Brain injury and homelessness

What is an Acquired Brain Injury? 

Acquired Brain Injury (ABI) covers all situations in which brain injury has occurred since birth. This includes:

• Trauma to the head, caused by things like violence/assault, falls, road traffic collisions, sports injuries (this type is called a Traumatic Brain Injury – TBI)
• Cardiac arrest
• Brain haemorrhage
• Serious asthma attack
• Stroke
• Alcohol misuse – which can lead to Korsakoff Syndrome and alcohol-related dementia
• Brain tumour

How do brain injuries affect people?

The brain is complex and controls everything we do, think and say. Every person will have their individual experience, however there are some common themes:

Cognitive

• The ability to think through problems may be reduced
• Imagining and understanding consequences of actions may be difficult
• Putting yourself in someone else’s shoes and showing empathy is a complex cognitive skill which may be affected
• Lack of insight is common in people with brain injury
• Memory may be impaired, including short term memory or memory of specific events.
• Working memory is very important when planning, problem solving and weighing up things – all these abilities may be reduced.
• Communication may be affected in different ways e.g. being able to explain your current situation and understanding instructions
• A person with a brain injury may ‘confabulate’, this means talking about things which have no truth in reality but may be linked to things which are true, but have got very confused.
• Responding to what, where, why, how questions – all common in assessment – may be very challenging for someone with brain injury.

Emotion

• Control of emotional responses may be weakened
• Emotional responses may be flat e.g. humour may not be understood in context
• Where cognition is affected, this may mean a person cannot understand why others behave as they do and, in turn, their own emotional response may seem inappropriate
• Some people with a brain injury become sexually inappropriate or disinhibited in other ways.

Physical

• Senses may be affected e.g. vision may be blurred, bright lights overwhelming etc.
• Noise may be distressing
• Coordination of movement may be diminished
• There may be obvious physical effects such as problems with walking or reduced use on one side of the body
• Dribbling, difficulty with eating, choking may be present
• An individual may refuse certain foods because they find it difficult to swallow.
• Hormonal changes can cause weight gain, reduce body hair, affect sleep and many other symptoms.

What are the links between brain injury and homelessness?

Around 50% of people who are experiencing homelessness have had a traumatic brain injury. If we also include alcohol-related brain damage, and those with a learning disability, this can equate to around 70-80% of the homeless population. However, if we also take into consideration the impact of trauma on the brain, it could be argued that 100% of people experiencing homelessness have a neuropsychological need. ​

There is a two-way relationship between brain injury and homelessness. A brain injury can make it much harder for someone to keep stable housing because it can affect:

• Memory and attention – difficulty remembering appointments, bills etc.
• Executive functioning – planning, organising and problem solving
• Impulse control and emotional regulation
• Work capacity – difficulty maintaining employment
• Social relationships – difficulty maintaining positive relationships.

Brain injury often co-occurs with other risk factors such as mental health conditions, substance use, domestic violence and involvement with the criminal justice system, which all increases the risk of homelessness.

People experiencing homelessness are also at a much higher risk of sustaining brain injuries because of increased exposure to:

• Physical assault, especially for people sleeping rough
• Domestic abuse
• Falls
• Unsafe living conditions
• Lack of access to medical care

Brain injuries are often missed or undiagnosed because symptoms can look like:

• Depression
• Intoxication
• Psychosis
• ADHD
• Challenging behaviour

How can frontline staff support those affected by a brain injury? 

Information gathering

• Start with a broad assessment with the individual to gather information about possible brain injuries.
• Do not rely on asking directly about ‘brain injuries’, as memory difficulties may mean the individual does not remember or recognise a previous injury.
• Rather than asking about a ‘brain injury’, as this can carry stigma for some people, ask about ‘blows to the head’, being ‘knocked out’ or accidents, falls, assaults, or fights.
• Explore the individual’s full life history, not just recent circumstances
• Watch out for signs that may indicate possible brain injury, such as memory problems, difficulty following conversations, confusion, inconsistent recall of events and impulsive or disorganised behaviour.
• In your assessment, focus on the behaviour and evidence you witness to help you consider whether brain injury may be a factor for the individual you are supporting. Keep a record of this behaviour.

Use a screening tool

Brainkind has developed the Brain Injury Screening Index (BISI), a validated tool that can be used within prison, probation, community and rehabilitation settings to establish whether someone has sustained a brain injury.

The BISI is an 11-question screening tool to help identify people with a brain injury. The BISI is not a diagnostic tool but records an individual’s self-reported history of brain injury. It has been developed for use by all levels of practitioners and is available with guidance for its use.

Access the screening tool here

Raise the brain injury with the individual

After your observations, you may think brain injury is a possibility, so consider how to raise this with the individual. Some people might be relieved to know that there is a possible physical issue that may account for some of their difficulties, but others may not. Some suggested wording is below, but you will know the individual best so think about how they may react to decide on the most appropriate approach:

• “I’ve been reading about the brain and found it really interesting.
• The brain is in charge of everything we do, from talking to remembering birthdays.
• If someone has a bang to the head / an accident / fight, the brain can get injured just like your arm might get broken.
• When that happens it can affect someone’s mood or memory / communication.
• You told me that you had an accident / fight back in xxxx, did you or others notice any difference in your mood / thinking / memory after that?”

Be clear that you are raising the issue because help may be available to improve their situation. Remember that you may need to raise this issue a few times before someone feels comfortable taking the next step.

Contact a GP

• The GP will need to know what has raised the concerns about brain injury so be prepared to provide details about your observations.
• The individual’s GP may not be an expert in brain injury. Headway UK provides this document for GPs to help them work with patients with brain injuries - you may want to read it before the appointment to help you know what to ask for.
• The GP may carry out some form of cognitive screening and will access the individual’s medical records to find information about previous conditions which may have affected the brain or clear information about previous brain injury.
• If the GP agrees that brain injury is a concern, then a referral to specialist services such as Neurology or Memory Clinics may be the way forward.
• You can also search on the Headway UK website to find a wide range of brain injury support and services in your area.

Contact your Local Authority

• If you are concerned that the individual you are supporting is experiencing abuse or neglect, your Local Authority Safeguarding Team can provide advice and support to address the issue. Ensure you follow your own organisation’s safeguarding procedure and remember that, if a crime is suspected of taking place, the Police should be involved. Read our guidance on safeguarding.
• Contact your Local Authority Adult Social Care Team if you believe the individual you are supporting has care and support needs and requires a Care Act assessment. For more information on how to request a Care Act assessment, read out guidance.
• If the individual you are supporting is homeless, or at risk of homelessness, contact your Local Authority Housing Options Service. If the individual has a brain injury, this can be put forward as evidence of their vulnerability, and therefore the Local Authority may determine that they are in ‘priority need’, and provide emergency accommodation.

Adapt the way you are providing support

When working with an individual with a suspected/confirmed brain injury, you may need to think about adapting your ‘typical’ ways of working:

• Ensure any information about your service/how you can support the individual is available in different formats e.g., easy to read lists, pictures rather than lots of text
• The effects of brain injury on memory can be severe so you may have to repeat instructions or expectations
• If someone is exhibiting challenging behaviour, don’t immediately evict or ban them from your service, think about ways to support them instead. We have published guidance on preventing evictions and abandonments, available here.

Further resources and guidance

Headway UK is the largest charity for brain injury in the UK. It has a wealth of information on its website about many different types of brain injury and factsheets on coping with brain injury for those affected, including carers. It has a national nurse-led Helpline (0808 800 2244) which can be used by individuals and organisations for initial advice or more detailed discussion. Headway UK also campaigns on issues linked to brain injury and carries out research: www.headway.org.uk

People with brain injuries can exhibit challenging behaviour. We have developed a 9-part bitesize E-Learning on ‘Managing Challenging Behaviour’. The videos provide an understanding of what may cause challenging behaviours, how to reduce the chances of them occurring, and how teams can regulate their own emotions and in turn, be able to provide the support individuals need. Access the E-Learning here.

Series 3, Episode 5 of our Going Beyond Podcast explores the prevalence and impact of brain injury for people experiencing homelessness and discusses how frontline workers can best support these individuals.