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 be alcoholics and suffer from 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] 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.^[4] 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.^[5]

The first documented case of a psychiatrist addressing the issue of homelessness and mental health was in 1906 by Karl Wilmanns.^[6]

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.^[7]: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.^[8]: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”.^[9]:12 Ultimately, Morrissey and Goldman argue that while each transition expanded the American mental health system into today’s “pluralistic patchwork of public and private” structural efforts, each failed to make lasting effects on the societally debilitating nature of chronic mental illness, including the linked effects of poverty and homelessness.

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 for treatment of the mentally ill.^[8]: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.^[9]: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.^[9]: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.^[7]:10 The modern results of deinstitutionalization show the dissonance between policy expectations and the actualized reality.^[10]: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.” ^{[8]: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.^[11]: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.^[11]:470 Ongoing issues with mental disorders like affective and anxiety disorders, substance abuse, depression, schizophrenia are elevated for the homeless.^{[11]:465 [12]:82} One explanation for homelessness states that “mental illness or alcohol and drug abuse render individuals unable to maintain permanent housing.”^[13]: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.^[12]:85

Trauma

There are patterns of biographical experience that are linked with subsequent mental health problems and pathways into homelessness.^[11]: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."^[12]:82 Moreover, up to 50 percent of homeless adolescents report experience with physical abuse, and almost one-third report sexual abuse.^[11]: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.^[14] Once impoverished, the social dimension of homelessness manifests from “long exposure to demoralizing relationships and unequal opportunities.”^[12]:81

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.”^[15]:566

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.^[14]: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.^[14]:508

Racial inequality

One dimension of the American homeless is the skewed proportion of minorities. In a sample taken from Los Angeles, 67.5 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.^[12]:89 Furthermore, Lee notes that minorities have a heightened risk of the “repeated exit-and-entry pattern”^[14]:511

Institutional barriers

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.”^[13]:116 Through their correlational analysis, they reinforce the finding that areas with more spending on mental health care have “notably lower levels of homelessness.”^[13]: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.”^[13]: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.^[12]:470

On a psychological level, Lee notes that the “stressful nature of structural hard times (high unemployment, a tight housing market, etc.) helps generate personal vulnerabilities and magnifies their consequences.” ^[14] 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.^[15]:566 Thus, systemic factors tend to compound mental instability for the homeless.

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 formal education.^[15]:566 Overall, according to Raphael and Stoll, over 60 percent of United States jail inmates report mental health problems.^[16]: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 (manic depression, bipolar disorder, or a psychotic disorder) is 3.1-6.5 times the rate observed for the general population.^[16]: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.^[16]: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.” ^[16]:190

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."^[14]:513

Modern efforts to reduce homelessness include “housing-first models”, where individuals and families are placed in permanent homes with optional wrap-around services.^[14]: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.^[16]:128

References

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