Needs of homeless people coping with psychiatric problems: findings from an innovative advocacy project

In this article the authors report on the self-perceived needs of 40 homeless people who are coping with psychiatric problems. These people were among 207 with psychiatric problems participating in an innovative advocacy project based outside the formal mental health system. Compared with domiciled participants, the homeless participants had more accentuated and somewhat different major daily living needs in the areas of income and benefits, housing, legal services, employment, and health care. On the basis of these findings, the authors draw implications for social work practice with homeless people coping with psychiatric problems.     

Dutch homeless people 2.5 years after shelter admission: what are predictors of housing stability and housing satisfaction?

Housing stability is an important focus in research on homeless people. Although definitions of stable housing differ across studies, the perspective of homeless people themselves is generally not included. Therefore, this study explored the inclusion of satisfaction with the participant's current housing status as part of the definition of housing stability and also examined predictors of housing stability with and without the inclusion of homeless person's perspective. Of the initial cohort consisting of 513 homeless participants who were included at baseline in 2011, 324 (63.2%) were also interviewed at 2.5‐year follow‐up. To determine independent predictors of housing stability, we fitted multivariate logistic regression models using stepwise backward regression. At 2.5‐year follow‐up, 222 participants (68.5%) were stably housed and 163 participants (51.1%) were stably housed and satisfied with their housing status. Having been arrested (OR = 0.36, 95% CI: 0.20–0.63), a high level of somatisation (physical manifestations of psychological distress) (OR = 0.52, 95% CI: 0.30–0.91) and having unmet care needs (OR = 0.77, 95% CI: 0.60–0.99) were negative predictors of housing stability. Having been arrested (OR = 0.43, 95% CI: 0.25–0.75), high debts (OR = 0.45, 95% CI: 0.24–0.84) and a high level of somatisation (OR = 0.49, 95% CI: 0.28–0.84) were negative predictors of stable housing when satisfaction with the housing status was included. Because inclusion of a subjective component revealed a subgroup of stably housed but not satisfied participants and changed the significant predictors, this seems a relevant addition to the customary definition of housing stability. Participants with characteristics negatively associated with housing stability should receive more extensive and individually tailored support services to facilitate achievement of housing stability.     

Community psychiatric care for homeless people in inner London.

Data about 'homeless' and 'home-based' clients referred to and recorded by community psychiatric nurses (CPNs) in Bloomsbury, an inner London health district, in 1985 and 1986 were reviewed. Of the 974 people seen, 642 were home-based and 322, homeless at time of referral. The homeless were more commonly under 65-years-of-age, living alone and unemployed. Two thirds of both groups had a psychiatric history, with half also having been admitted to a mental hospital. CPNs identified mental health problems in both groups with equal frequency, but homeless people were more likely to express their main problem as related to housing, finance or unemployment. Four out of five home-based clients were referred by statutory services compared with only two out of five homeless clients. The latter were less likely to receive supportive care from the CPN service and were more often referred to other agencies; these differences remained after controlling for the presenting problems. One in three people referred to this service were homeless. The social aspects of their problems, and their lack of contact with statutory services, suggest that homeless people need a multi-disciplinary approach for mental health care.     

Long-Term Housing and Work Outcomes Among Treated Cocaine-Dependent Homeless Persons

Communities across the United States have initiated plans to end chronic homelessness. In many of these communities, addiction treatment programs remain the default point of entry to housing and services. This study examined the percentage of cocaine-using homeless persons (all with psychiatric distress) attaining stable housing and employment 12 months after entering a randomized trial of intensive behavioral day treatment, plus one of the following for 6 months: no housing; housing contingent on drug abstinence; housing not contingent on abstinence. Of 138 participants, the percentages with stable housing and employment at 12 months were 34.1 and 33.3%, respectively. Analyses suggested superior outcomes in trial arms that offered housing as part of the behavioral treatment. The majority of participants, however, did not achieve housing or employment, in part because of the limited capacity of the local housing programs to accommodate persons who had not achieved perfect abstinence. The findings demonstrate a helpful role for addiction treatment and suggest the need for services to support housing of persons who reduce but do not eliminate all substance use.     

Stressors, resources, and distress among homeless persons: a longitudinal analysis

Relations among stressors, resources, and psychological distress were examined using two waves of data obtained from a probability sample of homeless persons (N = 430) residing in a large, demographically diverse county in North California. The focus of research was to examine whether and how social resources and housing resources directly affect distress and mediate the impact of stress factors on depressive symptoms. Path analysis results revealed that levels of psychological distress were responsive to change in objective housing circumstances, with the attainment of domicile status being associated with fewer distress symptoms. Our findings, however, indicated only modest effects of social resources on psychological distress through direct effects and mediating effects of life stressors on distress. Overall, the study suggests that the relationships among stressors, resources, and distress for homeless persons may be understood within the same analytical framework for the general population.     

The health of homeless people in Britain: A review

Housing has long been identified as a prerequisite for goodhealth. In Britain not all members of the population have accessto housing. The homeless population may be divided into thosewho are officially accepted as homeless and the unofficial homelesspopulation. The official homeless population is dominated byfamilies with children whilst the unofficial homeless populationincludes a range of circumstances from those living in squatsto those literally living on the streets. In Britain the numberof official homeless tripled between 1978 and 1992 and is currently143,500 households (approximately 330,500 people). It is estimatedthat there are a further 6, 000 people living on the streetsand 50,000 in hostels giving a total estimated homeless populationof 386, 050. Demographic data indicate that there are importantdifferences in the composition of the official and unofficialhomeless populations. The official homeless group consists almostexclusively of young families, usually headed by a lone female.The unofficial homeless group is predominantly male and older.The official homeless population report higher prevalences ofchronic health problems and general psychiatric problems thanthe general population whilst the unofficial group are characterizedby elevated rates of psychiatric disturbance and alcohol consumption.These data indicate that homeless people are not a homogeneoussocial group but present a variety of different health needswhich require the provision of appropriate services.     

Housing outcomes for hospitalized homeless veterans

This study examines housing status at the time of hospital discharge in a national sample of 3,502 veterans who were homeless at admission to a Veterans Health Administration (VHA) medical center. A supplemental survey on homelessness was added to the annual VHA inpatient census over a 4-year period (1995 through 1998). Data from this survey were used to identify homeless veterans hospitalized on the final day of the fiscal year and to document their housing status at discharge. A signal detection technique, Receiver Operating Characteristic analysis, was used to identify predictors of housing status at discharge. At discharge, only 13% of the veterans in our analytic sample were literally homeless, 40% were doubled up, and 33% were transferred to another an institution; only 13% were living independently. Housing status at admission (specifically, staying with friends or family temporarily rather than literally homeless), treatment in a psychiatric or substance abuse program rather than a medical program, and a greater income level or access to VHA benefits were found to be associated with better housing outcomes. As one might expect, homelessness was infrequently resolved during an acute inpatient hospitalization, but few veterans returned to literal homelessness at the time of discharge.     

Developing programs for homeless veterans: understanding driving forces in implementation

Between 1992 and 2003, services for homeless veterans at the Veterans Affairs Greater Los Angeles Healthcare System went from inappropriate utilization of hospital medical and psychiatric beds, to a continuum of residential treatment, transitional housing, and employment programs through arrangements with private agencies. The authors use elements of Hasenfeld and Brock's Political Economy Model (1991) to explain this transformation in service delivery that was spearheaded by a VA social work leadership team. It is argued that three driving forces crucial to program implementation were present: technological certainty, economic stability, and concentration of power. Evidence of the implementation's impact includes creation of new homeless program beds, a reduction in use of medical/psychiatric beds, and a large number of formerly homeless veterans with housing and employment at program discharge. Study limitations and implications for future studies are discussed.     

Service delivery and community: social capital, service systems integration, and outcomes among homeless persons with severe mental illness

OBJECTIVES: This study evaluated the influence of features of community social environment and service system integration on service use, housing, and clinical outcomes among homeless people with serious mental illness. STUDY SETTING: A one-year observational outcome study was conducted of homeless people with serious mental illness at 18 sites. DATA SOURCES: Measures of community social environment (e.g., social capital) were based on local surveys and voting records. Housing affordability was assessed with housing survey data. Service system integration was assessed through interviews with key informants at each site to document interorganizational transactions. Standardized clinical measures were used to assess clinical and housing outcomes in face-to-face interviews. RESEARCH DESIGN: Structural equation modeling was used to determine the relationship between (1) characteristics of the social environment (social capital, housing affordability); (2) the level of integration of the service system for persons who are homeless in each community; (3) access to and use of services by individual clients; and (4) successful exit from homelessness or clinical improvement. PRINCIPAL FINDINGS: Social capital was associated with greater service systems integration, which was associated in turn with greater access to assistance from a public housing agency and to a greater probability of exiting from homelessness at 12 months. Housing affordability also predicted exit from homelessness. Neither environmental factors nor systems integration predicted outcomes for psychiatric problems, substance abuse, employment, physical health, or income support. CONCLUSION: Community social capital and service system integration are related through a series of direct and indirect pathways with better housing outcomes but not with superior clinical outcomes for homeless people with mental illness. Implications for designing improved service systems are discussed.     

Lifestyle and health status of homeless people around Shibuya Station, Tokyo]

The number of homeless people in Tokyo is estimated to be 3,200-3,300. While studies on the health status of homeless people, including illness, injury and deaths have been previously reported, most of these reports concern the homeless who resided in housing facilities for the homeless or who admitted to hospitals. We undertook a comparison of lifestyle and health status between homeless people and people who live in houses (as a control group). Health status was also analyzed for differences among homeless people. Subjects were asked by questionnaire regarding their age, the length of being homeless, former and present employment, sleeping condition, food, whether they have friends or not, the amount of smoking per day, and Short-Form-36 Health Survey (SF36). As objective findings, measurement of blood pressure and blood testing were also performed. Fifty-three homeless people, 49 male, 4 female, average age 52, from the areas around Shibuya station and Yoyogi park, were enrolled. While 98% of the homeless people had previous employment, 73% were not working when the study was performed. Compared with control group, the homeless had fewer meals per day, fewer friends, excessive smoking, greater history of gastro-duodenal ulcer and injury, greater limitation due to physical problems, and higher general mental health as measured by SF36. The diastolic blood pressure of the homeless was higher than that of the control. The blood testing showed higher white blood cell counts and platelet counts. It was suggested that changes in the social structures were largely influential in causing life, and that access to health care was limited because of financial and social barriers. Further studies with more samples, survey of social volunteers involved in care of homeless and qualitative data would be necessary to find and develop better support system for the homeless.     

Young homeless people and service provision

This paper focuses on access to services, and views of service provision amongst young homeless people aged 14–25 years. Two hundred young homeless people were interviewed in locations throughout Greater Manchester, the majority in towns surrounding the city of Manchester. A semistructured interview schedule was used with interviews being taped and transcribed to provide additional qualitative data. The operational definition of homelessness included not only those who were roofless, but also those residing in hostels, bed and breakfast accommodation, or staying temporarily with friends. Topics examined include: access to services such as housing, health, advice and information; appraisal of service provision; confidence in securing help; and the use of both formal and informal support services. Results show that the provision and use of services for young homeless people varies widely across the county, with the majority of services being concentrated in the city of Manchester. Respondents made good use of certain services such as streetwork agencies, but exhibited a lack of confidence in securing help with the most basic needs, such as food. A desire to avoid being labelled as 'homeless' appeared to make some people unwilling to make use of non-statutory agencies specifically for homeless people. Overall, respondents found particular difficulties in accessing help from statutory services, such as housing and health. Findings point to the necessity of providing adequately resourced services which reach out to young homeless people.     

Housing stressors and persons with serious mental health problems

This paper describes the correlates and predictors of exposure to housing stressors among a sample of people with serious mental health problems and assesses the extent to which this experience detracts from their well-being in the community. Data were collected in a cross-sactional, two-city sample study conducted in two of New Zealand's largest cities, Auckland and Christchurch. Respondents were 203 former psychiatric inpatients, who, compared to random samples of the general population in the two cities, were younger, more often single, more residentially mobile, and more likely to be of ethnic minority status. Measures of respondents’ housing situations and standard demographic variables were collected, along with outcome measures including the World Health Organization Alcohol Use Disorders Identification Test (AUDIT) (Babor & Grant 1989) and the 12-item General Health Questionnaire (GHQ-12) (Goldberg & Williams 1988). The principal housing problem in both cities was overcrowding. Coldness, cost and issues of maintenance were also of concern. Respondents could generally cite only passive coping strategies for dealing with these housing problems. Factor analysis was used to identify three housing stressor scales:‘physical condition’,‘cost’, and 'space/amenity’. Multiple regression analysis demonstrated that socio-economic factors are significant predictors of housing stressors, with those respondents most dependent on social welfare living in the worst dwellings, as measured by the‘physical condition’ scale. This scale had the strongest relationship with psychiatric distress, as measured by the GHQ. These results lead us to conclude that concerns with respect to housing for people with serious mental health problems must move beyond issued of availability and affordability and embrace the quality of housing.     

Housing Stability and Recovery Among Chronically Homeless Persons With Co-Occuring Disorders in Washington,DC

Pathways Housing First provides access to housing, support, and treatment services to clients having the most complex needs—persons who have been homeless for at least 5 years and have both a psychiatric disability and substance dependency. In a 2-year Housing and Urban Development-funded demonstration project in Washington, DC, in 2007 and 2008, we observed promising outcomes in housing retention and reductions in psychiatric symptoms, alcohol use, and demand for intensive support services. The program is designed to be fiscally self-sustaining through extant public disability benefits for housing, treatment, and support services. This approach shows strong support for first providing a permanently supported housing solution for chronically homeless and severely disabled individuals in need of housing and treatment of co-occurring disorders.

KEY FINDINGS

• ▪Housing retention of severely disabled and chronically homeless individuals having extensive service needs, each alcohol dependent and homeless for a minimum of 5 years at intake, was 97% in the first year and 84% in the second year.
• ▪Highly distressed individuals showed significant reduction in psychiatric symptoms within the first year of housing, with client-centered housing support and voluntary psychiatric treatment provided as desired by the client.
• ▪Psychiatrically disabled and alcohol-dependent individuals can make significant mental and behavioral health improvements in recovery within a year of housing without abstinence or treatment compliance demands upon enrollment and with voluntary addiction treatment as desired by the client.
• ▪Demand for intensive ACT services was reduced to much less intensive and costly community support services for 14% of clients within 2 years.

Individuals who remain chronically homeless frequently suffer debilitating effects of serious mental illness and addiction. These frequently co-occurring disorders represent an extremely difficult hurdle for individuals to overcome. Typical housing programs demand sobriety and compliance with psychiatric and behavioral treatment as a condition of admission and continued enrollment. A more realistic, compassionate, and effective approach provides housing without such prerequisites and instead provides immediate access to permanent housing with supports as a foundation for recovery.     

A typology of childhood problems among chronically homeless adults and its association with housing and clinical outcomes

Studies of chronically homeless adults have not adequately investigated the impact of adverse childhood experiences. The current retrospective, longitudinal study profiles the childhood experiences reported by 738 participants in an 11-site supported housing initiative and examines how their childhood profile is related to their homeless history, their psychosocial status before entry into supported housing, and their outcomes once enrolled in supported housing. A two-step cluster analysis revealed three childhood profiles: Relatively Numerous Childhood Problems, Disrupted Family, and Relatively Few Childhood Problems. Results found that participants with Relatively Numerous Childhood Problems were significantly younger when they were first homeless and had worse drug use before entry into supported housing than other participants. There were no differences in housing, substance use, or mental and physical health outcomes once participants were enrolled in supported housing. Prevention of homelessness should focus, to the extent possible, on individuals with extensive childhood problems.     

Mastery matters: consumer choice,psychiatric symptoms and problematic substance use among adults with histories of homelessness

Previous research demonstrated the importance of consumer choice and mastery to residential stability and psychiatric functioning for adults with histories of homelessness. In the present study, we investigated whether these relationships hold, even in the context of problem‐related substance misuse. Questionnaire data were collected in Ireland from 101 residents of long‐term homeless accommodation in 2010. Hayes’ PROCESS macro for mediation and moderation analysis in SPSS was employed to test our hypotheses. Findings demonstrated that the indirect effect of choice through mastery on psychiatric functioning was stronger for individuals with more recent problem‐related substance use than for those with no or distant histories of problem‐related substance use. Our findings confirm that consumer choice in housing and services is important to homeless services users’ recovery experiences. Because of its relationship with mastery, consumer choice in housing and services protects homeless services users’ psychiatric functioning, especially when substance use‐related choices have had negative consequences. Our findings suggest that if homeless services take away consumer choice when substance use causes problems, they may actually undermine, rather than foster, service users’ psychiatric functioning.     

The Neighborhood Context of Homelessness

Objectives. We examined and compared the changing neighborhood characteristics of a group of homeless adults over time.Methods. We collected the addresses of previous housing and sleep locations from a longitudinal study of 400 homeless adults in the St. Louis, Missouri, region and compared census measures of housing and economic opportunities at different points along individual pathways from housing to homelessness and at 1- and 2-year follow-up interviews.Results. Sleep locations of homeless adults were much more concentrated in the urban core at baseline than were their previous housed and follow-up locations. These core areas had higher poverty, unemployment, and rent-to-income ratios and lower median incomes.Conclusions. The spatial concentration of homeless adults in areas with fewer opportunities and more economic and housing distress may present additional barriers to regaining stable housing and employment. A big-picture spatial and time-course viewpoint is critical for both policymakers and future homelessness researchers.Living in emergency shelters or on the streets amplifies the influence of environmental factors on homeless adults, which, in turn, makes a difficult situation even worse. People who find themselves without stable housing are vulnerable to high rates of victimization,1,2 more health problems,3,4 and less access to social support, sustainable employment, and affordable housing. Several studies have suggested that homeless people have been geographically “warehoused” in concentrated urban areas and that the particular environmental attributes of these areas make it more difficult for homeless individuals to improve their situation.5–9 For example, homeless people cite affordable housing as being critically important but also as one of the most difficult needs to meet.10 If the surrounding environment where homeless adults are concentrated has less available and affordable housing and more economic distress, this spatial segregation may be one of the many real barriers to obtaining stable housing in the future.Large urban areas with relatively high concentrations of poverty become the natural targets for the placement of emergency homeless shelters and other social services, developing into what Dear and Wolch11 referred to as service ghettos. This dynamic is typically associated with the skid row era of the early and middle parts of the 20th century, and over the past 2 decades many cities have attempted to decentralize and disperse these areas of concentrated poverty in an ongoing policy of poverty management.12 Although these policies have been mostly unsuccessful in dispersing those who are homeless, the geography of homeless individuals has become more complex and polynucleated than in previous decades.13Few studies have examined the complexities of the physical and social environments surrounding people living on streets and shelters. One promising approach to understanding these environments is to use census data as indicators of social, economic, and housing conditions in the areas in which individuals reside before, during, and after homeless episodes. Culhane et al.14 geocoded previous addresses collected from shelter admissions in New York City, New York, and Philadelphia, Pennsylvania. They matched these addresses with census tracts and corresponding census data for those areas and identified several predictors of shelter admission on the basis of previous residence, namely crowding, higher poverty rates, and higher rents. Generally, these neighborhoods also had higher proportions of African Americans and female-headed households. Using a similar data set from the Philadelphia shelter system and a factor-analytic approach, Wong and Hillier15 reported associations between homelessness risk and what they labeled distressed neighborhoods (higher proportions of African Americans, poverty, boarded-up houses, vacant houses, unemployment, female-headed households, and public assistance income) and unstable neighborhoods (higher proportions of 1-person households, recent moves, and rentals and higher rent-to-income ratios). The authors of both of these studies highlighted the importance of prior neighborhood characteristics yet were unable to identify any longitudinal patterns after the initial shelter admission because they were restricted by the single point of contact collected in the administrative database.In the current study, we explored and compared the neighborhood characteristics of where homeless people come from and end up after 1 or 2 years in a large urban area. By comparing neighborhood characteristics between these 3 points on the homeless pathway, we hoped to better understand whether and how homeless adults are concentrated or dispersed over each individual time course. Were there significant differences in demographics, economic distress, and housing from when they were last housed to where they ended up living in a shelter or on the streets? If we followed these individuals over the next 2 years, would they end up moving away from baseline homeless locations to better or worse neighborhoods? We could only explore these questions in a combined spatial and longitudinal context, which is critical to understanding not just the “who” of homelessness, but also the “where.” With this knowledge, city planners and homeless service providers can better use limited resources to address the barriers to housing on macro and individual levels.     

Identifying homelessness at an urban public hospital: a moving target?

Hospitals do not routinely collect data about homelessness. The objectives of the present study were to (1) describe rate of patient reports of homelessness among inpatients at a public hospital, (2) assess the agreement between patient report of housing status on a study questionnaire with clinical and administrative data about homelessness, and (3) assess changes in housing status during hospitalization. We conducted a cross-sectional survey of inpatients at an urban public hospital to assess housing status; we then examined subjects' medical charts to assess agreement with the questionnaire on housing status. Of inpatients, 25.6% were homeless at discharge. An additional 19.4% were marginally housed. One third of homeless persons had their housing status change during their hospitalization. Administrative data identified 25.6% and physicians' notes identified 22.5% as homeless. Clinical, administrative, and survey data did not agree. Homelessness and changes in housing status are common among inpatients at an urban public hospital. Poor agreement on who is homeless limits the usefulness of data.     

Effects of a behavioural weight loss intervention in people with serious mental illness: Subgroup analyses from the ACHIEVE trial

BackgroundPersons with serious mental illnesses (SMI) such as schizophrenia and bipolar disorder have an increased risk of obesity and related chronic diseases and die 10–20 years earlier than the overall population, primarily due to cardiovascular disease. In the ACHIEVE trial, a behavioural weight loss intervention led to clinically significant weight loss in persons with SMI. As the field turns its attention to intervention scale-up, it is important to understand whether the effectiveness of behavioural weight loss interventions for people with SMI, like ACHIEVE, differ for specific subgroups.MethodsThis study examined whether the effectiveness of the ACHIEVE intervention differed by participant characteristics (e.g. age, sex, race, psychiatric diagnosis, body mass index) and/or their weight-related attitudes and behaviours (e.g. eating, food preparation, and shopping habits). We used likelihood-based mixed effects models to examine whether the baseline to 18 month effects of the ACHIEVE intervention differed across subgroups.ResultsNo statistically significant differences were found in the effectiveness of the ACHIEVE intervention across any of the subgroups examined.ConclusionsThese findings suggest that the ACHIEVE behavioural weight loss intervention is broadly applicable to the diverse population of individuals with SMI.     

Previously diagnosed psychiatric illness among inhabitants of common lodging houses.

STUDY OBJECTIVE: The aim of the study was to determine the characteristics of the homeless population and their previously diagnosed psychiatric illnesses in a well defined inner city area. DESIGN: The study involved a one in 10 sequential sample collected over three years. SETTING: Hostels and day care centres for the homeless in Manchester. PARTICIPANTS: 420 homeless people were interviewed; 17 were excluded because of lack of rapport. RESULTS: The majority were single middle aged catholic males who left school early and were unemployed; 48.7% had a history of alcoholism, 38.5% of diagnosed psychiatric illness, and 22.6% of psychiatric inpatient treatment. Only 21% of those with psychiatric diagnoses were being treated or followed up at the time of study. There was a strong association between criminal behaviour and previous admission to a psychiatric unit. CONCLUSIONS: There is a high incidence of psychiatric illness among the homeless, particularly among those originating from the locality studied. They tend to be geographically stable and therefore accessible to the provision of facilities for continuing care.     

Causes of homelessness among older people in Melbourne, Australia

OBJECTIVE: A comparative study of the causes of new episodes of homelessness among people aged 50 years and over has been undertaken in Australia, the United States and England. Semi-structured questionnaires were used to collect information on the circumstances and problems that contributed to homelessness. METHODS: This paper presents the findings from Australia, where information was obtained from 125 older homeless people (aged 50+ years) and their key workers in Melbourne. All three participating nations followed identical research methodologies. RESULTS: The factors most frequently reported by respondents as contributing to their homelessness were problems with people with whom they lived, followed by physical and mental ill-health and problems associated with the housing itself. The most frequently reported factors by case workers were problems with alcohol, followed by physical and mental health factors. CONCLUSIONS: This study demonstrates a significant under-utilisation of housing and support services among recently homeless older people and provides evidence that people who had previously been homeless appear to be more resigned to their homelessness than do those who had not experienced homelessness before. Significant issues relating to depression and gambling were also noted. The findings support the need for more targeted, specialised services to be developed or improved such that older homeless people can readily gain access to them and for improved collaboration or information exchange among housing providers and welfare agencies.