Sunday, March 3, 2019

Is Chronic Homelessness a Mental Health Problem?

Individuals who are chronically homeless face different challenges in meeting their basic needs than other homeless subpopulations including homeless families and other homeless individuals. The U.S. Department of Housing and Urban Development defines chronic homelessness as four or more prior experiences of homelessness usually with a disabling condition (HUD, 2018). According to HUD, chronically homeless individuals constituted twenty-four percent of the total homeless population in their latest point in time count (HUD, 2018). This represents a two percent increase from the previous year (HUD, 2018), which does not seem like much until you compare individual states. While 17 states experienced declines in the number of chronically homeless individuals 33 states, including Washington D.C., experienced a spike in cases of chronic homelessness over the same period (HUD, 2018). Additionally, about half of chronically homeless individuals are located in just three states: California, Washington, and New York (HUD, 2018). Sixty-five percent of the 88,640 chronically homeless individuals nationwide remain unsheltered, which is significantly higher than the forty-eight percent unsheltered rate for all homeless individuals (HUD, 2018). Similarly, thirty-percent of chronically homeless people in families with dependent children remain unsheltered compared to nine percent of all homeless people in families with dependent children (HUD, 2018). These discrepancies present a unique policy challenge for HUD, similar state and municipal agencies and their partnering institutions. Chronic homelessness may have distinct underlying problems that are less severe or absent in cases of temporary or one time homelessness. Identifying these distinct underlying problems will allow all stakeholders striving to reduce homelessness to tailor their policy approaches to the specific needs of the chronically homeless population.

One avenue that may hold answers to the underlying problems of chronic homelessness is the field of clinical psychology. The general consensus among social science researchers, is that homeless persons who reside in the shelters longer tend to have more mental health problems, medical problems and substance abuse problems than homeless persons who reside in shelters for shorter periods of time (Castellow, Kloos, & Townley, 2015). A study comparing the prevalence of mental health and substance abuse disorders among housed low income and homeless mothers with children with similar data on the general population, compiled in the National Comorbidity survey, found that more than two-thirds of the publicly housed and homeless mothers had at least one lifetime mental health disorder diagnosis while nearly half had two or more lifetime diagnoses (Bassuk, Buckner, Perloff & Bassuk, 1998). Housed low income mothers and homeless mothers with dependent children are specifically overrepresented in lifetime diagnoses of PTSD, major depression disorders, and substance use disorders compared to rates for the same diagnoses in the National Comorbidity Survey (Bassuk et al., 1998). In fact, PTSD rates were found to be three times higher for participants in the study than for the general population; the study found that 35% of low income and homeless mothers have a lifetime diagnosis of PTSD (Bassuk et al., 1998). The high PTSD rates are related to childhood physical abuse, sexual abuse and partner violence; 88% of homeless women and 79% of low income women had suffered physical and/or sexual abuse at some time in their past (Bassuk et al., 1998). Alcohol use disorder was also found to be twice as high for low income and homeless mothers while other forms of drug abuse were three times as high compared to the National Comorbidity Survey (Bassuk et al., 1998). In general, the experience of homelessness is associated with higher rates of psychiatric distress and alcohol use for people diagnosed with psychiatric disorders and the duration of homelessness is positively associated with lower recovery rates from mental disorders (Castellow et al., 2015).

Although chronic homelessness is closely associated with mental disorders and substance or alcohol abuse the latter is not necessarily the cause of the former. In fact, much of the literature has found that chronic homelessness, mental disorders and substance/alcohol abuse fits the traditional stress-diathesis model i.e. that the experience of homelessness itself may exacerbate vulnerabilities to certain mental disorders, and, in turn, the mental disorders may lead to maladaptive behaviors that prolong homelessness creating a vicious cycle of chronic homelessness (Castellow et al., 2015). Thus, mental illness and substance or alcohol abuse are both predictors and risk factors for chronic homelessness. Many studies have found that the experience of homelessness is actually a precursor to illicit substance and alcohol abuse, which is adopted as a maladaptive coping mechanism to diminish the stress of homelessness (Castellow et al., 2015). Homelessness often results in negative outcomes similar to those experienced by people diagnosed with PTSD such as learned helplessness, substance abuse (as a coping mechanism), social isolation and alienation (Castellow et al., 2015).

The evidence suggests a need to expand community based mental health services to address chronic homelessness, especially those that focus on providing support networks and integrating the chronically homeless back into the community (Castellow et al., 2015). Evidence based programs that address these needs include systematic medication management, assertive community treatment, employment and job training programs, family psychological education, illness management and recovery, and treatment for comorbid disorders (Drake & Latimer, 2012). Finding meaningful work for the chronically homeless through employment and job training programs would go a long way in increasing their independence and autonomy while reducing stigmatization. Giving them mental health care and treatment options would also facilitate recovery (Drake & Latimer, 2012). This should, in many cases, be coupled with drug and alcohol rehabilitation for those with comorbid substance use and mental disorders. In addition mental health services should include comprehensive team based care for individuals with serious mental illness and disabilities; this would shift costs away from hospitals and the criminal justice system while also relieving personal suffering (Drake & Latimer, 2012).


Bassuk, E. L., Buckner, J. C., Perloff, J. N., & Bassuk, S. S. (1998). Prevalence of Mental Health and Substance Use Disorders Among Homeless and Low-Income Housed Mothers. American Journal of Psychiatry, 155(11), 1561-1564. doi:10.1176/ajp.155.11.1561

Castellow, J., Kloos, B., & Townley, G. (2015). Previous Homelessness as a Risk Factor for Recovery from Serious Mental Illnesses. Community Mental Health Journal, 51(6), 674-684. doi:10.1007/s10597-014-9805-9

U.S. Department Of Housing And Urban Development. (2018). The Annual Homeless Assessment Report to Congress (2009). SSRN Electronic Journal. doi:10.2139/ssrn.1680873

Drake, R. E., & Latimer, E. (2012). Lessons learned in developing community mental health care in North America. World Psychiatry, 11(1), 47-51. doi:10.1016/j.wpsyc.2012.01.007

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