People experiencing homelessness and their experiences with substance use services for alcohol treatment in England:...

Alcohol consumption at high levels is common among people experiencing homelessness and contributes to inequalities. In relative terms these individuals are underrepresented in substance use services. This study captured common trajectories and identified barriers and facilitators to accessing treatment among a group of people currently experiencing homelessness and who have used or have been eligible for alcohol treatment.

Qualitative study in which we conducted 32 semi-structured 'journey-mapping' interviews with individuals currently experiencing homelessness and currently or previously using alcohol harmfully. Interviews were conducted in London homeless centres (UK), audio-recorded and transcribed verbatim. We used a life course-informed, journey-mapping thematic analysis (with elements of reflexive thematic analysis) to capture how participants made sense of their trajectories of alcohol use and recovery.

Overall, we generated six themes describing participants' journeys: 'Early access & exposure to alcohol', 'Drivers and vulnerabilities for heavy alcohol use', 'Sustained heavy alcohol use: coping mechanisms, consequences and compounding challenges', 'Systemic, interpersonal and environmental barrier to recovery', 'Internal path towards recovery: growth, relationships and motivation' and 'Recovery through external support systems and structures'. Participants often situated the onset of heavy drinking in childhood trauma and adverse family environments, describing alcohol as a coping mechanism for emotional pain. Homelessness was narrated as both a consequence and driver of drinking, with environmental factors such as sleeping rough and shared identities around heavy drinking reinforcing consumption. Recovery was portrayed as a deeply personal process requiring internal motivation, autonomy and supportive relationships. Barriers of accessing care included long waiting times, administrative hurdles and negative service experiences, while facilitating factors comprised stable housing, personalised care and peer support. Transformative shifts in perspective and the development of self-compassion were described as pivotal turning points.

Among people experiencing homelessness, heavy drinking appears to be commonly rooted in childhood trauma and adverse family environments, with homelessness described as both a consequence and a reinforcing driver of alcohol use. Recovery is portrayed as a highly personal process supported by stable housing, personalised care and meaningful relationships, including peer support.