As difficult as it is to suffer from just one or the other, mental illness and homelessness far too often go hand-in-hand. Cityscape, a publication from the U.S. Department of Housing and Urban Development (HUD), paints an accurate picture of this combination:
It is difficult to imagine a more dangerous or more distressing combination of problems to befall any one person than to be homeless and to suffer from a severe mental illness. Yet those who are homeless and mentally ill are often diagnosed with many accompanying disabilities—such as drug addiction, alcoholism, HIV/AIDS, diabetes, and tuberculosis. Mentally ill homeless people tend to be the sickest, the most ragged, and the most difficult people for society to accept. In addition, because rationality itself is compromised by mental illness, they are often the least able to help themselves, either economically or medically, and thus they slide more deeply into danger.
While every homeless subpopulation has its challenges, homeless individuals with severe mental illness are considered by homeless providers to be the most challenging to reach. Treatment is crucial to the well-being of the individual. But on the streets, treatment isn’t a high priority when you’re simply trying to survive. This presents multiple obstacles for providers to overcome in coordinating care for both mental health and homelessness issues.
How can communities most effectively serve this subpopulation?
Through better coordination of housing, care, and existing community programs, service providers can begin to address the unique characteristics of those who are experiencing both homelessness and severe mental illness.
In this article, we’ll take a look at:
- What is the correlation between mental illness and homelessness?
- Disabling characteristics
- Barriers to assistance
- How can we help homeless individuals with severe mental illness?
- Prioritizing the Housing First model
- Enhancing permanent supportive housing
- Integrating mental health services into existing programs
By the end of this article, you will have a better understanding of the relationship between mental illness and homelessness, as well as a few ideas for how to better coordinate aid for this subpopulation in your community.
What Is the Correlation Between Mental Illness and Homelessness?
According to the HUD 2015 Point-In-Time Count report (the most up-to-date count available at the time this article was written), homeless adults with severe mental illness constitute the largest HUD-defined homeless subpopulation. (The most common mental health conditions that tend to lead to homelessness are schizophrenia and bipolar disorder.) Compare that to other subpopulations, listed in the image below taken from the report.
With approximately 104,083 homeless adults with severe mental illness nationwide, this subpopulation composes approximately 18.4 percent of the entire homeless population. This ratio is drastically different from that of the general population, where the percentage of severely mentally ill individuals hovers at a much lower level of 4.2 percent, according to the National Institute of Mental Health.
Why is this?
The disabling characteristics of mental illness lie at the heart of homelessness among the severely mentally ill. However, other causes include deinstitutionalization, as well as societal and social barriers to assistance.
Let’s take a look at each of these 3 primary causes.
1. Disabling Characteristics of Severe Mental Illness
The severely mentally ill suffer immense challenges that can prohibit them from functioning in daily life, often leading to homelessness. These symptoms—according to Abnormal Psychology —can be divided into 3 categories:
- Emotional Disruption
- Incapacitating and uncontrollable emotion, mood and/or anxiety
- Cognitive Disruption
- Highly impaired concentration abilities, along with delusions, paranoia, and/or hallucinations
- Disorganized thinking
- Poor problem-solving skills
- Inability to mobilize oneself for action (especially in Major Depressive Disorder)
- Social Disruption
- Disruption in family and other personal relationships that creates severe difficulty in establishing a personal social support system, which can lead to social isolation and eventual homelessness
These factors lead to the inability to obtain or maintain employment, and carry out the basic tasks of everyday living. They also disrupt the individual’s ability to obtain food, clothing, shelter, and transportation. Substance abuse, which is common among the mentally ill, also further compounds these difficulties.
Overall, mental illness leads individuals (especially youth) to pursue life goals in unrealistic and irrational ways that lead to personal resource depletion and loss of social support.
The National Alliance on Mental Illness provides a list of various mental health conditions and corresponding symptoms and treatment here.
2. The Role of Deinstitutionalization in Homelessness
Deinstitutionalization is the process of replacing long-stay psychiatric hospitals with less isolated community mental health services for those diagnosed with a mental disorder or developmental disability.
In contrast to common belief, deinstitutionalization is not entirely the direct cause of the high rate of homelessness among the severely mentally ill. The highest rate of deinstitutionalization occurred in the 1950s and 1960s, but increases in homelessness among the severely mentally ill did not occur until the 1980s.
The National Alliance to End Homelessness writes—and other experts agree—that the decrease in income and affordable housing that characterized the 1980s is more to blame than the deinstitutionalization that occurred three decades prior.
3. Barriers to Assistance
In 2003, the U.S. Department of Health and Human Services stated that most homeless persons who suffer from mental illness do not necessarily need to be institutionalized if they have appropriate supportive housing options.
The problem lies in the fact that many severely mentally ill homeless persons are unable to access supportive housing and/or treatment services, often due to societal reasons. For example, the current lack of an effective system of mental health care and the criminalization of the mentally ill represents a societal barrier to receiving mental health services.
How Can We Help Homeless Individuals with Severe Mental Illness?
While there are certainly challenges in helping those who are both homeless and suffering from severe mental illness, there is good news in that communities nationwide are finding ways to better serve these individuals.
Prioritizing the Housing First Model
As reported by The Pew Charitable Trusts, there is a critical shortage of state psychiatric beds. This forces mentally ill patients with severe symptoms to be held in emergency rooms, hospitals, and jails while they wait for a bed—sometimes for weeks.
Nonprofit Quarterly writes that for some cities, cuts in funding for community-run psychiatry centers, housing programs, and social workers has caused jails and prisons to take up the responsibility of caring for people with mental illnesses.
However, individuals suffering from mental illness do not belong behind bars.
For those who are homeless or at risk of homelessness, this promotes further urgency to place mentally ill patients in housing quickly. In line with the Housing First model, treatment is not a precondition to placement. Instead, permanent supportive housing (PSH) should be provided to the homeless mentally ill immediately, giving them a sense of security before providing mental health services.
In support of this approach, Tory Gunsolley—president and chief executive of the Houston Housing Authority—says, “Every time you have the homeless person in front of you, that’s the time to get stuff done. Every time you let them go, they wind up back on the street.”
For more on homelessness and housing for individuals suffering from mental illnesses, the Substance Abuse and Mental Health Services Administration (SAMHSA) has a helpful list of resources here.
Enhancing Permanent Supportive Housing
Even when supportive housing for the severely mentally ill is provided, it is difficult for them to maintain the stability necessary to stay off the streets unless they have access to continuous treatment and services.
For example, in an American Psychological Association article, Dan Herman, DSW, shares this story:
A homeless man with schizophrenia, just released from a New York City hospital, moves into transitional housing. He has a steady income from a government-issued stipend and a studio apartment paid for by a university-funded housing program. It’s a safe base from which to look for a job. But when he moves in, he finds he can’t close the window blinds and he’s embarrassed to ask for help.
Night falls and the streetlights keep him awake. This goes on for days and he grows increasingly frustrated. He’s about to give up on the apartment when a social worker checks in on him to make sure everything’s OK.
Everything’s not OK, the weary man explains. The streetlights are too bright and he’s thinking about leaving. The social worker shows him how to operate the blinds and the man decides to stay.
Though a small gesture, many more like them are critical to helping the homeless mentally ill regain stability in their lives. “He might not have figured it out himself and he might not have asked somebody and he might have just left the place,” Herman says.
According to the National Coalition for the Homeless, permanent supportive housing for severely mentally ill individuals has been found successful when combining the following treatments and resources:
- Mental health treatment
- Physical health care
- Variety of flexible treatment options
- Services that reintegrate the mentally ill into their communities
- Education and employment opportunities
- Peer support
- Daily living skills (e.g. money management skills training)
- Implementation of outreach and engagement workers
Integrating Mental Health Services with Existing Programs
It’s important to consider the different ways in which homeless individuals with severe mental illness interact within their community, such as law enforcement and public libraries. The integration of mental health services and homeless services with these potential access points is key to meeting these individuals where they are and not inhibiting their path to success.
In many cities, local police don’t have the tools needed to offer solutions to the mentally ill homeless they encounter; they are only permitted to disperse or arrest these individuals.
In 2012, the United States Interagency Council on Homelessness (USICH) and the U.S. Department of Justice collaborated to publish a major joint report, Searching Out Solutions: Constructive Alternatives to the Criminalization of Homelessness. Some of the solutions offered in this report include cross-training police officers and service providers to facilitate information sharing and promote ongoing coordination.
For many homeless, the public library has become a safe haven—a place where they can rest, find access to computers and the Internet, and search for social services and employment. Recognizing the opportunity to meet these individuals where they already gather, the San Francisco Public Library hired a full-time psychiatric social worker to serve the library’s homeless patrons. Since then, more than 150 homeless people have received permanent housing, and more than 800 have enrolled in social and mental health services.
Severe mental illness and homelessness can be an intimidating combination for service providers, especially being the largest HUD-defined homeless subpopulation. But it doesn’t have to be. Even with small, sustainable steps toward the proper coordination of housing, care, and existing community programs, providers can begin to see transformation in the lives of their clients.
Immediate supportive housing for the severely mentally ill couldn’t be more critical. With the disabling characteristics this particular subpopulation experiences, supportive housing provides the stability and security they need to receive continuous support and treatment. And through the efforts of a community working together to integrate the necessary services into existing programs, communities can ensure no individual suffering from both mental illness and homelessness slips through the cracks.