Historical context
United States
In the United States, there are broad patterns of reform within the history of psychiatric care for persons with mental illness. These patterns are currently categorized into three major cycles of reform. The first recognized cycle was the emergence of moral treatment and asylums, the second consists of the mental hygiene movement and the psychopathic (state) hospital, and most recent cycle includesAsylums
Within the context of transforming schemas of moral treatment during the early nineteenth century, the humanitarian focus of public intervention was linked with the establishment of asylums or snake pits for treatment of the mentally ill. The ideology that emerged in Europe disseminated to America, in the form of a social reformation based on the belief that new cases of insanity could be treated by isolating the ill into "small, pastoral asylums" for humane treatment. These asylums were meant to combine medical attention, occupational therapy, socialization activities and religious support, all in a warm environment. In America, Friends Asylum (1817) and the Hartford Retreat (1824) were among the first asylums within the private sector, yet public asylums were soon encouraged, withDeinstitutionalization
Toward the end of World War II, the influx of soldiers diagnosed with "war neurosis" incited a new public interest in community care. In addition to this, the view that asylums and state hospitals exacerbated symptoms of mental illness by being "inherently dehumanizing and antitherapeutic" spread through the public consciousness. When psychiatric drugs like neuroleptics stabilized behavior andCommunity mental health centers
In response to the flaws of deinstitutionalization, a reform movement reframed the context of the chronically mentally ill within the lens of public health and social welfare problems. Policy makers intentionally circumvented state mental hospitals by allocating federal funds directly to local agencies. For example, the Community Mental Health Centers (CMHC) Act of 1963 became law, "which funded the construction and staffing of hundreds of federal centers to provide a range of services including partial hospitalization, emergency care, consultation, and treatment." Despite efforts, newly founded community centers "failed to meet the needs of acute and chronic patients discharged in increasing numbers from public hospitals". With decreased state collaboration and federal funding for social welfare, community centers essentially proved unable "to provide many essential programs and benefits", resulting in a growth of homelessness and indigency, or lack of access to basic necessities. It is argued that an over reliance on community health has "left thousands of former patients homeless or living in substandard housing, often without treatment, supervision or social support."State mental hospitals
As debates regarding the deteriorating role of American asylums and psychiatry amplified around the turn of the century, new reformation arose. With the founding of the National Committee for Mental Hygiene, acute treatment centers like psychopathic hospitals, psychiatric dispensaries and child guidance clinics were created. Beginning with the State Care Act in New York, states began assuming full financial control for the mentally ill, in an effort to compensate for the deprivations of asylums. Between 1903 and 1950, the number of patients in state mental hospitals went from 150,000 to 512,000. Morrissey recognizes that despite persistent problem of chronic mental illness, these state mental hospitals were able to provide a minimal level of care. United States president John F. Kennedy signed thePersonal factors
Neurobiological determinants
The mental health of homeless populations is significantly worse than the general population, with the prevalence of mental disorders up to four times higher in the former. It is also found that psychopathology and substance abuse often exist before the onset of homelessness, supporting the finding that mental disorders are a strong risk factor for homelessness. Ongoing issues with mental disorders such as affective and anxiety disorders, substance abuse and schizophrenia are elevated for the homeless. One explanation for homelessness states that "mental illness or alcohol and drug abuse render individuals unable to maintain permanent housing." One study further states that 10–20 percent of homeless populations have a dual diagnoses, or the co-existence of substance abuse and of another severe mental disorder. For example, in Germany there is a link between alcohol dependence and schizophrenia with homeless populations.Trauma
There are patterns of biographical experience that are linked with subsequent mental health problems and pathways into homelessness. Martens states that reported childhood experiences, described as "feeling unloved in childhood, adverse childhood experiences, and general unhappiness in childhood" seem to become "powerful risk factors" for adult homelessness. For example, Martens emphasizes the salient dimension of familial and residential instability, as he describes the prevalence of foster-care or group home placement for homeless adolescents. He notes that "58 percent of homeless adolescents had experienced some kind of out-of-home placement, running away, or early departure from home." Moreover, up to 50 percent of homeless adolescents report experience with physical abuse, and almost one-third report sexual abuse. In addition to family conflict and abuse, early exposure to factors like poverty, housing instability, and alcohol and drug use all increase one's vulnerability to homelessness. Once impoverished, the social dimension of homelessness manifests from "long exposure to demoralizing relationships and unequal opportunities."Trauma and homeless youth
Youth experiencing homelessness are more susceptible to developing post-traumatic stress disorder (PTSD). Common psychological traumas experienced by homeless youth include, sexual victimization, neglect, experiences of violence, and abuse. In an article published by Homeless Policy Research Institute it notes that homeless youth are subjected to many different forms of trauma. A study was done and found that 80% of youth that experienced homelessness in Los Angeles suffered at least one traumatic experience. Another study was conducted in Canada that showed a more severe statistic that Canadian homeless youth have been through 11 to 12 traumatic experiences. While trauma is prevalent in homeless youth, it is not uncommon for an adolescent to experience an increase of trauma after they experience homelessness. The LGBTQ community represents 20% of the homeless youth population. The reason for this high percentage is due to the issues and/or rejection from their family due to the sexual orientation.Societal factors
Draine et al. emphasize the role of social disadvantage with manifestations of mental illness. He states that "research on mental illness in relation to social problems such as crime, unemployment, and homelessness often ignores the broader social context in which mental illness is embedded."Social barriers
Stigma
Lee argues that societal conceptualizations of homelessness and poverty can be juxtaposed, leading to different manifestations of public stigma. In his work through national and local surveys, respondents tended to deemphasize individual deficits over "structural forces and bad luck" for homeless individuals. In contrast, the respondents tended to associate personal failures more to the impoverished than homeless individuals. Nonetheless, homeless individuals are "well aware of the negative traits imputed to them – lazy, filthy, irresponsible dangerous – based on the homeless label." In an effort to cope with the emotional threat of stigma, homeless individuals may rely on one another for "non-judgmental socializing". However, his work continues to emphasize that the mentally ill homeless are often deprived of social networks like this.Social isolation
People who are homeless tend to be socially isolated, which contributes negatively to their mental health. Studies have correlated that those who are homeless and have a strong support group tend to be more physically and mentally healthy. Aside from the stigma received by the homeless population, another aspect that contributes to social isolation is the purposeful avoidance of social opportunity practiced by the homeless community out of shame of revealing their current homeless state. Social isolation ties directly to social stigma in that homeless socialization outside of the homeless community will affect how the homeless are perceived. This is why homeless individuals talking with those who are not homeless is encouraged since it can combat the stigma that is often associated with homelessness.Racial inequality
One dimension of the American homeless is the skewed proportion of minorities. In a sample taken from Los Angeles, 68 percent of the homeless men were African American. In contrast, the Netherlands sample had 42 percent Dutch, with 58 percent of the homeless population from other nationalities. Furthermore, Lee notes that minorities have a heightened risk of the "repeated exit-and-entry pattern"Institutional barriers
Shinn and Gillespie (1994) argued that although substance abuse and mental illness is a contributing factor to homelessness, the primary cause is the lack ofConsequences
Incarceration
It is argued that persons with mental illness are more likely to be arrested, simply from a higher risk of other associated factors with incarceration, such as substance abuse, unemployment, and lack of formal education. Furthermore, when correctional facilities lack adequate coordination with community resources upon release, the chances of recidivism increase for persons who are both homeless and have a mental illness. Every state in the United States incarcerates more individuals with severe mental illness than it hospitalizes. Incarcerations are due to lack of treatments such as psychiatric hospital beds. Overall, according to Raphael and Stoll, over 60 percent of United States jail inmates report mental health problems. Estimates from the Survey of Inmates in State and Federal Correctional Facilities (2004) and the Survey of Inmates in Local Jails (2002) report that the prevalence for severe mental illness (the psychoses and bipolar/manic-depressive disorders) is 3.1–6.5 times the rate observed for the general population. In relation to homelessness, it is found that 17.3 percent of inmates with severe mental illness experienced a homeless state before their incarceration, compared to 6.5 percent of undiagnosed inmates. The authors argue that a significant portion of deinstitutionalized mentally ill were transitioned into correctional facilities, by specifically stating that "transinstitutional effect estimates suggest that deinstitutionalization has played a relatively minor role in explaining the phenomenal growth in U.S. incarceration levels."Responses
Responses to mental health and homelessness include measures focused on housing and mental health services. Providers face challenges in the form of community adversity.Housing
Modern efforts to reduce homelessness include "housing-first models", where individuals and families are placed in permanent homes with optional wrap-around services. This effort is less expensive than the cost of institutions that serve the complex needs of people experiencing homeless, such as emergency shelters, mental hospitals and jails. The alternative approach of housing first has shown positive outcomes. One study reports an 88 percent housing retention rate for those in Housing First, compared to 47 percent using traditional programs. Additionally, a review of permanent supportive housing and case management on health found that interventions using “housing-first models” can improve health outcomes among chronically homeless individuals, many of whom have substance use disorders and severe mental illness. Improvements include positive changes in self-reported mental health status, substance use, and overall well-being. These models can also help reduce hospital admissions, length of stay in inpatient psychiatric units, and emergency room visits. There is a new intervention called "Permanent Supportive Housing" that was designed help independent living and help with employment and health care. 407,966 individuals were homeless in shelters, transitional housing programs, or on the streets. Those with mental illnesses have difficulty not only with their current housing issues, but have issues with housing if they get evicted. Youth can benefit from permanent housing, increases social activity, and improve mental health. Federally funded rental assistance are in place, but due to the high demand of the funds, the government is unable to keep up. One study evaluating the efficacy of the Housing First model followed mentally ill homeless individuals with criminal records over a two-year period, and after being placed in the Housing First program only 30% re-offended. Overall results of the study showed a large reduction in re-conviction, increased public safety, and a reduction in crime rates. A significant decline in drug use was also seen with the implementation of the Housing First model. The study showed a 50% increase in housing retention and a 30% increase in methadone treatment retention in program participants.Mental health services
Uninterrupted assistance greatly increases the chances of living independently and greatly reduces the chances of homelessness and incarceration.Yoon, Bruckner, & Brown, 2013 Through longitudinal comparisons of sheltered homeless families and impoverished domiciled families, there are a collection of social buffers that slow one's trajectory toward homelessness. A number of these factors include "entitlement income, a housing subsidy, and contact with a social worker." These social buffers can also be effective in supporting individuals exiting homelessness. One study utilizing Maslow's hierarchy of needs in assessing housing experiences of adults with mental illnesses found a complex relationship between basic needs, self-actualization, goal setting, and mental health. Meeting self-actualization needs are vital to mental health and treatment of mental illness. Housing, stable income, and social connectedness are basic needs, and when met can lead to fulfillment of higher needs and improved mental health. Those with a brief history of homelessness and managed disabilities may have better access to housing. Research calls for evidence based remediation practices that transform mental health care into a recovery oriented system. The following list includes practices currently being utilized to address the mental health needs of homeless individuals: * Integrated service system, between and within agencies in policy making, funding, governance and service delivery. * Low barrier housing with support services. * Building Assertive Community Teams (ACT) and Forensic Assertive Community Teams (FACT). * Assisted Community Treatment (ACT). * Outreach services that identify and connect homeless to the social service system and help navigate the complex, fragmented web of services.Challenges
Fear surrounds the introduction of mentally ill homeless housing and treatment centers into neighborhoods, due to existing stereotypes that homeless individuals are often associated with increased drug use and criminal activity. The Housing First Model study, along with other studies, show that this is not necessarily the case. Proponents of theConclusion
For some individuals, the pathways into homelessness may be upstream. E.g. issues such as housing, income level, or employment status. For others, the pathways may be more personal or individual. E.g. issues such as compromised mental health and well ‐ being, mental illness, and substance abuse. Many of these personal and upstream issues are interconnected.See also
*References
Bibliography * * * * * *External links