Mental Health of the Homeless

            Homelessness is a harsh reality for many people throughout the United States and around the globe. The homeless are a highly stereotyped and stigmatized group within American culture. Many are feared and dehumanized because of society’s lack of understanding. They are often associated with psychiatric disorders, alcohol and substance abuse, and criminal activity. Why do the homeless often carry these characteristics? The mental health of the homeless population remains not fully understood, and adequate homeless support programs are in short supply.

            There is plenty of research that has been done on the mental health of homeless populations, but the research has many complications. To start with, there is no generally accepted definition of homeless. Almost all definitions include people who lack housing of their own, but many studies use divergent definitions of homelessness. This causes discrepancies amongst the data collected in different studies. A cohesive definition would be beneficial for the interpretation of research studies and for the understanding the conditions of homelessness in other regions. Another problem with the research is that most of it is funded by agencies that have their own agendas, which results in biased study results. On top of that, the incidence of homelessness and its associated mental health problems vary from one community to another and evolves over time. Research done in a specific region is not always applicable to another, further diluting the knowledge of the subject. Despite these discrepancies, there is still valuable information about the mental health of homeless population that can be used from current research (Vazquez & Munoz 2001).

            People do not end up homeless simply by coincidence or because of lack of ambition and effort; there is a series of social reasons that have caused them to end up where they are. There are both structural and individualistic explanations for homelessness. Structural reasons include the lack of affordable housing, changes in the economy, an increase in the availability of illicit drugs, declining appeal of marriage, the prevalence of sexism and racism, and lack of support for the disabled (Vazquez & Munoz 2001). Lack of ambition or talent, traumatic life events, and debilitating effects of illness, including drug and alcohol dependency, are all individualistic causes of homelessness (Vazquez & Munoz 2001). It is also common for women and children to enter homelessness to flee domestic violence situations, especially since the increase in emergency housing within the U.S. (Vazquez & Munoz 2001). In other words, as emergency housing became more available, people suffering from domestic violence became more willing to leave their homes. However, the loss of employment and insufficient income to retain housing are the most prevalent reasons for homelessness (CIHI & CPHI 2007). Homelessness cannot be fully explained by either structural or individualistic explanations, as both are immense contributors to the problem.      

Whatever the cause, homelessness is an enormous problem in the United States; there are more than 630,000 people who are homeless every night (Burt et al. 2001). Approximately 30 percent of homeless people have serious mental disorders, and more than 80 percent, if other disorders such as anxiety and antisocial personality are included (Vazquez & Munoz 2001). Approximately half of homeless adults have substance dependencies, many of whom suffer from comorbidity (PRA & CMHS 2003). Other common mental illnesses among the homeless are PTSD (most frequently from domestic violence or war), depression, anxiety, manic-depressive disorder, schizophrenia, alcoholism, and, frequently, comorbidity. These are daunting statistics, but the U.S. has the information and capability to alleviate these problems.

Some people develop mental illness prior to losing their shelter. There is a complexity of biological, psychological, and sociological explanations of why these people develop mental illness. Regardless of what causes it, a person with a severe mental illness is more likely to become homeless than a person who does not suffer from one (Toro & Janisse 2004). Mental illness can create a burden upon family and friends, resulting in a loss of social support. Some mentally ill people find school difficult and lack substantial education. With many of the mentally ill finding it difficult to maintain job security and proper self-care, they often end up institutionalized or on the streets. Although almost half of homeless people have a lifetime diagnosis of mental illness, it is argued that it is a relatively uncommon cause of homelessness (CIHI & CPHI 2007; Toro & Janisse 2004). If this is true, it is much more common for people to be diagnosed as mentally ill after they have become homeless. Unemployment rates, household resources (such as education and skills of workers, social support networks, financial resources, and vulnerabilities), the presence and severity of disabilities and illnesses, and social policy for people with disabilities, all affect income. The combination of low household income with the poor availability and high cost of housing often results in homelessness (Burt et al. 2001). This can be seen in Figure 1.1 on the next page, which was taken from Helping America’s Homeless by Martha Burt and co-authors. This cause of homelessness has become more common since 2008 when the recession began, increasing unemployment and lowering employment opportunities. The closing of mental institutions also accounts for much of the rise in homelessness throughout the last several decades (Toro & Janisse 2004). Other factors that distinguish the homeless from other populations include more alcohol and drug dependencies, dysfunctional backgrounds, community violence, and higher levels of stress (Toro & Janisse 2004).

            Most homeless individuals have very stressful life-circumstances, lack adequate social support, and have low levels of self-esteem. It is common for them to not have social support because they have fled a domestic situation or have burned-out their friendships and family support by being too much of a financial or emotional burden. The fall into poverty causes loss of self-esteem and self-worth. Without social support and self-esteem, which act as buffers against the effects of stress, stress can have a great impact on an individual’s mental health (Thoits 2010). Homelessness causes a great amount of stress on an individual:

The absence of shelter exposes homeless persons to the weather, violence, and other threatening conditions. They have trouble fulfilling basic needs that most Americans take for granted, such as finding a job, obtaining nutritionally adequate meals, getting around town, washing clothes, storing belongings, and locating toilet and bathing facilities. (Barrett 2001)

Because of this, many people who are biologically predisposed to mental illness are triggered by the stress of homelessness. Many others turn to alcohol or drugs to help alleviate their stress, which often leads to addiction and can also act as a trigger of other mental illnesses. 

         Alcohol and drug dependencies among the homeless population are huge problems, especially in the United States. The prevalence of substance dependence, including alcohol, was 72.6 percent in a Los Angeles sample (Vazquez & Munoz 2001).  This number is approximately twice as high as the prevalence among most European regions, with the exception of Germany where there is a high prevalence of alcohol dependency (Vazquez & Munoz 2001). The difference in these rates can be explained by the number and quality of treatment facilities in the region, along with the variance in cultural norms of alcohol and drug use. Europe has healthcare systems that are more inclusive of the lower class, and has lower rates of drug and alcohol dependencies. Substance abuse often is paired with affective disorders, which makes treatment more difficult (Vazquez & Munoz 2001). Substance abuse is problematic because it leads to mental and physical complications and deviant behavior: “more social problems (e.g., effects on work, school, or childcare), emotional problems (e.g., lack of interest, depression), and health problems (e.g., hepatitis) related to alcohol and drugs” (Vazquez & Munoz 2001). Drugs and alcohol dependencies prevent the homeless from spending their money on the things that they really need (food and shelter), which causes them to become less healthy. Homeless support programs and shelters typically do not allow drug or alcohol use. Because of this, many addicts choose to fulfill their substance dependency rather than taking advantage of available shelter and services. In order to afford both their addiction and their basic needs, they may participate in panhandling, exploitive labor, or illegal activities such as prostitution or drug dealing. Addictions cause people to dive deeper into homelessness and stay homeless longer (Vazquez & Munoz 2001).

            Different people have different durations of homelessness. Some are homeless for short amounts of time (about 80%), some are chronically homeless (about 10%), and others are episodically homeless (about 10%) (Vazquez & Munoz 2001).  The median episode of homelessness is around 5 months, which puts most of the homeless into the short-term category (Lee 2001). People who have severe mental illness and/or addictions frequently fall into the chronic category. As individuals spend increasing amounts of time being homeless, they become more comfortable doing what they need in order to cope with the stresses of homelessness. Many pick up panhandling, going to the bathroom and sleeping in public places, and committing petty crimes. Many are banned from shelters because of alcohol or drug problems, or because they have caused other problems for the shelter’s administration. With more harsh exposure to the environment, they are also more likely to pick up infections. They break an abundance of social norms, act strangely, and do things that the non-homeless typically do not. While the short-term homeless often blend-in or are out of sight at various shelters and social services, it is mostly the chronically homeless that shape the public’s view.

             These negative perceptions lead people to think that ending homelessness is a hopeless cause, as the homeless are just too far gone. The public’s lack of understanding of the path into insanity, addiction or poverty, causes dehumanization and leaves them as others and disenchanted individuals (Weinberg 2005:193). Americans value individualism and the belief that we all have control over our destiny, which leads to the view that “if one is poor, it is one’s own fault, and that poor people are somehow less worthy, less blessed, less chosen, and also less fit than those with money” (Burt et al. 2001).  This individualistic view causes the general public to be less proactive in helping the homeless, as people are more willing to provide assistance to people who are in bad situations because of an external force (Burt et al. 2001).

If homelessness is a primary cause of mental illness, substance dependence, and criminal activity among the homeless population, then it is obvious that the best solution in helping their mental health would be to take steps towards irradiating homelessness (Burt et al. 2001).  The current programs designed to help the homeless of the United States are scarce and insufficient. There needs to be more funding provided to homeless services and the funds need to be better allocated. The homeless are among the most vulnerable people in the United States, but we are not doing a very good job at taking care of them.

The government has put a great deal of emphasis on emergency shelters in recent years. These shelters are costly, not expansive enough to assist entire homeless populations, have done little to irradiate homelessness, and the homeless that are assisted still have the stress of not knowing where they will sleep the next night. It is an ineffective system that needs to be changed. More funds should be allocated to transitional programs designed to get people out of homelessness, rather than to emergency shelters. It is important that people get enough emergency assistance to survive homelessness, but it is common for people to misuse shelters by living in them for extended periods of time. It is more expensive to operate and maintain emergency shelters than it is to provide subsidized housing. In order to relieve homelessness we simply need to “make housing more available and affordable” (Burt et al. 2001:324). If more funds were allocated to transitional programs and rent subsidization, more people would sleep with a roof over their head. Not only are transitional programs less expensive than emergency shelters, but they can also relieve stress and provide consistent social support and encouragement that most homeless individuals desperately need. This support is necessary for many to transition. It is also necessary for many to create and reach goals that will help them become self-sustaining, from gaining employment to engaging them in drug or alcohol treatment (Burt et al. 2001).

            The individuals who are too mentally ill to be successful in transitional programs should be put into permanent supportive housing. Many people have the perception that this would be too costly, but it actually would save money. The seriously mentally ill rack up costs for the government at emergency rooms, prisons, and emergency shelter programs that would be prevented if they were put into permanent supportive housing. The current lack of assistance for this disadvantaged population of our country is unethical and more assistance needs to be implemented (PRA & CMHS 2003).

            It should be taken into account that homeless people tend to cluster in areas that offer the best support services. This can be seen locally in the Willamette Valley. Many people travel from Springfield and other poorer cities in Oregon to Eugene, where there are better services for them. Some of these facilities include The Eugene Mission, ShelterCare, Looking Glass, First Place Family Shelter, The Relief Nursery, Woman’s Space, Egan Warming Center, Oregon Health Plan, and a variety of other organizations. When there are large numbers of transients they can overwhelm the system, causing everyone longer waits for assistance and less quality care. The police force also has a problem with the large numbers of the homeless. They have to work extra diligently to make sure the homeless do not commit crimes, to attempt to keep drugs away, and ensure that there are not conflicts between homeless people and community members. It would make sense for services to be more spread-out and community based. This would allow the homeless to not have to abandon any social support that they have in order to receive assistance, and spread out the homeless problem so that it would not be such a burden on certain areas.

There are also disproportionate groups within homeless populations. There are higher prevalences of males and racial minorities. One explanation for the different prevalence of sexes is the greater abundance of programs available for women, teenagers, and children, than there are for men. Racial minorities are more commonly homeless partially because they are more typically members of the lower class, which is the most common class for the homeless to come from (Duneier 2001). Teenagers frequently become homeless, and have different patterns than homeless adults. Research shows they have lower levels of substance abuse and mental illness than adults. This is because they typically become homeless not out of financial or mental problems, but family problems. It is also because many mental disorders tend to not appear until later in life and they do not have as easy access to alcohol and drugs (Toro & Janisse 2004).

         Approximately 70 percent of the homeless population consists of single adult males. This can be seen at the Eugene Mission, which provides 350-400 guests meals and shelter every night, with a ratio of five single men for every single woman. There is no definite reason why there are so many more homeless men than women. One possibility is that they more frequently have drug and alcohol dependencies (about 70 percent). It is possible that women do not do drugs as frequently as men in order to be better mothers, or that their drug use is underrepresented because of denying drug use to prevent their children from being taken away to protective custody (Toro & Janisse 2004). It could also be argued that not as many women do drugs because society pressures them to internalize their emotions, and that men do drugs to externalize their emotions (Rosenfield 2000).

         Even though there are still many discrepancies in the research of the mental health of the homeless, many important conclusions have been drawn from it. People in the United States need to realize that homelessness is a circumstance, not a personal characteristic. The homeless are vulnerable people who deserve proper assistance, not disenchantment. The United States is capable of more effectively serving the homeless but needs to evolve its homeless support systems in order to do so. The research and understanding of how to do so exists, it just needs to be implemented.

           

Bibliography

Breakey, W. 2004. Mental illness and health. In D. Levinson (Ed.), pp. 383-388 of Encyclopedia of homelessness. Thousand Oaks, CA: SAGE Publications

Burt, M. R. 2001. Helping America's homeless: Emergency shelter or affordable housing? Washington, D.C: Urban Institute Press.

Canadian Institute for Health Information, & Canadian Population Health Initiative. 2007. Improving the health of Canadians, 2007-2008: Mental health and homelessness. Canadian Population Health Initiative.

Duneier, M. 2001. Sidewalk. New York: Farrar Straus & Giroux.

Lee, Barrett A. 2001. Homelessness. Encyclopedia of Sociology. University of Washington: Borgatta, University of Kansas: Montgomery, Rhonda J.V.

Thoits, Peggy A. 2010. Stress and Health:  Major Findings and Policy Implications. 

Journal of Health and Social Behavior 51 (Special Issue):S41-S53.

Toro, P. & Janisse, H. 2004. Homelessness, patterns of. pp. 245-251 of D. Levinson (Ed.), Encyclopedia of homelessness. Thousand Oaks, CA: SAGE Publications

Turner, J, Brown, R. 2010. Social Support and Mental Health. Pp. 200-212 of Scheid, T, & Brown, T. A handbook for the study of mental health: Social contexts, theories, and systems. (2 ed.). New York, NY: Cambridge University Press.

Policy Research Associates (PRA), & U.S. Center for Mental Health Services (CMHS). 2003. Blueprint for change: Ending chronic homelessness for persons with serious mental illnesses and/or co-occurring substance use disorders. Rockville, MD: U.S. Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.

Vazquez, C. & Munoz, M. 2001. Homelessness, Mental Health, and Stressful Life Events. International Journal of Mental Health, 30,

Weinberg, D. 2005. Of Others Inside: Insanity, addiction, and belonging in America. Philadelphia: Temple University Press.