The role that Clinical Psychologists can play in regard to housing insecurity in the UK: a social justice perspective

Introduction

It is estimated that one in three people in the UK live in poor quality housing, this raises to four in ten when considering those living in privately rented housing (Barnes et al., 2013). In 2010, the Marmot Review concluded that bad housing conditions and insecure housing constitute a risk to health (Marmot et al., 2010). Housing conditions such as overcrowding, damp, and cold have all been associated with ill health (Harker, 2006). Furthermore, children living in bad housing conditions are more likely to experience anxiety and depression, and have delayed cognitive development (Harker, 2006).

Housing insecurity can be characterised by frequent relocation, an inability to pay rent or mortgage, overcrowded households, sofa surfing with family or friends, or staying in insecure shelter due to economic hardship (Hatem et al., 2020). It also refers to poor housing quality, unstable neighbourhoods, and homelessness (Johnson & Meckstroth, 1998). Austerity, gentrification, and neoliberal policy such as the right to buy scheme along with the systematic privatisation and deregulation of the private rented sector have contributed to a deterioration in housing security over the last decade (Watt & Minton, 2016; Marmot, 2020; Gamble, 2015). It has been predicted that the COVID 19 pandemic will accelerate the significant problem of housing security in the UK because of job loss and an inability to keep on top of bills (Hu, 2020).

This essay will critically consider the role that Clinical Psychologists (CPs) can play in relation to housing insecurity. The link between housing and mental health will be considered, followed by the importance of housing in relation to the COVID 19 pandemic. The essay will then consider who is most at risk of insecure housing and the implications for the profession. After this, what traditional models of mental health practice can offer will be critically considered, followed by the potential utility of liberation psychology approaches, and what this could look like in practice.

Position statement

I am a White Welsh cisgender man studying a DClinPsy at the University of Hertfordshire. My childhood was mostly spent in the South Wales Valleys and both of my parents are working class and non-university educated. Growing up in a single parent council house in an area considered deprived means that this subject is one very close to my heart. I acknowledge that being so called “academic” as a young person allowed me great educational opportunities not afforded to others, leaving me with a great amount of guilt. As a result of the privileges afforded to me, I no longer experience insecure housing. I have been allowed to move away from where I was brought up, and throughout this process housing has rarely been an issue for me; I believe that this is probably because of my whiteness and educational background. Much of my family still experience insecure housing.

It is important for me to mention that the bulk of this essay does not necessarily speak directly to rough sleeping. It is with regret that this was beyond the scope of this essay due to word count limit (this is a submitted piece of academic work). I believe rough sleeping and homelessness is a subject that requires much more care and attention than this essay could offer. I must also mention that homeless men have shamefully been overlooked at times in this essay, and I invite the reader to hold this in mind as they read.

I believe that secure and good quality housing is a human right. I believe that a lack of access to housing is a result of political decisions made by those in power. I unapologetically acknowledge that these beliefs, along with my identity and experiences, have shaped how I approached this subject matter.

Housing and mental wellbeing

Insecure housing has consistently been linked with poor mental health. Kyle and Dunn (2008) found that it is more common for people with mental health difficulties to be living in insecure housing. A literature review carried out by Evans et al. (2003) concluded that housing quality and type are both associated with poor psychological health. A report by Shelter (2005) surveyed 417 homeless families and found that fifty six percent said they were suffering from depression. Sugaila et al. (2011) found that an overcrowded household and moving frequently in a short period of time was associated with probable depression in mothers, and that housing instability was associated with anxiety.

More recently, Shelter (2017) found that GPs spontaneously identified housing when discussing factors involved in their clients’ mental health difficulties. They also found where housing was the primary cause of mental health difficulties, the most cited problems were anxiety and depression. 3509 English adults were also interviewed, twenty one percent reported that a housing issue had negatively impacted their mental wellbeing in the last five years, with housing affordability being the most raised issue. Pevalin et al. (2017) adds to this body of evidence by providing evidence that living in persistently poor housing harms mental health and that the development of new housing problems is associated with poorer mental health. Perhaps a more damning reality of the negative impacts of housing insecurity comes from a study which found that Swedish adults facing eviction were four times more likely to attempt suicide compared to those not exposed to this experience (Rojas & Stenberg, 2016). This was after controlling for several demographic and socioeconomic factors, as well as mental health conditions prior to the notice of eviction.

Patel et al., (2020) argue that COVID will disproportionately effect people from lower income groups and cites housing insecurity such as overcrowding as a particularly important factor. Furthermore, there is evidence that poor quality housing is associated with higher risks of death from COVID 19 and that such risks are more likely to be experienced by people with lower incomes living in deprived areas (Marmot, 2020). An example being the positive correlation between COVID 19 mortality rates and overcrowding by local authority in England (Marmot, 2020). Over the lockdowns, people have spent more time at home, increasing exposure to unhealthy and overcrowded conditions, both adding to the stress of living in insecure housing and increasing risk of contracting the virus. In summary, during the pandemic, housing inequality has increased, and housing quality has become an even greater determinant of health and wellbeing (Marmot, 2020).

The foreign-born population are more likely to rely on the private rental sector, compared to the UK-born population (Vergas-Silva, 2015). Housing conditions of asylum seekers and refugees are often poor because of this (Phillips, 2006). The housing experience of new migrants to the UK is often one of instability, especially during the first few months when having to live in hostels, short-term lettings, and endure changes in the level of support they receive due to changes in asylum status (Phillips, 2006).

Victims of domestic abuse are also vulnerable to housing insecurity. Without access to affordable housing, women who are abused find themselves unable to leave; and those who do leave tend to live in poor conditions or return to the home of their abusers to have a place to reside (Sev’er, 2002). The need for secure housing is even more pronounced for immigrant women who often do not have established systems of support who can offer accommodation (Graham & Thurston, 2005). Thurston et al. (2013) conducted interviews with thirty-seven abused immigrant women in three Canadian cities. They found that low income, low English literacy, and being a sponsored immigrant were indicators of increased risk of homelessness. The women reported housing insecurity and felt trapped in such situations predominantly for reasons of income. They reported a desire to move from their current housing due to lack of safety because of the abuser, but often were not able to due to lack of housing options. Even when they were able to leave, they would often return to the abuser in their desire for a stable home for their children.

Trauma

Broadly speaking, psychological trauma refers to events that are experienced as life-threatening or harmful which have impacts on mental, emotional, and social wellbeing (SAMHSA, 2014). These can be single event or multiple events over time and can include experiences of violence, bullying, abuse, neglect, war, gang culture, abandonment, and family separation (Sweeney et al., 2016). However, there may be other more idiosyncratic examples of trauma when considering Van der Kolk’s (2003) definition: psychological trauma being anything that has overwhelmed a person’s ability to process psychologically something that has happened to them.

Many people in contact with mental health services have experienced sexual or physical trauma (Mauritz et al., 2013). There is evidence that traumatic events experienced in childhood can have negative lasting effects on health and wellbeing (Boullier & Blair, 2018). In a survey of 2028 adults in Wales, it was found that those with four or more adverse childhood experiences (ACEs) were four times more likely to be a high-risk drinker, fourteen times more likely to be a victim of violence in adulthood, and sixteen times more likely to have used crack cocaine or heroin (Bellis et al., 2016). A strong, dose-response positive correlation between number of ACEs and recent and lifetime depressive disorder in adulthood has also been found (Chapman et al., 2004). Furthermore, sexual and physical abuse, as well as witnessed violence have been found to increase the risk of post-traumatic stress disorder (PTSD) and depression in adolescents (Kilpatrick et al., 2003).

There is evidence that groups who experience insecure housing at higher rates are more likely to have experienced trauma. Rates of depression are higher amongst women who have experienced domestic violence (DV) compared to women who have not experienced DV, particularly if they have experienced other trauma (Warshaw et al., 2013). In a sample of 129 Kosovar refugees, the mean number of war related traumatic events reported was fifteen, ninety percent reported at least ten traumatic events, and sixty percent showed a symptom pattern consistent with PTSD (Ai et al., 2002). Moreover, interviews with forty asylum seekers in Sydney revealed that seventy-nine percent had experienced a traumatic event such as being assaulted, witnessing homicide, or suffering captivity and torture, and thirty-seven percent met full criteria for PTSD (Silove et al., 1997). Other authors have been keen to highlight more insidious forms of trauma resulting from chronic oppression, discrimination, and racism (Sanchez-Hucles, 1999; Bryant-Davis & Ocampo, 2005); which is all too common in the everyday lives of minoritized ethnic groups (Deitch et al., 2003).

Traditional ways of working

CPs aim to reduce psychological distress and enhance psychological well-being (BPS, 2000). Psychological distress is associated with insecure housing, so it is likely that CPs work with people who have or are currently experiencing housing insecurity. Considering the evidence suggesting that groups who experience insecure housing are also more likely to have experienced trauma, CPs have an obligation to consider how housing affects psychological wellbeing and incorporate these understandings into their work (Ali, 2019).

CPs can employ traditional ways of working if they are aiming to reduce the distress related to experiences of insecure housing. CPs provide predominantly individual therapy (Norcross et al., 2005) with Cognitive Behavioural Therapy (CBT) being the most recommended psychosocial intervention by the National Institute of Clinical Excellence (NICE, n.d.). In 2003, an eclectic modal orientation was the most common theoretical orientation, closely followed by cognitive therapy, psychodynamic, and behavioural therapy (Norcross et al., 2005); all are individually focussed interventions.

The improving access to psychological therapies programme in England (IAPT) is an example of how evidence-based psychological therapies can be offered in a timely manner to a high number of people. IAPT was set up in 2008 on the premise that many people with a common mental health disorder receiving an evidenced based psychological intervention would recover and return to work, therefore reducing the welfare benefit cost burden (Wakefield et al., 2020). There are now over 200 IAPT services across England (Wakefield et al., 2020). The average wait time between assessment and the start of treatment is twenty-nine days, and the mean number of therapy sessions (often CBT) is 6.4 (Clark, 2018). The recommended number of CBT sessions varies from six to sixteen (NICE, 2020) and recovery rates vary between twenty-one and sixty-three percent (Marks, 2018). However, it is difficult to know if IAPT is reaching the people who need it the most, including those who experience housing insecurity and trauma. Thomas et al. (2019) found that patients from low-income backgrounds perceived self-referral as an obstacle for accessing IAPT, despite the initiative being set up to improve access. They also found in the sample of low-income patients that over forty percent of those who received a recommendation from their GP for self-referral did not follow this through.

IAPT is not without its critics. Griffiths and Steen (2013) posit that IAPT’s claim of forty-four percent recovery rate is due to the exclusion of people who do not complete a course of therapy. When those who did not complete therapy, but attended at least one appointment were included, the recovery rate falls to twenty-four percent. When all people referred are included in the analysis, only twelve percent show recovery. Furthermore, Scott (2018) assessed ninety IAPT clients who had experienced a personal injury claim using a standardised semi-structured interview; they found that only 9.2% of individuals recovered. Again, this raises questions as to whom IAPT is improving access for.

A further challenge to IAPT comes from Williams (2015), who explains how IAPT’s reliance on NICE guidelines is not necessarily a strength. CBT is seen as the “gold standard” in many cases due to the hierarchy of evidence favoured by NICE which places Randomised Control Trials (RCT) and meta-analyses at the top, and expert opinion or research informed by social constructivism paradigms at the bottom. It is argued that this could be skewing services towards quantitative outcome data as the only indicator of recovery. Glasby and Beresford (2006) advocate for a new paradigm of knowing, where lived experience of services users and practice wisdom of practitioners can be viewed as just a valid way of understanding the world as the current dominant empirical epistemology. They argue that service user narratives can assist the evaluation of CBT and help us to understand the context in which people live and access services. Ways in which CPs can contribute to such research will be discussed later.

CBT places the responsibility to change on the individual. An indicator of whether someone will benefit from CBT is if they are able to recognise that they are individually responsible for change (Westbrook et al., 2007). Binnie (2015) argues that many people are referred for help with problems which result from systemic and community issues and applying a medical model constitutes to blaming individuals for their problems. They also argue that therapists working in IAPT must assume the efficacy of psychiatric diagnosis, therefore encouraged to not take a critical perspective and failing to see people as individuals.

Of course, CBT is not the only intervention that CPs have at their disposal. Psychological interventions focussed on reducing the symptoms of PTSD following trauma may also be useful when considering the cohort of people who experience housing insecurity. Recommended interventions include cognitive therapy for PTSD, cognitive processing therapy, and eye movement desensitisation and reprocessing (NICE, n.d.). Having said this, the same criticisms aimed at CBT — such as expecting the individual to change as opposed to changing the environment — could apply to them. Moreover, can people be expected to overcome trauma if they still live in precarious, and potentially ongoing traumatic environments due to insecure housing? Cohen, Mannarino, and Murray (2011) argue that trauma focussed cognitive behavioural therapy (TF-CBT) can help people experiencing ongoing trauma. The authors outline strategies that they argue have benefited young people in both the USA and Zambia who are exposed to ongoing domestic violence, sexual abuse, and HIV exposure. They argue that these young people have little time to reflect on trauma before the next trauma occurs, so it is important to help them develop coherent narratives with adaptive cognitions, even in the context of ongoing trauma. Despite the claim, there is limited data presented in support of it. An RCT cited does provide evidence that TF-CBT results in significantly greater improvement in anxiety and PTSD symptoms compared to treatment as usual, however there is no evidence that the participants were in fact experiencing ongoing trauma (Cohen, Mannarino, & Iengar, 2011).

New ways of working

The discourse of disorder and illness posited by the medical model through the Diagnostic and Statistical Manual of Mental Disorders, and the International Classifications of Diseases, suggests that causes of distress are situated within an individual. Boyle and Johnstone (2020) state that people are encouraged to blame themselves for failure and that psychology and psychiatry play a major role in reinforcing this by suggesting that causes of distress lie within individuals’ personalities or psychological dysfunctions. They argue that this disconnects problems from the social and political context and maintains an oppressive status quo.

This language of disorder has been accepted by CBT, IAPT, and more broadly clinical psychology as a profession (Read et al., 2014). There are CBT sub-types aimed at specific mental disorders (Borza, 2017; Beck, 1979) and it is a competency which must be taught by accredited Doctoral programmes in Clinical Psychology in the UK, meaning that all trainees must demonstrate competency in applying CBT to “specific problems” (BPS, 2019, p. 60).

The Power Threat Meaning Framework (PTMF) offers an alternative to models of human distress based on psychiatric diagnosis (Johnstone & Boyle, 2018). In traditional mental health, difficulties are often framed as symptoms of an illness. In the PTMF, difficulties are referred to instead as threat responses. These are the strategies used by people to survive and meet their core needs in the face of the negative use of power. The framework also includes how people make sense of these experiences, and how messages from society can increase feelings of guilt, self-blame, and shame. It is argued that the PTMF makes clear links between social factors — such as inequality and discrimination — with trauma and emotional distress.

Considering the link between housing insecurity and mental health through the PTMF could be useful in guiding CPs in how to engage with the issue more efficaciously. The lack of safe and secure housing which is characteristic of housing insecurity in the UK could be viewed as a misuse of power by the state and society. The lack of a basic need understandably poses many threats to individuals; stress being one example (Shelter, 2017). Further experiences of asylum, racism, poverty, and DV can also be viewed as the negative use of power. The framework then encourages us to view difficult experiences such as low mood, panic, and attentional difficulties as responses to threat posed by the misuse of power, which are necessary and creative strategies for survival. The meaning people make of their experiences of housing insecurity is an important facet of using the framework, as it can help explain individual differences in threat responses to a similar threat (Boyle & Johnstone, 2020). Some of these meanings have already been explored through research. In one study, fathers expressed feeling that they are unable to fulfil the responsibility of providing for and protecting their children because of homelessness (McArthur et al., 2006). Rough sleepers have expressed self-stigmatization and self-blame because of harassment and discrimination from the general public (Williams & Stickley, 2011). Indigenous Australians have expressed disconnection from their histories and a sense of ‘spiritual homelessness’ because of insecure housing (Zufferey & Kerr, 2004), and children experiencing homelessness have spoken of a cherished past in which the family was safe and happy together; home being represented as something which they once had, but now yearn for (Kirkman et al., 2010). This research gives us an insight into the unique experiences of particular groups, and the PTMF can help CPs unpack what influences the meanings made.

It is suggested in the PTMF that we do not always have full control over meaning making, as these narratives are limited by broader social and cultural context and norms; we can see the potential influence of wider power structures in the accounts above. It is argued that in ‘western’ culture this wider political context is one of neo-liberalism which disseminates amongst all the meanings of human distress. Neoliberalism is an economic philosophy which depends on the idea of independent rational individuals competing with one another, to consume and achieve. A diagnostic perspective locates the cause for distress, and the responsibility to overcome it, within individuals rather than in social structures. It is through these distal powers that people, and their therapists can locate the responsibility to recover within the individual (McLelland, 2013) therefore neglecting housing insecurity as a significant threat and misuse of power at the hands of the state. The PTMF helps people locate their distress within this context.

Narrative therapy (Freedman & Combs, 1996) is one approach available to clinical psychologists which is compatible with the PTMF. When people seek help, their lives have often become single storied and limited, instead of richly textured and multiply storied (Johnstone & Boyle, 2018). Even if people have not had contact with mental health services, these stories may have become pathologizing and individualizing. The aim in narrative therapy is to therefore promote a development of rich and multiply storied narratives; it can provide a basis for developing stories which engage actively with inequalities and injustice (Combs & Freedman, 2012), allowing for new narratives to emerge for those who have experienced insecure housing.

Overall, the PTMF could be useful when formulating the difficulties of all people, especially marginalised groups who often experience insecure housing. It can enable clinical psychologists and those they support to view distress in the context of injustice. Having said this, Carey (2019) states that the PTMF is often used within individual therapy, therefore potentially perpetuating the idea of individual responsibility for change. A focus on strength and resilience may also play in to blaming language and could be used to cover up the role of injustice, oppression, and privilege, much like the diagnostic framework which it intends to offer an alternative to. Also, narrative therapy, despite its utility in exploring more adaptive discourses still expects individuals engaged in therapy to make the necessary changes to their narrative, as opposed to tackling wider structures. CPs aiming to tackle the wider structures underlying housing oppression, as alluded to in the PTMF, may need to consider further interventions. The case for this is strengthened when considering housing as a fundamental right.

Housing, a human right

The right to adequate housing is recognised as a basic human right by the United Nations and is enshrined in international law through the Universal Declaration of Human Rights 1948. This right should not be interpreted narrowly and should include protection against forced eviction, the right to choose one’s residence, security of tenure, equal and non-discriminatory access to adequate housing, and affordability (Office of the United Nations High Commissioner for Human Rights, 2009). Maslow’s ‘Hierarchy of Needs’ (Maslow, 1943 as cited in McCleod, 2018) is a motivational theory in psychology made up of five-tiers of human need. Needs lower down in the hierarchy need to be satisfied before needs higher up can be attended to. At the bottom of the hierarchy lay the basic needs which include physiological needs: food, water, warmth, rest; and safety needs which include security, and safety. Housing should therefore not only be considered a human right, but a fundamental human need. Maslow posits that only after basic needs are met can psychological needs such as relationships and accomplishment be sought after and obtained.

Often, people seek therapy for difficulties in their relationships with others and their emotional experience (NHS, 2018). How do CPs expect meaningful and long-lasting positive change for those they support, if they are unable to meet their basic need of a home?

Liberation as intervention

In line with a human rights approach, critical CP, David Smail (2011) argues that a psychological analysis of distress must “diagnose not individuals, but their environments” (p. 235). They are critical of individual therapy, stating that it endorses the narrative that success and survival depend on individual initiative and an ability to exercises agency. They posit that psychotherapy offers little for ‘ordinary people’ as the cause of their distress is a combination of power and influence which is well beyond their own, or any CPs’ ability to control. He encourages us to abandon the illusion of psychological therapy and turn our attention to making the world a better place for people to live in.

It has been argued that poor housing and homelessness are caused by structural factors perpetuated by a neoliberal political landscape (Forrest & Hirayama, 2009), therefore Smail’s argument might be one that CPs consider. Having said this, realising the enormity of such a problem can leave people feeling paralysed; the long-term effort required might be intimidating to those CPs who feel they have limited time, expertise, and availability (Rogers et al., 2012). In 2010, an American Psychological Association survey found that ninety percent of CPs were open to working with the homeless, however many felt they needed more training, time, or funding to get involved (APA, 2010, as cited in Rogers et al., 2012). Ecological systems theory (EST) (Bronfenbrenner, 1992) can offer a framework when thinking about where to intervene in a system and help overcome some of these barriers. The four-levels include the microsystem (individual’s immediate environment, such as their home), mesosystem (level of interaction between microsystems), exosystem (environment which indirectly affects the individual), macrosystem (societal beliefs, political context), and chronosystem (transitions and shifts in one’s lifespan). So, we know ‘where’, but ‘how’ do we implement change as CPs?

Liberation psychology (Martίn-Baró & Martίn- Baró, 1994) could hold the answer. It posits that social structures which lead to violence, poverty, and prejudice are the underlying causes of oppression, and therefore distress. It argues that western clinical psychology interventions are often inadvertently used to promote social control and conformity that are necessary to sustain the oppressive political, economic, and social status quo (Duran, 2006, as cited in Duran et al., 2008). It is therefore interested in liberation and collective social action in order to transform oppressive structures and alleviate human distress (Moane, 2003). The “cycle of liberation” (Moane, 2003, p.99) advocates for implementing change at the personal, interpersonal, and political level. Taking inspiration from the Irish Republican women’s liberation movement, Moane (2003) acknowledges a need to first build strengths at the personal level such as developing a sense of history, assertiveness, and cultivating creativity, due to internalised oppression. At the interpersonal level, making connections through a group context can foster solidarity, support, and cultivate community. The aims of intervention at the political level are to develop strategies and a sense of agency, in order that individuals can take collective action.

Housing insecurity is oppressive, especially for those from marginalised groups. CPs already offer some support to these groups at the personal level. Many of the approaches endorsed by the PTMF aim to contextualise distress as a response to the misuse of power and to explore alternative narratives. However, in taking a liberation approach, CPs must work at the other levels and do more at the personal. McClelland (2013) argues for a social inequalities approach to formulation, which goes beyond traditional methods, emphasising the effects of social and cultural contexts on distress. At the interpersonal and exo level, this could include encouraging colleagues to consider an alternative approach, which is less individualistic and considers the impact of housing oppression on psychological wellbeing (Carey, 2019). CPs could also consider using power mapping in their work, a form of formulation that sees distress as a consequence of lack of power and resources available to an individual (Hagan & Smail, 1997).

CPs could also intervene at the macro level through use of media, and social media. Psychologists for social change (PSC), a network of psychologists who are interested in applying psychology to policy and political action, are an example of this (PSC, n.d.). Through online campaigns, briefing papers, and position statements, they have spoken out on the negative psychological impacts of austerity (McGrath et al., 2016), COVID 19 (Head, 2020), and racism (Patel et al., 2020). Furthermore, CPs could make challenging neutrality on issues of oppression such as housing insecurity and homelessness a part of everyday work (Reynolds, 2012).

Collaborative research can be an intervention at the macro level. CPs can choose to carry out neo-pragmatic (Polkinghorne, 1992) research which is meaningful, contributing to positive social change for insecure tenants. This requires challenging the hierarchy of knowledge perpetuated by NICE, which privileges empirical and modernist methods. Such socially informed research has been carried out by Ali (2019), who through qualitative research methods explored the bond between people and their social housing, and Carey (2019), who gave voice to single mothers and their experiences of temporary accommodation and mental health.

If the profession is to stand alongside the oppressed and be critical of power (Moane, 2003) it is important to consider the wider implications. Browne (2016) interviewed CPs who have been involved in macro level work and found that working at this level often came with challenges, professionally and personally. Wider power and the political climate at the time determined remit of work, demonstrating the difficulty of being both in the system, and against it. CPs working withing multi-disciplinary teams (MDTs) in a modern NHS may feel constrained by the system and conflicted whilst trying to facilitate positive change through building relationships with other disciplines. The amount of emotional investment placed practitioners at risk of burnout. Despite this, CPs felt they had contributed to positive policy change and highlighted the danger of viewing such work as on the ‘fringe’ of psychology. It is argued that CPs can draw on well mastered skills to effectively engage in macro level work, such as interpersonal skills and empathy. Notably, a literature review found little support that improved mental health was associated with housing policy interventions (Browne, 2016). This might be due to issues such as poor reputation of area and subsequent lack of opportunities still prevailing, even after the implementation of housing improvements (Thomas et al., 2005). This highlights the importance of considering wider issues and the lived experienced voice in the planning process.

Conclusion

Poor psychological and mental wellbeing are associated with insecure housing. Health and housing inequalities have already been exposed by the pandemic, with people from lower socioeconomic groups facing the brunt. Groups such as asylum seekers, refugees, victims of DV, and minoritized ethnic people are more likely to experience insecure housing, as well as psychological trauma. It is therefore imperative that CPs consider their role in regard to housing insecurity.

Traditional ways of working such as individual NICE recommended therapy may not be appropriate for many people. CPs can learn from the IAPT experiment and aim to challenge the hierarchy of knowledge perpetuated by NICE through socially informed research, seeing lived experience of housing insecurity as an integral source of knowledge.

The PTMF enables CPs to formulate the distress of people linked to housing insecurity in the context of injustice and the misuse of power. This is important considering the little power that marginalised groups might have at their disposal. CPs can move beyond individual therapy, working at the exo and macro level to influence positive change in housing policy. They can also draw on clinical knowledge to ensure the psychological impact of political and social factors which maintain oppressive housing is communicated to policy makers. Liberation psychology and EST can guide CPs in this work; however, a pragmatic approach may need to be taken given the constraints of working within imperfect organisations.

“Therapeutic psychology may just prove to be the great red herring of the twentieth century” (Smail, 2011, p. 226).

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