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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. It is estimated that 20–25% of homeless people, compared with 6% of the non-homeless, have severe mental illness. Others estimate that up to one-third of the homeless have a mental illness. 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.
Being chronically homeless also means that people with mental illnesses
are more likely to experience catastrophic health crises requiring
medical intervention or resulting in institutionalization within the
criminal justice system.
Majority of the homeless population do not have a mental illness.
Although there is no correlation between homelessness and mental health,
those who are dealing with homelessness are struggling with
psychological and emotional distress. The Substance Abuse and Mental
Health Services Administration conducted a study and found that in 2010,
26.2 percent of sheltered homeless people had a severe mental illness.
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. 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.
The first documented case of a psychiatrist addressing the issue of homelessness and mental health was in 1906 by Karl Wilmanns.
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.
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.
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".
Asylums
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 for treatment of the mentally ill.
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.
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.
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 disabled people began to shift, as religious and non-profit
organization assumed the role of supplying basic needs. The modern results of deinstitutionalization show the dissonance between policy expectations and the actualized reality.
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."
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. United States president John F. Kennedy signed the Community Mental Health Act that was put in place to give funding for community-based facilities rather than having patients going to state hospitals.
Decades later, once the Community Mental Health Act was implemented a
lot of state hospitals suffered and were on the verge of forced to close
which pushed patients to the community-based facilities. The closures
of the state hospitals lead to an overcrowding in the community
facilities and there was a lack of support, which lead to patients not
having access to the medical help they needed.
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.
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.
Ongoing issues with mental disorders such as affective and anxiety
disorders, substance abuse and schizophrenia are elevated for the
homeless.
One explanation for homelessness states that "mental illness or alcohol
and drug abuse render individuals unable to maintain permanent
housing."
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.
Trauma
There are
patterns of biographical experience that are linked with subsequent
mental health problems and pathways into homelessness.
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."
Moreover, up to 50 percent of homeless adolescents report experience
with physical abuse, and almost one-third report sexual abuse.
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.
Once impoverished, the social dimension of homelessness manifests from
"long exposure to demoralizing relationships and unequal opportunities."
Trauma and homeless youth
Youth
experiencing homelessness are more susceptible to developing
post-traumatic stress disorder (PTSD). Common psychological traumas
experienced by homeless youth include, sexual victimization, neglect,
experiences of violence, and abuse.
In an article published by Homeless Policy Research Institute it notes
that homeless youth are subjected to many different forms of trauma. A
study was done and found that 80% of youth that experienced homelessness
in Los Angeles suffered at least one traumatic experience. Another
study was conducted in Canada that showed a more severe statistic that
Canadian homeless youth have been through 11 to 12 traumatic
experiences.
While trauma is prevalent in homeless youth, it is not uncommon for an
adolescent to experience an increase of trauma after they experience
homelessness. The LGBTQ community represents 20% of the homeless youth
population. The reason for this high percentage is due to the issues
and/or rejection from their family due to the sexual orientation.
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."
Social barriers
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.
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.
Social isolation
People who are homeless tend to be socially isolated, which contributes negatively to their mental health.
Studies have correlated that those who are homeless and have a strong
support group tend to be more physically and mentally healthy.
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.
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.
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. Furthermore, Lee notes that minorities have a heightened risk of the "repeated exit-and-entry pattern"
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.
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."
Through their correlational analysis, they reinforce the finding that
areas with more spending on mental health care have "notably lower
levels of homelessness."
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."
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.
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."
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. 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 have 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. Overall, according to Raphael and Stoll, over 60 percent of United States jail inmates report mental health problems.
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.
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.
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."
Responses
Responses
to mental health and homelessness include measures focused on housing
and mental health services. Providers face challenges in the form of
community adversity.
Housing
Modern
efforts to reduce homelessness include "housing-first models", where
individuals and families are placed in permanent homes with optional
wrap-around services.
This effort is less expensive than the cost of institutions that serve
the complex needs of people experiencing homeless, such as emergency
shelters, mental hospitals and jails. The alternative approach of
housing first has shown positive outcomes. One study reports an 88
percent housing retention rate for those in Housing First, compared to
47 percent using traditional programs.
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 have 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.
There is a new intervention called "Permanent Supportive Housing" that
was designed help independent living and help with employment and health
care. 407,966 individuals were homeless in shelters, transitional
housing programs, or on the streets.
Those with mental illnesses have difficulty not only with their current
housing issues, but have issues with housing if they get evicted. Youth
can benefit from permanent housing, increases social activity, and
improve mental health. Federally funded rental assistance are in place, but due to the high demand of the funds, the government is unable to keep up.
One study evaluating the efficacy of the Housing First model
followed mentally ill homeless individuals with criminal records over a
two-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.
A significant decline in drug use was also seen with the implementation
of the Housing First model. The study showed a 50% increase in housing
retention and a 30% increase in methadone treatment retention in program
participants.
Mental health services
Uninterrupted
assistance greatly increases the chances of living independently and
greatly reduces the chances of homelessness and incarceration.
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." These social buffers can also be effective in supporting individuals exiting homelessness. One study utilizing Maslow's hierarchy of needs
in assessing housing experiences of adults with mental illnesses found a
complex relationship between basic needs, self-actualization, goal
setting, and mental health.
Meeting self-actualization needs are vital to mental health and
treatment of mental illness. Housing, stable income, and social
connectedness are basic needs, and when met can lead to fulfillment of
higher needs and improved mental health. Those with a brief history of
homelessness and managed disabilities may have better access to housing.
Research calls for evidence based remediation practices that transform mental health care into a recovery oriented system. The following list includes practices currently being utilized to address the mental health needs of homeless individuals:
- 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.
Challenges
Fear
surrounds the introduction of mentally ill homeless housing and
treatment centers into neighborhoods, due to existing stereotypes that
homeless individuals are often associated with increased drug use and
criminal activity. The Housing First Model study, along with other
studies, show that this is not necessarily the case. Proponents of the NIMBY
(not-in-my-backyard) movement have played an active role in the
challenges faced by housing and mental health service interventions for
the homeless.
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.
