Homelessness and mental health

In a study in Western societies, homeless people have a higher prevalence of mental illness when compared to the general population. They also are more likely to suffer from alcoholism and drug dependency.[1] It is estimated that 20–25% of homeless people, compared with 6% of the non-homeless, have severe mental illness.[2] Others estimate that up to one-third of the homeless suffer from mental illness.[3] In January 2015, the most extensive survey ever undertaken found 564,708 people were homeless on a given night in the United States. Depending on the age group in question, and how homelessness is defined, the consensus estimate as of 2014 was that, at minimum, 25% of the American homeless—140,000 individuals—were seriously mentally ill at any given point in time. 45% percent of the homeless—250,000 individuals—had any mental illness. More would be labeled homeless if these were annual counts rather than point-in-time counts.[4]

Nikes and Homeless

Studies have found that there is a correlation between homelessness and incarceration. Those with mental illness or substance abuse problems were found to be incarcerated at a higher frequency than the general population.[5] Fischer and Breakey have identified the chronically mentally ill as one of the four main subtypes of homeless persons; the others being the street people, chronic alcoholics, and the situationally distressed.[6]

The first documented case of a psychiatrist addressing the issue of homelessness and mental health was in 1906 by Karl Wilmanns.[7]

Historical context

United States

In the United States, there are broad patterns of reform within the history of psychiatric care for persons with mental illness.[8]:11 These patterns are currently categorized into three major cycles of reform. The first recognized cycle was the emergence of moral treatment and asylums, the second consists of the mental hygiene movement and the psychopathic (state) hospital, and most recent cycle includes deinstitutionalization and community mental health.[9]:727 In an article addressing the historical developments and reforms of treatment for the mentally ill, Joseph Morrissey and Howard Goldman acknowledge the current regression of public social welfare for mentally ill populations. They specifically state that the "historical forces that led to the transinstitutionalization of the mentally ill from almshouses to the state mental hospitals in the nineteenth and twentieth centuries have now been reversed in the aftermath of recent deinstitutionalization policies".[10]:12

Asylums
Further information: Greyhound therapy

Within the context of transforming schemas of moral treatment during the early nineteenth century, the humanitarian focus of public intervention was linked with the establishment of asylums or snake pits[11] for treatment of the mentally ill.[9]:727 The ideology that emerged in Europe disseminated to America, in the form of a social reformation based on the belief that new cases of insanity could be treated by isolating the ill into "small, pastoral asylums" for humane treatment. These asylums were meant to combine medical attention, occupational therapy, socialization activities and religious support, all in a warm environment.

In America, Friends Asylum (1817) and the Hartford Retreat (1824) were among the first asylums within the private sector, yet public asylums were soon encouraged, with Dorothea Dix as one of its key lobbyists. The effectiveness of asylums was dependent on a collection of structural and external conditions, conditions that proponents began to recognize were unfeasible to maintain around the mid-nineteenth century. For example, with the proliferation of immigrants throughout industrialization, the original purpose of asylums as small facilities transformed into their actualized use as "large, custodial institutions" throughout the late 1840s.[10]:15 Overcrowding severely inhibited the therapeutic capacity, inciting a political reassessment period about alternatives to asylums around the 1870s. The legislative purpose of state asylums soon met the role society had funneled them toward; they primarily became institutions for community protection, with treatment secondary.

State mental hospitals

As debates regarding the deteriorating role of American asylums and psychiatry amplified around the turn of the century, new reformation arose. With the founding of the National Committee for Mental Hygiene, acute treatment centers like psychopathic hospitals, psychiatric dispensaries and child guidance clinics were created. Beginning with the State Care Act in New York, states began assuming full financial control for the mentally ill, in an effort to compensate for the deprivations of asylums. Between 1903 and 1950, the number of patients in state mental hospitals went from 150,000 to 512,000. Morrissey recognizes that despite persistent problem of chronic mental illness, these state mental hospitals were able to provide a minimal level of care.[10]:20

Deinstitutionalization

Toward the end of World War II, the influx of soldiers diagnosed with "war neurosis" incited a new public interest in community care. In addition to this, the view that asylums and state hospitals exacerbated symptoms of mental illness by being "inherently dehumanizing and antitherapeutic" spread through the public consciousness. When psychiatric drugs like neuroleptics stabilized behavior and milieu therapy proved effective, state hospitals began discharging patients, with hope that federal programs and community support would counterbalance the effects of institutionalization. Furthermore, economic responsibility for the disabled began to shift, as religious and non-profit organization assumed the role of supplying basic needs.[8]:10 The modern results of deinstitutionalization show the dissonance between policy expectations and the actualized reality.[12]:60–61

Community mental health centers

In response to the flaws of deinstitutionalization, a reform movement reframed the context of the chronically mentally ill within the lens of public health and social welfare problems. Policy makers intentionally circumvented state mental hospitals by allocating federal funds directly to local agencies. For example, the Community Mental Health Centers (CMHC) Act of 1963 became law, "which funded the construction and staffing of hundreds of federal centers to provide a range of services including partial hospitalization, emergency care, consultation, and treatment." Despite efforts, newly founded community centers "failed to meet the needs of acute and chronic patients discharged in increasing numbers from public hospitals". With decreased state collaboration and federal funding for social welfare, community centers essentially proved unable "to provide many essential programs and benefits", resulting in a growth of homelessness and indigency, or lack of access to basic necessities. It is argued that an over reliance on community health has "left thousands of former patients homeless or living in substandard housing, often without treatment, supervision or social support."[9]:727–728

Personal factors

Neurobiological determinants

The mental health of homeless populations is significantly worse than the general population, with the prevalence of mental disorders up to four times higher in the former.[13]:465 It is also found that psychopathology and substance abuse often exist before the onset of homelessness, supporting the finding that mental disorders are a strong risk factor for homelessness.[13]:470 Ongoing issues with mental disorders such as affective and anxiety disorders, substance abuse and schizophrenia are elevated for the homeless.[13]:465[14]:82 One explanation for homelessness states that "mental illness or alcohol and drug abuse render individuals unable to maintain permanent housing."[15]:114 One study further states that 10–20 percent of homeless populations have a dual diagnoses, or the co-existence of substance abuse and of another severe mental disorder. For example, in Germany there is a link between alcohol dependence and schizophrenia with homeless populations.[14]:85

Trauma

There are patterns of biographical experience that are linked with subsequent mental health problems and pathways into homelessness.[13]:465 Martens states that reported childhood experiences, described as "feeling unloved in childhood, adverse childhood experiences, and general unhappiness in childhood" seem to become "powerful risk factors" for adult homelessness. For example, Martens emphasizes the salient dimension of familial and residential instability, as he describes the prevalence of foster-care or group home placement for homeless adolescents. He notes that "58 percent of homeless adolescents had experienced some kind of out-of-home placement, running away, or early departure from home."[14]:82 Moreover, up to 50 percent of homeless adolescents report experience with physical abuse, and almost one-third report sexual abuse.[13]:465 In addition to family conflict and abuse, early exposure to factors like poverty, housing instability, and alcohol and drug use all increase one's vulnerability to homelessness.[16] Once impoverished, the social dimension of homelessness manifests from "long exposure to demoralizing relationships and unequal opportunities."[14]:81

Trauma and homeless youth

Youth experiencing homelessness are more susceptible of developing Post traumatic Stress Disorder (PTSD). Common psychological traumas experienced by homeless youth include, sexual victimization, neglect, experiences of violence, and abuse. [17]

Societal factors

Draine et al. emphasize the role of social disadvantage with manifestations of mental illness. He states that "research on mental illness in relation to social problems such as crime, unemployment, and homelessness often ignores the broader social context in which mental illness is embedded."[18]:566

Social barriers
Main article: Discrimination against the homeless

Stigma

Lee argues that societal conceptualizations of homelessness and poverty can be juxtaposed, leading to different manifestations of public stigma. In his work through national and local surveys, respondents tended to deemphasize individual deficits over "structural forces and bad luck" for homeless individuals. In contrast, the respondents tended to associate personal failures more to the impoverished than homeless individuals.[16]:511

Nonetheless, homeless individuals are "well aware of the negative traits imputed to them – lazy, filthy, irresponsible dangerous – based on the homeless label." In an effort to cope with the emotional threat of stigma, homeless individuals may rely on one another for "non-judgmental socializing." However, his work continues to emphasize that the mentally ill homeless are often deprived of social networks like this.[16]:508

Social Isolation

People who are homeless tend to be socially isolated, which contributes negatively to their mental health.[19] Studies have correlated that those who are homeless and have a strong support group tend to be more physically and mentally healthy.[20] Aside from the stigma received by the homeless population, another aspect that contributes to social isolation is the purposeful avoidance of social opportunity practiced by the homeless community out of shame of revealing their current homeless state.[21] Social isolation ties directly to social stigma in that homeless socialization outside of the homeless community will affect how the homeless are perceived. This is why homeless individuals talking with those who are not homeless is encouraged since it can combat the stigma that is often associated with homelessness.[21]

Racial inequality

One dimension of the American homeless is the skewed proportion of minorities. In a sample taken from Los Angeles, 68 percent of the homeless men were African American. In contrast, the Netherlands sample had 42 percent Dutch, with 58 percent of the homeless population from other nationalities.[14]:89 Furthermore, Lee notes that minorities have a heightened risk of the "repeated exit-and-entry pattern"[16]:511

Institutional barriers

Shinn and Gillespie (1994) argued that although substance abuse and mental illness is a contributing factor to homelessness, the primary cause is the lack of low-income housing.[22] Elliot and Krivo emphasize the structural conditions that increase vulnerability to homelessness. Within their study, these factors are specifically categorized into "unavailable low-cost housing, high poverty, poor economic conditions, and insufficient community and institutional support for the mentally ill."[15]:116 Through their correlational analysis, they reinforce the finding that areas with more spending on mental health care have "notably lower levels of homelessness."[15]:122 Furthermore, their findings emphasize that among the analyzed correlates, "per capita expenditures on mental health care, and the supply of low-rent housing are by far the strongest predictors of homelessness rates."[15]:127 Along with economic hardship, patterns of academic underachievement also undermine an individual's opportunity for reintegration into general society, which heightens their risk for homelessness.[14]:470

On a psychological level, Lee notes that the "stressful nature of hard times (high unemployment, a tight housing market, etc.) helps generate personal vulnerabilities and magnifies their consequences."[16] For example, poverty is a key determinant of the relationship between debilitating mental illness and social maladjustment; it is associated with decreased self-efficacy and coping. Moreover, poverty is an important predictor of life outcomes, such as "quality of life, social and occupational functioning, general health and psychiatric symptoms", all relevant aspects of societal stability.[18]:566 Thus, systemic factors tend to compound mental instability for the homeless. Tackling homelessness involves focusing on the risk factors that contribute to homelessness as well as advocating for structural change.

Consequences

Incarceration

It is argued that persons with mental illness are more likely to be arrested, simply from a higher risk of other associated factors with incarceration, such as substance abuse, unemployment, and lack of formal education. Furthermore, when correctional facilities lack adequate coordination with community resources upon release, the chances of recidivism increase for persons who are both homeless and suffering from a mental illness. Every state in the United States incarcerates more individuals with severe mental illness than it hospitalizes. Incarcerations are due to lack of treatments such as psychiatric hospital beds.[18]:566 Overall, according to Raphael and Stoll, over 60 percent of United States jail inmates report mental health problems.[23]:189 Estimates from the Survey of Inmates in State and Federal Correctional Facilities (2004) and the Survey of Inmates in Local Jails (2002) report that the prevalence for severe mental illness (the psychoses and bipolar/manic-depressive disorders) is 3.1–6.5 times the rate observed for the general population.[23]:192 In relation to homelessness, it is found that 17.3 percent of inmates with severe mental illness experienced a homeless state before their incarceration, compared to 6.5 percent of undiagnosed inmates.[23]:197 The authors argue that a significant portion of deinstitutionalized mentally ill were transitioned into correctional facilities, by specifically stating that "transinstitutional effect estimates suggest that deinstitutionalization has played a relatively minor role in explaining the phenomenal growth in U.S. incarceration levels."[23]:190

Evidence based remediation practices
  • Integrated service system, between and within agencies in policy making, funding, governance and service delivery.
  • Low barrier housing with support services.
  • Building Assertive Community Teams (ACT) and Forensic Assertive Community Teams (FACT).
  • Assisted Community Treatment (ACT)
  • Outreach services that identify and connect homeless to the social service system and help navigate the complex, fragmented web of services.
  • A community based project funding with collaborations between individuals and organizations.

[24]

Modern responses

Through longitudinal comparisons of sheltered homeless families and impoverished domiciled families, there are a collection of social buffers that slow one's trajectory toward homelessness. A number of these factors include "entitlement income, a housing subsidy, and contact with a social worker."[16]:513

Modern efforts to reduce homelessness include "housing-first models", where individuals and families are placed in permanent homes with optional wrap-around services.[16]:514 Furthermore, this effort is less expensive than the cost of institutions that serve tangled needs of the homeless, such as emergency shelters, mental hospitals and jails. Overall, this alternative approach has shown positive outcomes. For example, one study reports an 88 percent housing retention rate for those in Housing First, compared to 47 percent using traditional programs.[23]:128

Additionally, a review of permanent supportive housing and case management on health found that interventions using “housing-first models” can improve health outcomes among chronically homeless individuals, many of whom suffer from substance use disorders and severe mental illness. Improvements include positive changes in self-reported mental health status, substance use, and overall well-being. These models can also help reduce hospital admissions, length of stay in inpatient psychiatric units, and emergency room visits.[25]

Strides have also been made to dress the issue of social isolation within the homeless community.

At last count, 3,000 of the 500,000 residents in Sonoma County were homeless. Of those 3,000 roughly 35% reported suffering from mental illness, and each year these numbers continue to rise. Massive cuts to funding and facility closures throughout the area have forced these individuals to find treatment at local emergency rooms and even the county jail. This proves to be very costly for the county, and a very temporary fix for those in the throes of a mental health crises. Mental illness is never cured after one hospital visit, but rather requires continual treatment and care far beyond a crisis. Studies have shown that long-term treatment can improve the quality of life for many individuals and can reduce the number of homeless in the community. Uninterrupted assistance greatly increases the chances of living independently and greatly reduces the chances of homelessness and incarceration [26]. Fear surrounds the introduction of mentally ill homeless housing and treatment centers into neighborhoods, as they are often associated with increased drug use and criminal activity. Studies show that this is not necessarily the case. One such study was conducted to evaluate the benefits of the Housing First model, which focuses on rapid rehousing in permanent accommodations without sobriety or treatment requirements but facilitates access to treatment resources in order to help individuals attain their mental health/sobriety goals after being housed. Mentally ill homeless individuals with criminal records were studied over a 2-year period, and after being placed in the Housing First program only 30% re-offended. Overall results of the study showed a large reduction in re-conviction, increased public safety, and a reduction in crime rates [27]. A significant decline in drug use was also seen with the implementation of the Housing First model. A study was conducted that showed a 50% increase in housing retention and a 30% increase in methadone treatment retention in program participants [28]. The mentally ill make up a significant portion of the homeless population in Sonoma County, and without long term treatment options they are forced into a cycle of living that puts both themselves and the community at risk. Greatly improving their long-term treatment options can lead to permanent and stable living environments which can reduce the homeless population, improve crime rates, and increase overall public safety.

Conclusion

For some individuals, the pathways into homelessness may be upstream. E.g. issues such as housing, income level, or employment status. For others, the pathways may be more personal or individual. E.g. issues such as compromised mental health and well ‐ being, mental illness, and substance abuse. Many of these personal and upstream issues are interconnected.

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References
  1. Fazel, S; Khosla, V; Doll, H; Geddes, J (2008). "The Prevalence of Mental Disorders among the Homeless in Western Countries: Systematic Review and Meta-Regression Analysis". PLoS Med. 5 (12 b): e225. doi:10.1371/journal.pmed.0050225. PMC 2592351. PMID 19053169.
  2. "Mental Illness and Homelessness" (PDF). National Coalition for the Homeless. July 2009. Retrieved 12 June 2013.
  3. Kami Lloyd. "Homelessness and Mental Health". A Campaign for Mental Healthcare. Archived from the original on 2012-12-31. Retrieved 13 June 2013.
  4. Org, M. I. P. "Homeless Mentally Ill Facts and Figures". Mental Illness Policy Org. Retrieved 2020-01-19.
  5. Greenberg, GA; Rosenheck, RA (2008). "Jail incarceration, homelessness, and mental health: a national study". Psychiatr Serv. 59 (2): 170–177. doi:10.1176/appi.ps.59.2.170.
  6. Fischer, Pamela J.; Breakey, William R. (Winter 1985–1986). "Homelessness and Mental Health: An Overview". International Journal of Mental Health. 14 (4): 10.
  7. Bhugra (2007), p. 19.
  8. Gittelman, Martin (2005). "The Neglected Disaster". International Journal of Mental Health. 34 (2): 9–21. doi:10.1080/00207411.2005.11043402. JSTOR 41345126.
  9. Goldman, Howard; Joseph Morrissey (1985). "The Alchemy of Mental Health Policy: Homelessness and the Fourth Cycle of Reform". American Journal of Public Health. 75 (7): 727–731. doi:10.2105/AJPH.75.7.727. PMC 1646312. PMID 4003648.
  10. Morrissey, Joseph; Howard Goldman (1986). "Care and Treatment of the Mentally Ill in the United States: Historical Developments and Reforms". The Annals of the American Academy of Political and Social Science. 484 (12): 12–27. doi:10.1177/0002716286484001002.
  11. https://www.youtube.com/watch?v=NGY6DqB1HX8
  12. Williams, Donald (1980). "Deinstitutionalization and Social Policy: Historical Perspectives and Present Dilemmas". American Orthopsychiatric Association. 50 (1).
  13. Shelton, Katherine; Pamela J. Taylor; Adrian Bonner; Marianne van den Bree (2009). "Risk Factors for Homelessness: Evidence from Population-Based Study". Psychiatric Services. 60 (4): 465–472. doi:10.1176/appi.ps.60.4.465. PMID 19339321.
  14. Martens, Willem (2002). "Homelessness and Mental Disorders: A Comparative Review of Populations in Various Countries". International Journal of Mental Health. 30 (4): 79–96. doi:10.1080/00207411.2001.11449534. JSTOR 41344992.
  15. Elliott, Marta; Lauren J. Krivo (1991). "Structural Determinants of Homelessness in the United States". Social Problems. 38 (1): 113–131. doi:10.2307/800641. JSTOR 800641.
  16. Lee, Barrett; Kimberly Tyler (2010). "The New Homelessness Revisited". Annual Review of Sociology. 36: 501–521. doi:10.1146/annurev-soc-070308-115940. JSTOR 25735089. PMC 4045444. PMID 24910495.
  17. Crosby, Shantel; Hsun-Ta Hsu (2018). "Factors that contribute to help-seeking among homeless, trauma-exposed youth: A social-ecological perspective". Children and Youth Services Review. 93: 126–134. doi:10.1016/j.childyouth.2018.07.015.
  18. Draine, Jeffrey (2002). "Role of Social Disadvantage in Crime, Joblessness, and Homelessness Among Persons With Serious Mental Illness" (PDF). Psychiatric Services. 53 (5): 565–573. doi:10.1176/appi.ps.53.5.565. PMID 11986504.
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  24. http://www.victoria.ca/assets/City~Hall/Documents/tskfrc_brcycl_exctvs.pdf
  25. "Rapid Evidence Review: What Housing-related Services and Supports Improve Health Outcomes among Chronically Homeless Individuals?". AcademyHealth: Advancing Research, Policy and Practice. AcademyHealth. Archived from the original on 2016-09-19.
  26. Yoon, Bruckner, & Brown, 2013
  27. Somers, Rezansoff, Moniruzzaman, Palepu, & Patterson, 2013
  28. Palepu, Patterson, Moniruzzaman, Frankish, & Somers, 2013

Bibliography

  • American Psychiatric Association. Task Force on the Homeless Mentally Ill (1992), Lamb, H. Richard; Bachrach, Leona L.; Kass, Frederic I. (eds.), Treating the Homeless Mentally Ill: A Report of the Task Force on the Homeless Mentally Ill, American Psychiatric Pub, ISBN 9780890422366
  • Bhugra, Dinesh (2007), Homelessness and Mental Health: Studies in Social and Community Psychiatry, Cambridge University Press, ISBN 9780521037730
  • Conrad, Kendon J.; Matters, Michael D.; Hanrahan, Patricia, eds. (1999), "Homelessness Prevention in Treatment of Substance Abuse and Mental Illness: Logic Models and Implementation of Eight American Projects", Alcoholism Treatment Quarterly, Psychology Press, ISBN 9780789007506
  • Kuhlman, Thomas L. (1994), Psychology on the streets: mental health practice with homeless persons, Personality Processes Series, 178, J. Wiley & Sons, ISBN 9780471552437
  • Seager, Stephen B. (1998), Street Crazy: America's Mental Health Tragedy, Westcom Press, ISBN 9780966582772
  • Whitbeck, Les B. (2012), Mental Health and Emerging Adulthood Among Homeless Young People, Psychology Press, ISBN 9781136910845
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