By Ellie Atkins
As a manager and safeguarding lead for a social work team in Manchester, I work with people experiencing severe multi-exclusion homelessness.In this article, I will explore the context in which people’s struggles appear and suggest what we can do as social workers to improve the lives of some of the most misunderstood people in our society.
Cast your mind back to the Covid pandemic when ‘The Everybody In’ initiative provided hotels for people to come indoors for safety, backed by financial investment, legal frameworks and political will.
Why refuse shelter?
Despite this humanitarian response, some people refused to come indoors or behaved in such a way they could not stay in.Why would you ‘choose’ to remain on the streets during a pandemic, when safety through hotels was being provided?"In Manchester, this group of people met the three-tier threshold for a safeguarding enquiry under the Care Act 2014: they had needs for care and support, they were neglecting their care for self and their basic needs and were behaving in ways in which they could not be protected or indeed protect themselves.
With professional curiosity and compassionate enquiry to understand the ‘why', alongside a research project, it became clear that the people remaining on the streets were likely to have hidden disabilities and differences that affected their executive functioning.
About executive function
Our executive functioning, which is located the frontal lobes of our brain, allows us to plan, problem-solve, inhibit our behaviour and emotions, make goals, see them through and have the ability to act out our wishes and be who we want to be.When our executive functions are compromised or impaired in some way, this is called executive dysfunction. It can be hard to spot and slippery, because it changes, depending on the environmental, emotional and social context we find ourselves in.
I would suggest using the wheel pictured below, which sets out eight dimensions of executive functioning, to help with understanding the concept.
Some conditions are well evidenced to affect out executive functioning, such as acquired brain injury, foetal alcohol syndrome disorder, complex post-traumatic stress disorder, attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD) and other forms of neurodivergence.
A 2022 study found that 92% of 115 people using a homelessness service had experienced trauma (Irving & Harding, 2022), whereas 48% of homeless respondents to a 2012 piece of research had acquired brain injuries (Oddy et al, 2012). This means that this group is much more likely to experience executive dysfunction than the wider population.
Focusing on safety
We can then move the power dynamic from, ‘What’s wrong with you?’, to, ‘What do you need?’, placing the onus on us as social workers to support the person to optimise their executive functioning before the Mental Capacity Act 2005 is considered or engaged in cases of significant self-neglect.You see, executive functioning can be stabilised and optimised when we meet the non-negotiable human need to feel safe: safe in body, safe in where we live, safe in who is around us and safe in the way that people work with us.
This truly strengths-based approach, underpinned by relational social work, the power of human connection, kindness and empathy, can mean everything and costs nothing.
Beryl's story
Can I introduce you to a lady called Beryl? Beryl will show you how we can use the Care Act, our assessments, support planning and safeguarding, alongside the executive functioning wheel and relational social work, to enable people to have better outcomes and better lives.Beryl had been known to our team for 10 years, as a lady with chronic and dependent alcohol addiction who said she did not want to work with services or receive help with her drinking.
When I moved our focus from her alcohol addiction and homelessness, during the Everyone In initiative, and tried to understand ‘why’ she would behave in this way, the context in which her struggles appeared started to become unveiled.
I used the Care Act provision to override a refusal of assessment when someone is experiencing, or at risk of, abuse or neglect, and a team around the person approach, to gain an understanding of Beryl’s life story.
Understanding the 'why'
Beryl had experienced adverse childhood experiences and significant trauma; she lost her baby in a car accident, she experienced a head injury and later witnessed her partner being murdered. Beryl drank all day, every day, because she was too scared to stop.Beryl’s behaviour became so distressing to herself and the wider public that we had to use police powers under section 136 of the Mental Health Act 1983 to take her to a place of safety and then placed her under section 2 of the MHA for a period of assessment. These decisions are not taken lightly.
Beryl was then moved to section 3 of the MHA and responded to treatment.
She states that this was the first time, in as long as she could remember, that her mind became safe and calm, enabling her to communicate in a way she wished to. It was during this time that she was diagnosed with ADHD, post-traumatic stress disorder and an acquired brain injury.
Whilst ‘labels’ may not always be helpful, Beryl had lived with hidden disabilities, with limited quality of life, believing that she was a moral failure for her alcohol dependency.
Being who you want to be
Beryl now lives in supported accommodation, she attends Alcohol Anonymous and supports other peers in their own recovery from addiction. Beryl states that, for the first time, she has the ability and capacity to be who she wants to be.If Beryl’s story resonates, please find out more by watching these videos about her.
Her story reminds me of what Desmond Tutu once said:
There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they’re falling in.”Ellie Atkins is manager and safeguarding lead for the entrenched rough sleeper social work team at Manchester City Council
References and further reading
Bramley, G et al (2015) Hard Edges: Mapping severe and multiple disadvantage, England Lankelly Chase Foundation
Grant, S et al (2016) Experiences of Homelessness and Brain Injury Sheffield Hallam University
Irving, A & Harding, J (2022) The Prevalence of Trauma among People who have Experienced Homelessness in England Oasis Community Housing
FEANTSA (2017) Recognising the link between trauma and homelessness
Oddy, M, Moir, J, Fortescue, D, & Chadwick, S (2012) The prevalence of traumatic brain injury in the homeless community in a UK city Brain Injury, 26(9), 1058–1064
