Homelessness - Provision of Mental Health and Substance Abuse Services
How many people are homeless?
In 1996, an estimated 637,000 adults were homeless in any given week. In the same year, an estimated 2.1 million adults were homeless over the course of a year. These numbers increase dramatically when children are included, to 842,000 and 3.5 million, respectively. Over a 5-year period, about 2 to 3 percent of the U.S. population (5 to 8 million people) will experience at least one night of homelessness. For the great majority of these people, the experience is short and often caused by a natural disaster, house fire, or community evacuation. A much smaller group, perhaps as many as 500,000 people, has greater difficulty ending homelessness. One researcher who examined a sample of homeless persons over a 2-year period found:
Most, or about 80 percent, exit from homelessness within 2 or 3 weeks. They often have more personal, social, and economic resources to draw from than people who are homeless for longer periods of time.
About 10 percent are homeless for up to 2 months, with housing availability and affordability adding to the time they are homeless.
Another 10 percent are homeless on a chronic, protracted basis, for as long as 7 or 8 months in a 2-year period. Disabilities associated with mental illnesses and substance use are common. On any given night, this group of homeless persons can account for up to 50 percent of those seeking emergency shelter.
Why are so many people homeless?
The reasons that people become homeless are as varied and complex as the individuals themselves. Several structural factors contribute greatly to homelessness:
Poverty. In 1996, the median monthly income for people who were homeless was $300, which is only 44 percent of the Federal poverty level for a single adult. Losses in the numbers of manufacturing and industrial jobs, combined with an 18 percent decline in the real value of the minimum wage between 1979 and 1997, have left significant numbers of people without a livable income.
Housing. The U.S. Department of Housing and Urban Development estimates that there are 5 million households in the U.S. with incomes below 50 percent of the local median that pay more than half of their income for rent or that live in severely substandard housing. This is made worse by a 5 percent decline since 1991 in the number of housing units affordable to extremely low-income households, a loss of more than 370,000 units. Federal rental assistance has not been able to bridge the gap; the average wait for Section 8 rental assistance is now 28 months.
Disability. People with disabilities who are unable to work and must rely on entitlements such as Supplemental Security Income (SSI) can find it virtually impossible to find affordable housing. In 2000, the federal SSI benefit was $512 per month, which would not cover the cost of an efficiency or one-bedroom apartment in any major housing market in the country.
There are also several individual factors that may increase a person's risk for becoming homeless and remaining homeless for a longer period of time:
Untreated mental illness can cause individuals to become paranoid, anxious, or depressed, making it difficult or impossible to maintain employment, pay bills, or keep supportive social relationships.
Substance abuse can drain financial resources, erode supportive social relationships, and make exiting from homelessness extremely difficult.
Co-occurring disorders. Individuals with co-occurring mental health and substance use disorders are among the most difficult groups to put in stable housing and treat. This is due to the limited availability of integrated mental health and substance abuse treatment in most locations.
Other circumstances. People may become homeless for a variety of other reasons, including divorce or separation, domestic violence, chronic or unexpected health care expenses, release from incarceration, or release from foster care.
Who is homeless?
An estimated 842,000 adults and children are homeless in any given week, with that number growing to as many as 3.5 million over the course of a year. People who are homeless are the poorest of the poor. While almost half (44%) of homeless people work at least part-time, their monthly income averages only $367, compared to a median monthly income of $2,840 for U.S. households. Those who have disabilities and are unable to work find it nearly impossible to secure affordable housing in virtually every major housing market in the country.
Most homeless persons are unaccompanied adults. Sixty-six percent are single adults, and three-quarters of these are men. However, the number of homeless families is growing:
Eleven percent are parents with children, 84 percent of whom are single women.
Twenty-three percent are children under 18 with a parent, 42 percent of whom are under 5 years of age.
Forty-one percent are non-Hispanic Whites (compared to 76 percent of the general population). However, racial and ethnic minorities, particularly African Americans, are overrepresented:
Forty percent are African Americans (compared to 11 percent of the general population).
Eleven percent are Hispanics (compared to 9 percent of the general population).
Eight percent are Native Americans (compared to 1 percent of the general population).
Homelessness continues to be a largely urban phenomenon:
Seventy-one percent are in central cities.
Twenty-one percent are in suburbs.
Only 9 percent are in rural areas.
People who are homeless frequently have health problems:
Thirty-eight percent report alcohol use problems.
Twenty-six percent report other drug use problems.
Thirty-nine percent report some form of mental health problem, and 20 to 25 percent meet criteria for serious mental illnesses.
Sixty-six percent report substance use and/or mental health problems.
Three percent report having HIV/AIDS.
Twenty-six percent report acute health problems other than HIV/AIDS such as tuberculosis, pneumonia, or sexually transmitted diseases.
Forty-six percent report chronic health conditions such as high blood pressure, diabetes, or cancer.
People who are homeless also share other common characteristics:
Twenty-three percent are veterans (compared to 13 percent of the general population).
Twenty-five percent were physically or sexually abused as children.
Twenty-seven percent were in foster care or institutions as children.
Twenty-one percent were homeless as children.
Fifty-four percent were incarcerated at some point in their lives.
Why are so many people with serious mental illnesses homeless?
Their symptoms are often active and untreated, making it extremely difficult for them to meet basic needs for food, shelter, and safety.
These individuals are impoverished, and many are not receiving benefits for which they may be eligible.
Up to 50 percent have co-occurring mental illness and substance use disorders.
People with serious mental illnesses have greater difficulty exiting homelessness than others. They are homeless more often and for longer periods of time than other homeless populations. Many have been on the streets for years.
What do we know about people with serious mental illnesses who are homeless?
The majority of people with serious mental illnesses who are homeless had prior contact with the mental health system, either as an inpatient or outpatient. These experiences were not always positive; they may have been hospitalized involuntarily or given treatment services or medications that did not benefit them.
The symptoms of mental illness, combined with the hygiene problems associated with homelessness, result in many untreated physical health problems such as respiratory infections, dermatological problems, and risk of exposure to HIV and tuberculosis.
These individuals typically are long-term citizens of the communities in which they are homeless.
The social support and family networks of these individuals usually have unraveled. Those who are members of families often have lost regular contact with their relatives or are no longer equipped to be primary caregivers.
These individuals are twice as likely as other homeless people to be arrested or jailed, mostly for misdemeanors. They are often good candidates for diversion programs that enable them to go from jail to more appropriate treatment, support, and housing.
How can we end homelessness for people with serious mental illnesses?
Research has provided much information about what services and practices are effective in ending homelessness for people with serious mental illnesses. Key findings show:
Outreach, whether in shelters or on the street, is effective. Given the opportunity, most homeless people with serious mental illnesses are willing to accept treatment and services voluntarily. Consistent outreach and the introduction of services at the client's pace are key to engaging people in treatment and case management services. A consistent, caring, personal relationship is required to engage people who are homeless in treatment.
Integrated mental health and substance abuse treatment provided by multidisciplinary treatment teams can improve mental health, residential stability, and overall functioning in the community. Regular assertive outreach, lower caseloads, and the multidisciplinary nature of the services available from these teams are critical ingredients that lead to positive treatment and housing outcomes.
Supportive services to people in housing have proven effective in achieving residential stability, improving mental health, and reducing the costs of homelessness to the community. Supported housing is preferred by many homeless people with serious mental illnesses. Many people who are homeless with serious mental illnesses can move directly from homelessness to independent housing with intensive support and attention.
Prevention. Homelessness among people with serious mental illnesses can be prevented. Discharge planning that helps people who are leaving institutions to access housing, mental health, and other necessary community services can prevent homelessness during such transitions. Ideally, such planning begins upon entry into an institution, is ready to be implemented upon discharge, and involves consumer input. Providing short-term intensive support services immediately after discharge from hospitals, shelters, or jails has proven effective in further preventing recurrent homelessness during the transition back into the community.