Mental Illness and Homelessness

What is homeless?

• Focuses on something the person lacks, assuming insufficiency

• Associated with stigma

• Assumes a traditional sense of “home”

What is unhoused?

• Focuses on the societal issues contributing to lack of suitable housing

• Less stigma

• Recognizes that “shelter” and “home: are different for different people

What is the connection between “homelessness” and mental health?

• Lack of a fixed permanent nighttime residence or living in nighttime residences that are temporary shelters, welfare hotels, transitional housing for mentally ill persons, or any public or private place not designated as sleeping accommodations for human beings

• Sheltered—temporary or transitional housing operated by public and private agencies for individuals and families who have no stable housing. 

• Unsheltered—homeless live in the places that are not used for housing such as cars, parks, abandoned buildings, tents, bus/train stations.

• Difficulty in meeting basic needs because of a lack of a consistent dwelling place

• Ignored or not seen by the general population

What are characteristics of people who are mentally ill and homeless?

• People with mental disorders are at greater risk for homelessness than the general population.

• Mental health problems increase with the duration of time the person is homeless.

• They have at least one psychiatric service encounter annually, usually in an ED rather than inpatient or outpatient units.

• They are homeless for longer periods, often years, than are those who are homeless and not mentally ill or substance abusing.

• They are more likely to be in poor physical health compared to other homeless people.

• They have more contacts with the legal system than other homeless or housed people.

• They are more likely to encounter employment barriers and less likely to benefit from societal economic growth.

• They are less likely to have contact with family or friends, especially if they come from higher-income households.

• Most are eligible for, but have difficulty obtaining, income maintenance such as Social Security Disability Insurance, Veterans Affairs disability benefits, or other benefits.

• Most are willing to accept treatment after basic survival needs are met and a therapeutic relationship has been established.

Where might someone live, or sleep at night, if they are homeless?

• Under a bridge

• Shelter

• Short-stay motel

• In their car

• At a friend or relative’s home

• In a park

• Abandoned building

What is epidemiology?

• Includes people of all ages, racial and cultural backgrounds, and geographic areas

• One in two unhoused persons are unsheltered

• One third are persons with untreated serious mental illnesses

• Personal, social, and economic deprivations

• Difficulty in determining the actual numbers who are homeless

• 65% single; 35% part of a family

• 60% men and 40% women; 1/5 were children (some studies say that up to 40% are children)

• Risk factors include survivors of domestic violence, members of the LGBTQIA+ community, immigrants, any marginalized group

What is SMI?

One or more mental, behavioral, or emotional disorder(s) resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities

What are the risk factors for being unhoused?

• People with severe mental illness

• Families with children

• Victims of domestic violence

• Adolescents and runaway youths

• Incarcerated or arrested individuals

• Combat veterans with PTSD (acute or delayed), anxiety disorders, and major depression

• New immigrants; refugees

• Migrant workers and their families

• Marginalized minorities (Blacks, LGBTQIA+, people who are HIV+, transgender, etc.)

What is the etiology for being unhoused?

• No single cause

• Individual risk factors - Charles Schwab reported in their “Modern Wealth Survey,” 2019, that 59% of Americans are just 1 paycheck away from homelessness.

• Environmental risk factors – public assistance programs being decreased

• Societal and family risk factors – fewer beds, abandonment

  • Lack of affordable housing (should be <30% of income)

  • Inadequate discharge planning from healthcare facilities

  • Economic shifts

What are some causes of homelessness?

• Poverty; history of childhood family instability

• Lack of affordable housing; doubling up with relatives or friends until the situation is intolerable

• Mental illness or substance abuse and lack of needed services

• Low-paying jobs; unemployment

• Domestic violence; flight from a violent home or abandonment; youth aging out of services

• Eviction for not paying rent; multiple movers

• Limited life coping skills; disturbing behavior

• Changes or reductions in public assistance programs

• Veteran status

• Prison release; having no money, job, or place to go

What is the effect of homelessness on mental health?

• Sense of depersonalization

• Fragmented identity

• Loss of self-worth or self-efficacy

• Stigma

• Social engagement is splintered

• Lack of comfort, convenience, shelter leads to chronic pain in feet, legs, hands, back, neck

• Difficulty accessing healthcare, medications, transportation, healthy food

• Exposure to trauma, abuse, & violence

• Mental illness and homelessness have a complex two-way relationship

  • Mental illness can cause cognitive and behavioral issues that make it hard to maintain stable employment and engage in healthy habits like paying bills on time.

  • Homelessness can can deprive people of self-worth, make it more challenging to access healthcare and preventative services, and make it hard to maintain a medication regimen.

What is recovery-oriented care for persons with mental illness who are unhoused?

• Teamwork and collaboration: Working toward recovery

  • SAMHSA

  • Substance abuse and mental health services administration

  • Five-stage process in homeless rehabilitation for persons who are homeless with a mental illness

• Safety Issues – self, others, staff at facility

• SBIRT for alcohol and drug use

  • Example of SBIRT is CAGE questionnaire for alcohol use: C – cut down (have you ever felt like you need to?)  A  – annoyed (do people ever annoy you by suggesting your drinking is a problem?)  G – guilt (do you ever feel guilty?)  E – eye opener (do you need a drink first thing in the morning to cope with hangover or steady your nerves?) 

  • Screening, brief interventions, and referral to treatment (SBIRT) – useful for homeless population (5 minutes for screening, 10 minutes for intervention)

• Homelessness and infection prevention – dense populations, hygiene concerns

What is evidence-based nursing care for persons with mental health who are unhoused?

• Mental health nursing assessment

• Physical health assessment

• Psychosocial assessment

• Mental status and appearance

• Behavioral responses – may not have insight, could be in denial

• Stress and coping skills – homelessness is a daily stressor!

What are common physical health problems experienced by homeless people?

• Injuries, fractures, epistaxis, or edema from trauma, falls, burns, assault, gunshot wounds

• Influenza, colds, bronchitis, asthma, shortness of breath

• Hypothermia, hyperthermia

• Arthritis, musculoskeletal disorders, headaches, fatigue

• Diabetes mellitus

• Hypertension

• Cardiovascular and peripheral vascular diseases

• Malnutrition

• Pulmonary tuberculosis

• Infestations, such as lice or scabies

• Dermatitis, sunburn or frostbite, bruises

• Foot injury, blisters, calluses

• Sexually transmitted diseases

• Hypothyroidism or hyperthyroidism

• Kidney or liver disease

• Cancer

• Epilepsy

• Impaired vision, glaucoma, cataracts

• Impaired hearing

• Dental caries, periodontal disease

What is included in establishing a therapeutic relationship?

• Examine homelessness myths and one's own feelings about people who are unhoused and experiencing mental illness

• Relating to people who are unhoused requires a gentle and compassionate approach

What are included in mental health nursing interventions?

• Interventions are to be directed at the social system, as well as at the individual or family level.

• Interventions should take advantage of community resources and the inner resources and support systems of the individual or family.

• Establishing recovery and wellness goals

• Overcoming barriers to care

• Improving quality of life

• Meeting spiritual needs

• Evaluation and treatment outcomes

• Examples

  • Stabilize physical health status.

  • Provide a list with addresses and telephone numbers of shelters and luncheon sites that provide food; discourage rooting through dumpsters and panhandling.

  • Provide a list of facilities that are safe, including shelters that provide clothing, a safe place to sleep, and opportunity for basic hygiene and laundry.

  • Give information on city ordinances that forbid sleeping on park benches, in building doorways, on sidewalk grates, at bus or train stations, in vacant buildings, or in viaducts.

  • Explore sources of income, such as gathering and selling aluminum cans or engaging in temporary day labor. Discourage selling blood or plasma.

  • Assist the person directly or by referral to pursue entitlements, such as Social Security, veterans, or other benefits.

  • Explore how to stay safe. Even in a night shelter, the person who is homeless may not be safe from assault. It is difficult for the person who is homeless to know who is trustworthy; carrying a bag or case is usually considered a marker for being robbed on the streets.

  • Explore how to secure privacy, which is difficult to achieve, and how to cope with loneliness, which can be overwhelming.

  • Give a list of names, addresses, and telephone numbers of agencies that offer services and socialization, such as the local mental health agency, the local chapter of NAMI, or the local Emotions Anonymous group.

  • Give information about meetings of Alcoholics Anonymous, Narcotics Anonymous, or Cocaine Anonymous if the person is using substances.

What are some community services for those who are unhoused with mental illnesses?

• Safe Havens

• Stable shelters or residences

• Accessible outreach

• Integrated case management

• Accessible and affordable housing options

• Treatment and rehabilitation services

• General health care services

• Vocational training and assistance with employment

• Income support

• Legal protection

• Emergency services

  • Street or mobile outreach program

• Integration with primary care

• Housing resources

  • Transitional housing may consist of a halfway house, a short-stay residence or group home, or a room at a hotel designated for people who are homeless

  • HEARTH Act (2009) - created Continuum of Care – long-term housing for those homeless with disabilities, primarily with mental illness

• U.S. Military Veterans Services

  • Health Care for Homeless Veterans (HCHV) – hub for housing and services to reach the homeless veteran population