Literal Homelessness Research Articles

The “Literally” (and Not So Literally) Homeless

Homelessness as a topic for public debate could be said not to have existed in the U.K. until November 16th, 1966, when BBC Television aired the play Cathy Come Home, which charted a young couple’s decline into homelessness and hopelessness when the breadwinner was injured at work. The charity Shelter began in the same year, and both were to prove powerful influences on public policy. The executive director of the U.S. Interagency Council on Homelessness is impressed by the fall in numbers of those sleeping rough (from 1,850 a night in England in 1998 to 500 now1). In claiming that “for the first time in 20 years” U.S. cities are also seeing a fall in persons sleeping on the streets or long-term in shelters and that “we are ending the disgrace of homelessness,” Mr. Philip Mangano cheerfully admits to stealing British ideas.2 Via legislation, which places a duty on local authorities to find shelter whatever the cause of the homelessness, and by initiatives such as the Rough Sleepers Unit (now part of the Homelessness Directorate in the Department of Communities), things have improved in Britain. Inevitably, there is debate about the true numbers and the problem has not yet gone away. Between 2000 and 2004 only 5 of London’s 33 boroughs recorded a fall in homelessness, and two-thirds of England’s 94,000 families in temporary accommodation were in the capital. The Government’s target is to halve the number in temporary accommodation by the year 2010. Medical publications on homelessness tend to focus on drug abuse and alcoholism, other mental health problems, and infections such as HIV/AIDS and tuberculosis, all conditions more likely to be found at the extreme end of homelessness, among those sleeping in shop doorways and under cardboard boxes, for instance. Another focus is access to health services;3 the University of Oxford has recently launched a postgraduate course on the provision of health care to this vulnerable group. However, there is a wider problem with housing shortages, and confusion can arise between those sleeping rough and individuals or whole families who find it difficult to buy or even rent a home. Both groups are in a sense “homeless”. The former are what a Californian study refers to helpfully as the “literally homeless”,4 but the struggles of the larger second group are not being ignored. In the U.K., where “getting on the property ladder” is most people’s dream, help with first homes is provided by hundreds of local housing associations and the parent body, the Housing Corporation. The Corporation’s strategy does now cover the literally homeless,5 but its main activity is the investment in 2006–2008 of £3.9 billion (US $1.97 billion) in 84,000 new homes, 58% for rent. The planning process also assists as, increasingly, approval of housing developments becomes easier when there is “affordable” or “social” housing in the project, and such provision is a focus of the Thames Gateway renovation project east of London. Preventing literal homelessness and its medical consequences requires knowledge of the underlying cause, or rather, causes. Some recent German research hints that simply providing a permanent home is not the whole answer.6 The roots of homelessness and the answers to it may not be purely economic. Cause and cure may also depend on where you are and on age, as illustrated by a few recent publications. In California, the average age of the elderly homeless surveyed was increasing by 8 months a year;4 in New York City, age and arrest history were predictors on longer-term homelessness;7 in Australia, at the other end of the age spectrum, it appears that family conflicts are a more important reason for running away from home than abuse, physical or other.8 The distinction between the literally and not so literally homeless is helpful but a bit artificial; a spectrum of causation and suffering is far more likely. The statistics for homelessness may be showing encouraging signs, but housing remains an important issue that requires cross-sectoral communication between medicine and public health, on the one hand, and politics and economics on the other.

Brief Reports: Psychiatric Illness and Substance Abuse Among Homeless Asian-American Veterans

Brief Reports: Psychiatric Illness and Substance Abuse Among Homeless Asian-American Veterans

Housing Outcomes for Hospitalized Homeless Veterans

This study examines housing status at the time of hospital discharge in a national sample of 3,502 veterans who were homeless at admission to a Veterans Health Administration (VHA) medical center. A supplemental survey on homelessness was added to the annual VHA inpatient census over a 4-year period (1995 through 1998). Data from this survey were used to identify homeless veterans hospitalized on the final day of the fiscal year and to document their housing status at discharge. A signal detection technique, Receiver Operating Characteristic analysis, was used to identify predictors of housing status at discharge. At discharge, only 13% of the veterans in our analytic sample were literally homeless, 40% were doubled up, and 33% were transferred to another an institution; only 13% were living independently. Housing status at admission (specifically, staying with friends or family temporarily rather than literally homeless), treatment in a psychiatric or substance abuse program rather than a medical program, and a greater income level or access to VHA benefits were found to be associated with better housing outcomes. As one might expect, homelessness was infrequently resolved during an acute inpatient hospitalization, but few veterans returned to literal homelessness at the time of discharge.

Homelessness, Substance Misuse, and Access to Public Entitlements in a Soup Kitchen Population

The study examined the effects of homelessness on access to public entitlements (Medicaid and food stamp programs) in a soup kitchen population. Data were collected between 1997 and 1999 from a sample of 343 adults at two soup kitchen sites in New York City. Five hypotheses, focusing on the effects of housing status (literal homelessness, unstable housing, and domiciled), frequency of drug/heavy alcohol use, drug/alcohol-user treatment history and childcare responsibilities on access to Medicaid and food stamp programs were tested. Multiple logistic regression analysis indicated that both literal homelessness and unstable housing were associated with less access to Medicaid and food stamps. Other significant findings were: current drug/alcohol-user treatment experience was associated with greater access to both Medicaid and food stamps, frequency of drug/heavy alcohol use was associated with less access to Medicaid only, and caring for children was associated with greater access to food stamps only. These findings support the crucial role of housing status in mediating access to entitlements, and the importance of drug/alcohol-user treatment involvement as a cue to seeking entitlements. The need to reduce health disparities through active and sustained outreach programs designed to enhance homeless persons’ access to Medicaid and food stamp programs was discussed.

Advocacy and Enumeration

Enumerating or estimating the numbers of homeless people has become an important research activity in the past few decades. The methodologies of almost all efforts to count homeless people have been closely linked to advocacy activities such as providing shelter and food to those in need. Yet the effect of advocacy work on estimating or enumerating homeless populations has not been much examined in the enumeration literature. This work reviews the methodology of enumeration as it has been influenced by the work of advocates both in general terms and through examining the methods used to conduct a study of a suburban homeless population in New York in 1994. Enumeration methods that overtly take local advocacy activities into account can provide an enriched assessment of homelessness as it exists in relation to surrounding structural conditions. In this case, advocacy work actively prevented literal homelessness for most families in the local community.

Housing Solutions

Key features of a comprehensive housing program serving formerly homeless and at-risk adults with serious and persistent mental illness are described. The program combines intensive case management, integrated dual-diagnosis treatment, and other clinical services with a range of housing options which are operated under the auspices of a single agency. For individuals with co-occurring substance use disorder, housing responses are guided by a four stage model of treatment and recovery. The authors offer a rationale for the continuum approach's relevance for high risk populations, especially those in poor, urban settings where safety and harm-reduction are a high priority. A controlled study comparing the continuum housing approach to another leading model is underway. Primary outcomes of interest are engagement in services, establishing and maintaining high quality housing, and avoiding returns to literal homelessness.

Providing Shelters or Low Income Housing? An Optimal Control Model

An optimal control model is developed to model the choice between short-term safety nets (shelter beds) and longer term investments (low income housing) for the alleviation of literal homelessness (people sleeping on the street). Society's objective function depends negatively on literal homelessness and the budget expenditure to fight it. A steady-state saddle point solution is found. The model is extended to take into account incentive effects in the provision of shelters and leakage effects in the provision of low income housing.Journal of Economic Literature ClassificationNumbers: H53, R21, C61.

Homeless Children and Their Families in New Hampshire: A Rural Perspective

Twenty case studies of homeless students and their families in New Hampshire reveal that homelessness is a problem in rural, as well as urban, areas. Homelessness for two-parent families came in the wake of economic reverses, while for singleparent families the precipitating event was family disruption. Homeless schoolchildren were found to suffer serious setbacks both academically and socially, including exhaustion, lack of time and a place to do homework, coordinating school schedules with work schedules, instability, out-of-school periods, frequent changes of school, and stigmatization. These problems characterized not only the period of literal homelessness but also the entire residential crisis episode surrounding that period.

Risk factors for homelessness among women with schizophrenia.

A study of risk factors for homelessness among the severely mentally ill was extended to include women, and a case-control study of 100 indigent women with schizophrenia meeting criteria for literal homelessness and 100 such women with no history of homelessness was conducted. Subjects were recruited from shelters, clinics, and inpatient psychiatric programs in New York City. Clinical interviewers used standardized research instruments to probe three domains of risk factors: severity of mental illness, family background, and prior mental health service use. Findings adjusted for ethnicity revealed that homeless women had higher rates of a concurrent diagnosis of alcohol abuse, drug abuse, and antisocial personality disorder. Homeless women also had less adequate family support.

Lifetime and five-year prevalence of homelessness in the United States: new evidence on an old debate.

A 1990 household-based telephone survey of 1,507 people was followed up by surveying a subsample of those interviewed for the initial report. Results showed very high prevalence figures for homelessness, quite close to those found in the earlier survey. Moreover, using explicit and stringent definitions of literal homelessness and doubling up, most periods of homelessness were found to last for more than one month and, particularly with regard to literal homelessness, to involve serious deprivations and violent victimization.

Lifetime and five-year prevalence of homelessness in the United States.

Intense debate exists concerning the number of homeless people in the United States. Previous studies, counting currently homeless people, have provided point-prevalence estimates of homelessness but have been criticized on methodological grounds. This study reports lifetime and 5-year prevalence estimates of homelessness using a different methodological approach. Random-digit dialing was used to interview 1507 adults living in households with telephones in the 48 contiguous states in the fall of 1990. Respondents were asked whether they had ever been homeless and if so, where they had slept while homeless. Lifetime and 5-year prevalence of all types of homelessness combined were 14.0% (26 million people) and 4.6% (8.5 million people), respectively. Lifetime "literal homelessness" (sleeping in shelters, abandoned buildings, bus and train stations, etc.) was 7.4% (13.5 million people). Five-year (1985 through 1990) prevalence of self-reported homelessness among those who had ever been literally homeless was 3.1% (5.7 million people). The magnitude of the problem of homelessness is much greater than most previous attempts to enumerate homeless people have led us to believe. This finding requires reconsideration of inferences about the causes of homelessness that were derived from point-prevalence studies of currently homeless people.

Risk factors for homelessness among schizophrenic men: a case-control study.

To identify risk factors for homelessness among the severely mentally ill, we conducted a case-control study of 100 indigent schizophrenic men meeting criteria for literal homelessness and 100 such men with no homeless history. Subjects were recruited from shelter, clinic, and inpatient psychiatric programs in Upper Manhattan. Clinical interviewers employed standardized research instruments to probe three domains of risk factors: severity of mental illness, family background, and prior mental health service use. Homeless subjects showed significantly higher levels of positive symptoms, higher rates of a concurrent diagnosis of drug abuse, and higher rates of antisocial personality disorder. Homeless subjects experienced greater disorganization in family settings from birth to 18 years and less adequate current family support. Fewer homeless subjects than subjects in the never-homeless comparison group had a long-term therapist. These differences remained when demographic variables were adjusted statistically. Homeless schizophrenic men differed from their domiciled counterparts in all three domains we investigated; family background, nature of illness, and service use history. Findings are discussed in relation to policy and programs for the severely mentally ill.

Housing instability and homelessness among rural schizophrenic patients

The authors examined housing instability among treated schizophrenic patients in a rural area and compared the findings with those from their previous study of urban patients. Seventy-five patients with schizophrenia or schizoaffective disorder who were treated in a rural mental health center were assessed with research interviews and ratings by their clinical case managers. The patients were followed for 1 year to identify episodes of psychiatric hospitalization, incarceration, and literal homelessness. Of the 75 patients, 19 (25%) had housing situations characterized as unstable by their case managers. For the majority, housing instability signified tenuousness of living arrangements rather than literal homelessness. Noncompliance with medications, alcohol use, and negative symptoms accounted for 30% of the variance in unstable housing. During follow-up, the unstably housed patients, compared to those in stable living situations, were no more likely to be rehospitalized but were somewhat more likely to be jailed and significantly more likely to be literally homeless. In the authors' previous study of urban psychiatric patients, unstably housed patients were more likely to be literally homeless, highly symptomatic, and rehospitalized during follow-up than the rural patients with unstable housing. Better outcomes in the rural area appeared to be related to the greater availability of housing alternatives and to intensive case management. For patients with unstable housing in both settings, noncompliance with medications and substance abuse, as well as housing arrangements, should be assertively addressed.

Homelessness old and new: The matter of definition

The contemporary emphasis on the pathologies of shelter denizens and street-dwellers tends to conceal the great variety of makeshift ways of life that have characterized “homelessness” over the centuries. Diversity notwithstanding, those considered “vagrants” were historically marked as suspect members of a poor apart, even when their numbers increased sharply. Because kin ties have consistently proven to be the first line of defense against “literal homelessness,” skid row researchers thought their absence (along with the lack of associated ties to work and community) to be diagnostic of the condition. Indeed, earlier research tended to see as “homeless” any “disaffiliated” persons, housed or not, who lived alone in unconventional dwellings. Not only have the new homeless poor, by contrast, proven to be more diverse—their geographic locus, age, gender, ethnicity, and signal disabilities having all changed-but their common element is less often ascribed to faulty social connectedness than to sheer absence of shelter. This paper discusses such changes and reviews definitions of homelessness and several approaches to its social construction. The paper argues that, although definitions owe as much to political as to logical considerations, it makes both practical and historical sense to view the streets and shelters as but one variant of a class of informal or makeshift residential settings that increasingly characterizes the marginally situated.