The mental health of the homeless viewed through the prism of the temporalities of survival and institutions

Charles-Henry Lelimouzin
Charles-Henry LelimouzinAfter obtaining a degree in Clinical Psychology and Psychopathology from the University of Lorraine in 2012, Charles-Henry Lelimouzin went on to work in social welfare and health and social care centres. His clinical practice enabled him to specialise in insecurity and its different origins (marginalisation, encounters with the judicial system, disabilities, addiction, early childhood, old age). He also leads professional practice analysis groups in these fields. In 2018, Charles-Henry Lelimouzin co-wrote an article focusing on the plurality of psychological approaches in two health and social care facilities dealing with similar pathologies. charles-henry.lelimouzin@arelia-asso.fr
Thibaut Besozzi
Thibaut BesozziAfter obtaining a Master’s degree in Sociology from the University of Lorraine, Thibaut Besozzi completed his sociology thesis in 2015, at the University of Caen-Normandie. He has been leading action-oriented research into homelessness and the social emergency in Nancy since 2016, in partnership with the institutional actors of the Reception-Housing-Integration (Accueil-Hébergement-Insertion – AHI in French) sector (the State, local municipalities, and non-profit organisations). In 2021-2022, he was awarded a research grant from the French Red Cross Foundation. Drawing on an ethnographic approach designed to document the experience and perspectives of participating stakeholders, his work has opened the way to operational actions and given rise to the publication of reports, scientific articles and a book. His research is situated at the crossroads between urban sociology, social work and the sociology of marginality, with the goal of improving public action taken to help the homeless. thibaut.besozzi@u-bourgogne.fr

Life on the streets generates mental health problems in the same way as conflicts or natural disasters. And here again, the temporality of the people concerned is not the same as that of the institutions. To understand this is already to give ourselves the means to bridge the gap in mutual expectations.

y drawing upon the intersecting perspectives of a sociologist and psychologist engaged in the provision of health and social care to homeless people in Nancy, this article seeks to illustrate the ways in which the experience of homelessness negatively impacts mental health. Though well-established in scientific literature,[1]Maryse Bresson, « Le lien entre santé mentale et précarité sociale : une fausse évidence », Cahiers internationaux de sociologie, vol. 2, n° 115, 2003, p. 311-326. Jean Furtos, … Continue reading this correlation continues to generate controversy in France and overseas,[2]Mario Poirier, « Santé mentale et itinérance. Analyse d’une controverse », Nouvelles pratiques sociales, vol. 19, n° 2, 2007, p. 76-91. in particular in terms of the disorders considered and methods of diagnosis. Clearly, it is important to remember that mental health disorders are manifold and on a spectrum of severity, encompassing acute psychiatric disorders, non-severe mood disorders, personality disorders and so forth.[3]Anne Laporte et Pierre Chauvin, La santé mentale et les addictions chez les personnes sans logement personnel d’Île-de-France, Rapport Samenta, Observatoire du Samusocial de Paris, 2010.

We have chosen to view mental health through the prism of the temporalities experienced by homeless people, both when they endure life on the street and when they are confronted with the institutional temporalities of health care and reintegration pathways. This article therefore asks the following question: to what extent can mental health disorders – in particular those caused by the lived temporality of survival – impede adherence to healthcare and reintegration pathways?

By “lived temporality”, we are referring to how individuals both relate to and punctuate time on a day-to-day basis and relate to the past and the future. Lived temporalities can only be subjective, as they stem from the perception and personal use of time in situations of extreme insecurity. In contrast, “institutional temporalities” are more objective. They are an external force on individuals, contributing to giving structure to their daily life and their future, in accordance with the norms and regulations enacted by the institutions and the professionals working there.

The temporalities of survival among the homeless

To survive in the public space, homeless people are forced to take urgent action in order to find short-term solutions to their vital needs (such as sleeping, eating, washing, making money and maintaining social relationships). The solutions to these imperatives not only need to be immediate, they are also in general extremely concrete and tangible (e.g. find shelter, food, a shower, etc.), not to mention uncertain and sometimes fruitless.

People who experience homelessness therefore develop a particular relationship to time: a relationship (de) constructed around the space-time reference points that shape their existence in the absence of domestic and professional space-time reference points that would otherwise punctuate their days and the links between them.[4]Patrick Gaboriau, Clochard. L’univers d’un groupe de sans-abri parisiens, Julliard, 1993. These space-time reference points include sleep in places not intended for habitation; social relations between homeless peers,[5]Julien Billion, « Les jeunes sans domicile et leurs pairs dans la rue », in Serge Paugam (dir.), L’intégration inégale, PUF, 2014, p. 227-242. potentially underpinned by the consumption of toxic products; the acquisition of minimal resources (through begging, minor dealing, scavenging, etc.), and basic self-care (eating, personal hygiene, sleep, etc.). All these windows in space-time create – to a greater or lesser degree depending on individual contexts – a “circuit of assistance”.[6]Pascale Pichon, Vivre dans la rue. Sociologie des sans domicile fixe, Publications de l’Université de Saint-Étienne, 2010. Survival routines are therefore put in place in an attempt to meet the basic needs that have to be met day after day. This routinisation is a vector of “ontological safety”,[7]Michel Parazelli, La Rue attractive. Parcours et pratiques identitaires des jeunes de la rue, Presses de l’Université du Québec, 2002. as observed in Nancy [a town in eastern France] during an eight-month immersive ethnographic research project into the homeless community between September 2017 and April 2018. Indeed, homeless individuals and groups of individuals report having routine practices, anchored in space and time, that structure their experience of survival.[8]Thibaut Besozzi, « La structuration sociale du monde des sans-abri », Sociologie, vol. 12, n° 3, 2021, p. 247-266.

However, given that responses to vital needs are always uncertain and that the space-time windows offering resources are competitive and must be negotiated and shared, day-to-day survival engenders high, adverse and mentally pathogenic levels of stress. This was described by Jeff[9]A 38-year-old homeless man having slept in an underground parking for seven months. This, and all other names used, is an alias. during an evening spent with him in “his” underground carpark:

“I’m always on edge! It’s hard living like this. You never know what’s going to happen to you. I’ve always been hyperactive, but now, forget it. It’s so stressful. I’ll go crazy if this continues!”

Experiencing extreme insecurity exposes homeless people to the hazards of daily life, lack of privacy in shelters, lack of safety in the public space, dependence on social services or on peers, and to the feeling of being unable to manage their daily lives. All these experiences are psychologically harrowing for the homeless, not to mention the impact of social disqualification[10]Serge Paugam, La disqualification sociale. Essai sur la nouvelle pauvreté, PUF, 1991. and stigmatisation they have on self-esteem and identity building.[11]Erving Goffman, Stigmate. Les usages sociaux des handicaps, Les Éditions de Minuit, 1975. These experiences can cause anxiety disorders and place the individual in an immediate, fragile temporality.[12]A 35-year-old homeless man sleeping in an unsanitary squat in the city centre. As Fred explains:

“I need to find some dosh right now! Not tomorrow or next week… Like at the day centre, they told me to come back in two days, but I needed my washing right then and there. They really stress me out!”

In this respect, addictive disorders, sometimes observable, are attempts to respond to stress and anxiety that in turn lead to the development of mental health problems.[13]Anne Laporte et Pierre Chauvin, La santé mentale…, op. cit. Finally, the difficulty of making plans for the future compounds the risk of depression by narrowing the question of life’s direction – both physically and philosophically – down to biological, social and self-identity survival alone. This “presentism” is explicitly referred to by Julien,[14]A 38-year-old homeless man sleeping in underground city carparks. who we regularly spent time begging with in Nancy:

“How do I see myself in five years? In a year? You must be mad, I’ve got no idea, I don’t think about it. I don’t know what’s going to happen tomorrow… street life is tough, we live a day at a time, no choice.”

Because of these realities, homeless people might already be dealing with deteriorating mental health conditions when confronted with institutional temporalities, i.e. when they leave the streets and move into “housing and social reintegration centres” (CHRS) and attempt to follow a reintegration programme.

The institutional temporalities of health and social care

When homeless people use housing and healthcare support systems, they are confronted with exogenous (i.e. determined by the external environment) institutional temporalities that force them to attempt to adapt to a different rhythm from that inherent to “day-to-day” survival. The fastest, most tangible response provided by the social assistance system in France is the provision of emergency housing in the first instance followed by social integration housing (in CHRS). These two responses differ in that emergency housing imposes “temporary shelter that is repeated” while reintegration housing provides “provisional shelter that lasts”.[15]Édouard Gardella, « Temporalités des services d’aide et des sans-abri dans la relation d’urgence sociale. Une étude du fractionnement social », Sociologie, vol. 7, n° 3, 2016, … Continue reading For individuals placed in a CHRS, the provisional solution in terms of housing (in renewable six-month periods) must be accompanied by a social reintegration plan that fits into an extended temporality and requires the capacity to plan more long term. The support given to sheltered individuals is based on context-specific factors and involves work to help the individuals become accustomed to their reinstated rights, access to healthcare, access to housing and access to work, as well as the development of psychosocial skills or help reconnecting with family members. In other words, the person receives help to acquire “social objects”,[16]Jean Furtos, « La précarité… », art.cit. in other words a level of insecurity that is more tolerable and more conducive to improved mental health. This process is naturally longer than the response to the immediate needs of survival. Furthermore, it seems less tangible and sometimes downright inaccessible and stressful for supported individuals who may react by disengaging themselves, i.e. through avoidance or escape coping strategies.[17]Gérald Delelis, Véronique Christophe, Sophie Berjot et al., « Stratégies de régulation émotionnelle et de coping : quels liens ? », Bulletin de psychologie, Tome 64 (5), n° 515, … Continue reading

In institutional contexts, the passing of time is therefore no longer perceived through the temporalities of actions with rapidly measurable results but through temporalities punctuated by appointments and administrative processing delays. These periods of time over which individuals have no agency include periods of delay, which are most often negatively experienced by accompanied individuals. These “empty” periods exacerbate perceived stress levels and contribute to the emergence of feelings of powerlessness and incomprehension. Confrontations between temporalities are often a source of day-to-day misunderstanding in CHRS housing between those giving and receiving support. For example, from their perspective, social workers and psychologists may see themselves as working within an accelerated temporality when they offer weekly appointments. However, this same temporality might be considered protracted and a sign of disinterest by the individual receiving assistance. Waiting times between appointments become opportunities for overthinking. A supported individual’s coping strategy may then be disengagement expressed through rejection behaviour, failure to honour appointments or even leaving their housing altogether.

We have observed that such difficulties may sometimes also be associated with prospective memory and cognitive planning processes (executive functions) leading to potentially severe consequences.[18]Gaëtan Chevreau, Marie-Carmen Castillo, Claire Vallat-Azouvi, « Une personne SDF sur 10 souffre de troubles cognitifs : que sait-on de ces troubles ? Une revue de littérature sur la … Continue reading Respecting institutional temporalities, for instance completing procedures within required timeframes, is perceived as the criterion for the individual’s engagement in the support given. The result may be the termination of an individual’s case, even though a process of development and adaptation of cognitive function may be underway, albeit imperceptibly. Thus emerges the risk that health and social care teams and the supported individual construct negative reciprocal representations and behaviours of mutual rejection.

Another important consideration is access to healthcare, above all psychiatric care. It can often take several weeks or even months for psychiatrists, whether in private practice or public mental health facilities, to accept patients. Such temporal inertia can also be experienced as a lack of interest at the very moment the need for support is at its most acute. This also increases the risk of disengagement from care. Mental health care becomes difficult as a result. Full-to-capacity caregivers cannot block appointment slots if they are not honoured, so the risk of individuals being side-lined from care increases. This is observed despite the fact that the health of insecure populations presents a higher concentration of problems than that found in the general population.[19]Emilio La Rosa, Santé, précarité et exclusion, PUF, 1998.

The clinical practice of psychologists within CHRS institutions is also impacted. Indeed, appointments are requested as a matter of emergency in order to address problems experienced “here and now”. Appointments scheduled too far ahead run a high risk of not being honoured or of becoming unnecessary by the time they arrive. Adapting the frequency of psychological care by intensifying them during periods of waiting can also act as a potential adjustment variable. The function of psychological support is then to facilitate and set in motion the various assistance processes by adapting and finding meaning in the temporalities and rhythms endured by both the individual receiving support and the professionals giving it.

Consequently, the psychological and temporal intricacies created by the experience of homelessness can lead to non-adherence to the pathways of reintegration and healthcare. Clearly, an awareness of the specific temporalities imposed by the context of survival invites us to adapt both shelter and housing access policies and institutional health and social care practices. The intention of the Housing First (Logement d’abord) policy is indeed to bypass the series of transitory steps that lead, potentially, to access to housing. In addition, an understanding of lived temporalities and their effects on mental health may help health and social care workers to adapt their practices to the specific rythms of the individuals that they assist – and potentially lead to a reconciliation between immediacy of response and the (re)construction of a relationship with the future.[20]Nicolas Chambon (dir.), Pascale Estecahandy, Élodie Gilliot et al., La politique du Logement d’abord en pratique, Presses de Rhizome, 2022.

Translated from the French by Naomi Walker

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References

References
1 Maryse Bresson, « Le lien entre santé mentale et précarité sociale : une fausse évidence », Cahiers internationaux de sociologie, vol. 2, n° 115, 2003, p. 311-326. Jean Furtos, « La précarité et ses effets sur la santé mentale », Le Carnet PSY, vol. 7, n° 156, 2011, p. 29-34. René Roussillon, « Se retirer pour survivre », Rhizome, vol. 2, n° 64, 2017, p. 13-14.
2 Mario Poirier, « Santé mentale et itinérance. Analyse d’une controverse », Nouvelles pratiques sociales, vol. 19, n° 2, 2007, p. 76-91.
3 Anne Laporte et Pierre Chauvin, La santé mentale et les addictions chez les personnes sans logement personnel d’Île-de-France, Rapport Samenta, Observatoire du Samusocial de Paris, 2010.
4 Patrick Gaboriau, Clochard. L’univers d’un groupe de sans-abri parisiens, Julliard, 1993.
5 Julien Billion, « Les jeunes sans domicile et leurs pairs dans la rue », in Serge Paugam (dir.), L’intégration inégale, PUF, 2014, p. 227-242.
6 Pascale Pichon, Vivre dans la rue. Sociologie des sans domicile fixe, Publications de l’Université de Saint-Étienne, 2010.
7 Michel Parazelli, La Rue attractive. Parcours et pratiques identitaires des jeunes de la rue, Presses de l’Université du Québec, 2002.
8 Thibaut Besozzi, « La structuration sociale du monde des sans-abri », Sociologie, vol. 12, n° 3, 2021, p. 247-266.
9 A 38-year-old homeless man having slept in an underground parking for seven months. This, and all other names used, is an alias.
10 Serge Paugam, La disqualification sociale. Essai sur la nouvelle pauvreté, PUF, 1991.
11 Erving Goffman, Stigmate. Les usages sociaux des handicaps, Les Éditions de Minuit, 1975.
12 A 35-year-old homeless man sleeping in an unsanitary squat in the city centre.
13 Anne Laporte et Pierre Chauvin, La santé mentale…, op. cit.
14 A 38-year-old homeless man sleeping in underground city carparks.
15 Édouard Gardella, « Temporalités des services d’aide et des sans-abri dans la relation d’urgence sociale. Une étude du fractionnement social », Sociologie, vol. 7, n° 3, 2016, p. 243-260.
16 Jean Furtos, « La précarité… », art.cit.
17 Gérald Delelis, Véronique Christophe, Sophie Berjot et al., « Stratégies de régulation émotionnelle et de coping : quels liens ? », Bulletin de psychologie, Tome 64 (5), n° 515, 2011, p. 471-479.
18 Gaëtan Chevreau, Marie-Carmen Castillo, Claire Vallat-Azouvi, « Une personne SDF sur 10 souffre de troubles cognitifs : que sait-on de ces troubles ? Une revue de littérature sur la cognition des personnes SDF », L’encéphale, vol. 45, n° 5, 2019, p. 424–432.
19 Emilio La Rosa, Santé, précarité et exclusion, PUF, 1998.
20 Nicolas Chambon (dir.), Pascale Estecahandy, Élodie Gilliot et al., La politique du Logement d’abord en pratique, Presses de Rhizome, 2022.