Mental Health and Housing, Mental Health Provider Forum, London

Thompson, S. (2007), "Home and loss: renegotiating meanings of home in the wake of relationship breakdown", Journal of Media and Culture, Vol. 10 No. 4, available at: http://journal.media-culture.org.au/0708/07-thompson.php (accessed 29 April 2016)

Ogden, L.P. (2014), "‘Waiting to go home’: narratives of homelessness, housing and home among older adults with schizophrenia", Journal of Aging Studies, Vol. 29, April, pp. 53-65

O’Hagan, M. (2014), Madness Made Me, Open Box, Wellington

Repper, J. and Perkins, R. (2003), Recovery and Social Inclusion. A Model for Mental Health Practice, Balliere Tindall, London

Repper, J. and Perkins, R. (2012), "Recovery: a journey of discovery for individuals and services", in Phillips, P., Sandford, T. and Johnston, C. (Eds), Working in Mental Health: Practice and Policy in a Changing Environment, Routledge, Oxford, pp. 71-80

Shaw, M. (2004), "Housing and public health", Annual Review of Public Health, Vol. 25, April, pp. 397-418

Somerville, P. (1992), "Homelessness and the meaning of home: rooflessness or rootlessness?", International Journal of Urban and Regional Research, Vol. 16 No. 4, pp. 529-39

van Doorn, A. and O’Dwyer, P. (2016), "Specialist mental health supported housing", paper presented at Royal College of Psychiatrists AIMS Rehab Annual Forum, London, 11 May, available at: www.rcpsych.ac.uk/pdf/Programme%20a3.pdf