Homelessness and Mental Illness
Research problem: Homelessness
Research question: Why is the mental health population and people with disabilities more susceptible to becoming homeless?
Mental health policies that underserve vulnerable people are a major cause of homelessness. The deinstitutionalization of mental hospitals, including the failure of aftercare and community support programs are linked to homelessness. Also, restrictive admission policies that keep all but the most disturbed people out of psychiatric hospitals have an effect on the rising number of homeless people. The New York State Office of Mental Health interviewed 107 randomly chosen men using shelters and found that fewer than 25 percent of them required psychiatric services. Bassuk clinically evaluated 78 guests at a Boston shelter on five successive nights and found a 90-percent rate of diagnosable mental illness. Something to note when doing research on homelessness is that the definition of what constitutes homelessness has not been established across studies.
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An examination of the Psychiatric Severity Index showed that a majority of the respondent group was in the zero category (69 percent). Of the remaining 31 percent, seventy scores were variable, but tended to follow the pattern of fewer and fewer respondents having more serious problems. For example, 18 percent of the respondent group had at least one problem, another 10 percent has two problem symptoms, and fewer than 5 percent had a combination of three or four symptoms.
The Behavioral Disturbance Severity Index suggested that behavioral disturbance problems tended to be more prevalent within the homeless group. Forty-six percent of the
Homelessness and Mental Illness 3 respondent group had scores of zero. Another 37 percent reported one or two problem symptoms, and the remainder, approximately 17 percent, had three or more symptoms at the moderate and above level of severity.
Traditional interpretations about psychiatric symptomatology among homeless people were confounded by the fact that a homeless lifestyle typically includes characteristics and behaviors that can result either from mental illness or the stresses of street life or both. Dohrenwend, Lovav, and Shrout argued that the Psychiatric Severity Index measures mental illness similar to how one’s temperature measures physical illness – “an elevated temperature does not indicate the source of the disorder but does suggest that illness might be present” (Bean et al.).
The presence of multiple symptoms as indicated of the Psychiatric Severity Index was a valid measure of problem magnitude or risk. Estimates based on the measure showed that about 31 percent of the respondent group presented problems or symptoms that possibly required a mental health service. Increasing Psychiatric Severity Index scores corresponded to increasing needs for more intensive services.
In past literature, it is presumed that most homeless people suffer from mental illness. In some studies that ranges vary from between 25 and 50 percent to more than 90 percent in other studies. The rate of 31 percent obtained in the current study is well below those averages because the rate reflected a range of problems and not just those that were chronic or severe.
When noting the behavioral disturbances that were found in this study, some of them may be related to mental illness, but they may also be related to the effects that a homeless lifestyle
Homelessness and Mental Illness 4 has on a person. “Dirty clothes, poor hygiene, flattened affect, and dulled responses are likely the rule rather than the exception for people faced with basic daily survival problems” (Bean et al.).
Some people believe that homeless people are psychiatrically impaired by virtue of their condition. For these people, homelessness becomes a principal diagnostic influence. Homeless people certainly possess many of the characteristics that have been found to increase the risks of mental illness – poor, minorities, minimal social support, general disenfranchisement. “Preconceived notions about the causal link between mental illness and homelessness introduces and insidious bias that can distort seriously prevalence estimates and clinical profiles” (Bean et al.).
According to the 2016 Annual Homeless Assessment Report, over 30,000 unaccompanied homeless young adults (ages 18 to 24) were identified across the United States (Narendorf). Prior studies have found that over two thirds of homeless youth and young adults meet criteria for a mental disorder. In a study of 161 homeless youth that accessed homeless services in London, Craig and Hodson (1998) found that 70% with diagnosable mental disorders reported onset of these disorders prior to homelessness. Another critical aspect of understanding mental disorders among homeless youth is the presence of trauma, both before and after homelessness.
Disrupted support networks, combined with challenging behaviors and fragile family systems, contributed directly to housing instability and homelessness. Homeless youth often reported getting “kicked out” which resulted in their homelessness. The participants acknowledged that their behavior played a part in this. “This behavior generally involved Homelessness and Mental Illness 5 substance use and impulsive behaviors, which were sometimes tied specifically to a diagnosis or stopping medications but other times just as a desire to be independent” (Narendorf).
While mental health problems contributed to the causes of homelessness, homelessness also contributed to mental health problems. Some participants described how homelessness only made their mental health problems or systems worse. One girl spoke about how her homelessness has led her to think that suicide is an option.
A prominent feature that appeared in multiple aspects of the narratives of homeless youth was substance use. Substance use was described as a contributing factor to both homelessness and mental health problems. Substance use fueled family conflict and led to participants being kicked out and it also increased financial problems that led to homelessness. Using substances as a way of managing mental health problems instead of medications was common among participants and linked to homelessness in a few ways. Sometimes, young people directly connected stopping their medications and starting substances as a reason for homelessness.
A number of participants talked about the intersection of homelessness and other types of adversity that then contributed to mental health problems. Examples of adversity across the sample included legal involvement, domestic violence, abuse on the streets, having children taken away by the child welfare system and testing positive for HIV. In some cases, homelessness, was part of a series of events that included traumatic experiences and mental health problems.
The findings illustrate the complex relationship between mental health problems and homelessness. We found that disrupted support networks, traumatic experiences, substance use, Homelessness and Mental Illness 6 and system involvement were all contributing factors that need to be considered and addressed in providing care for this group. Interventions should ideally include stable housing along with co-morbid substance abuse and mental health treatments that address the impacts of traumatic experiences. In addition, ongoing supports to assist youth in repairing and building supportive relationships are indicated since this was often at the heart of homeless experiences (Narendorf).
When homeless children age 6 to 17 years are compared with their peers, higher rates of mental disorders exist (Anderson, 2008). Unstable relationships associated with addiction issues and domestic violence were factors related to homelessness. In a study conducted in the United Kingdom with 113 homeless families, “it was found that 85% became homeless as a result of violence issues with 54% as a result of spousal separation. The study also found that 49% of the mothers experienced psychiatric disorders” (Amerson, 2008). Two studies conducted in 1993 and 2003 found an increase in women experiencing acute and chronic mental health problems such as depression and post-traumatic stress disorder.
When Harpaz-Rotem et al interviewed 195 mothers who were veterans of the US armed forces they found increased mental health issues in children was associated with the mother’s own emotional problems and a history of incarceration (Amerson, 2008). The research aslo shows that there is a connection between homelessness and how children perform in school. Homeless children are more likel to be asbsent in school and have parents who are not involved in their academic development. These children are more likely to be held back in school, not read at grade level or experience developmental delays. Improved education may help these families get out of the cycle of poverty. “If health providers do not address homeless children’s academic Homelessness and Mental Illness 7 and emotional needs, the chances of breaking the cycle of family violence and poverty are doomed for failure” (Amerson, 2008).
In a study of homeless veterans, homelessness history was associated with unemployment, lower disability income, severe depressive, anxiety, posttraumatic stress disorder, and post concussive symptoms, and lower performances on two of fifteen neurocognitive tests (Twamley et al., 2018). Current unemployment and substance use disorder was significantly associated with lifetime homelessness.
Risk factors for homelessness among Veterans include SUDs, mental disorders, history of traumatic brain injury (TBI), younger age, Black and Hispanic race/ethnicity, unmarried status, shorter duration of separation from the military, lower educational levels and military pay grades, and having received treatment for military sex trauma (Twamley et al., 2018). Cognitive deficits interfere with be ability to sustain income in order to live and support in rehabilitation. The deficits may interact with other mental health problems which increase the risk of sustained homelessness (Twamley et al., 2018).
The rate of lifetime homelessness in the sample was 6.8% and approximately 86.5% of the sample sustained mild TBIs. Ever-homeless Veterans were equally likely to fail the performance validity criterion relative to never-homeless Veterans. Homelessness history was not associated with TBI severity indicators (Twamley et al., 2018). Veterans with a history of homelessness were more likely to be unemployed, received lower levels of disability income, had more severe depressive, anxiety, PTSD, and postconcussive symptoms, and were more likely to have diagnoses of depression and PTSD.
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Amerson, R. (2008). Mental Illness in Homeless Families. The Journal for Nurse Practitioners, 4, 109–113. https://doi-org.ezp.waldenulibrary.org/10.1016/j.nurpra.2008.01.001
Bean, G. J., Stefl, M. E., & Howe, S. R. (1987). Mental health and homelessness: issues and findings. Social Work, 32(5), 411–416. Retrieved from https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=swh&AN=18468&site=eds-live&scope=site
Boyd, J. E., Hayward, H., Bassett, E. D., & Hoff, R. (2016). Internalized stigma of mental illness and depressive and psychotic symptoms in homeless veterans over 6 months. Psychiatry Research, 240, 253–259. https://doi-org.ezp.waldenulibrary.org/10.1016/j.psychres.2016.04.035
Fernández García-Andrade, R., Serván Rendón-Luna, B., Medina Téllez de Meneses, E., Vidal Martínez, V., Bravo Ortiz, M. F., & Reneses Prieto, B. (2018). Original Article: Criminal behavior among homeless individuals with severe mental illness. Spanish Journal of Legal Medicine, 44, 55–63. https://doi-org.ezp.waldenulibrary.org/10.1016/j.remle.2017.09.001
Martijn, C., & Sharpe, L. (2006). Pathways to youth homelessness. Social Science & Medicine, 62, 1–12. https://doi-org.ezp.waldenulibrary.org/10.1016/j.socscimed.2005.05.007
Narendorf, S. C. (2017). Intersection of homelessness and mental health: A mixed methods study of young adults who accessed psychiatric emergency services. Children and Youth Services Review, 81, 54–62. https://doi-org.ezp.waldenulibrary.org/10.1016/j.childyouth.2017.07.024
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Twamley, E. W., Hays, C. C., Van Patten, R., Seewald, P. M., Orff, H. J., Depp, C. A., … Jak, A. J. (2018). Neurocognition, psychiatric symptoms, and lifetime homelessness among veterans with a history of traumatic brain injury. Psychiatry Research, 271, 167–170. https://doi-org.ezp.waldenulibrary.org/10.1016/j.psychres.2018.11.049