BIOL. PSYCHIATRY 1992;32:383-386
383
EDITORIAL
Psychiatry and the Homeless
There are now countless thousands of homeless in our cities, living in the streets; sleeping in armories, shelters, and churches; holding out their cups for alms; and arousing guilt, fear, and shame among us. They are mostly men, but some are women, some are aged, and not infrequently family groups are seen, with or without fathers. Many are alcoholic, others are mentally ill, and well-intentioned efforts are periodically made to discover the psychiatric cases by street encounter to round them up for treatment or institutionalization. To what extent is homelessness a psychiatric problem? Is deinstitutionalization dumping these unfortunate into our streets; do many psychotics drift downward into this condition; does homelessness induce mental breakdown and disorder? An overemphasis on the psychiatric symptomatology encountered in homeless populations can create the impression that psychiatric disorder is a major cause of homelessness. Actually, it requires considerable ingenuity and adaptive skill to survive on the streets. On a number of relevant parameters those labeled mentally disturbed show no significant differences from those supposedly normal, viz, past histories, demographics, adaptive skills, substance abuse, social support (Caton et al 1990; Coh~.a and Sokolovsky 1989). Roper (1988) concluded there was no evidence to suggest that mental illness was a major cause of homelessness. Epidemiological studies show that, aside from substance abuse, about one-third of homeless persons have a DSM Ill Axis I diagnosable mental disorder (Dennis et al 1991), though the percentage with active psychotic illness may be between 10 and 13% (Fischer and Breakey 1991; Koegel et al 1988). Rates of substance abuse, mostly alcoholism, often exceed 50% (Eagle and Caton 1990). It must be realized that the severe stresses of homelessness, and accompanying malnutrition, inadequate sleep, exposure to weather, infection, and injury, can by themselves induce or exacerbate psychiatric disorders. Half the homeless are to some degree depressed (Cohen and Sokolovsky 1989; Rossi 1989) and show other psychological sequelae of chronic stress (Goodman et al 1991). Gruenberg (1967) long ago described a "social breakdown syndrome" as a state in which individuals under great and continued stress manifest withdrawal, aggressiveness, apathy, or negativism, regardless of any specific diagnosis they may acquire. Because of the many factors involved, Baxter and Hopper (1982) caution that all diagnoses must be provisional, because "were the same individuals to receive several nights of sleep, an adequate diet, and warm social contact, some of their symptoms might subside." A biomedical psychiatric approach to this hugh problem can at best provide only a modest contribution. There is no strong connection between homelessness and de~nstitutionalization (Tessler and Dennis 1989). Only 1 in 20 single adult homeless weLc,found to be in need of acute patient care (Mulkern et al 1985; Roth et al 1985; Struening 1987). The homeless themselves often resist the efforts of social workers to get them to accept psychiatric help: they do not wish to be isolated and stigmatized (or threatened) by placement in an institution, and sometimes prefer the freedom to live with their symptoms in the streets (Mossman and Perlin 1992). © 1992 Society of Biological Psychiatry
0006-3223/92/$05.00
384
BIOL PSYCHIATRY 1992;32:383-386
Editorial
Here, as elsewhere, a misplaced psychiatric emphasis can divert attention from real causes and necessary remedies. There has been a disastrous decline in affordable and available housing in recent years (more than 5 million low cost units were lost during 1973-1985), combined with a huge loss in both manufacturing and service jobs, at the same time that entitlements and other social service programs have been reduced (Cohen and Thompson 1992). One-third of American families are now shelter-poor (i.e., unable to pay for nonhousing necessities and still cover housing costs), and 60% are now living on incomes equivalent to what they had in the 1960s (Marcuse 1990; Wicker 1991). Thus, over the past two decades, the poor, the aged, the salaried worker, the mentally ill, and all powerless and vulnerable elements of the population have become increasingly impoverished, resourceless, and homeless. As columnist Russell Baker (1991) recently observed, "For the first time in 50 years people who cannot be dismissed as shiftless louts are worrying about how they are going to pay the doctor, pay the rent, and pay the butcher." In this social context remedial action will need broad alliances: in the specific area of homelessness psychiatry can make its contribution, but other forces must be mustered. At the service level, we propose a model that is more generic than clinically oriented. Programs that are open to all homeless and that offer a variety of entitlements and clinical services seem to work best (Cohen et al 1991; Susser et al 1991). As long as the client remains engaged, mental health often improves even if it is not targeted primarily. Moreover, those programs that have encouraged autonomy and individual choice have been more successful in maintaining contact (Barrow et al 1989, Dennis et al 1991; Susser et al 1991). Availability of resources that allow for a wider array of options has been found to be a better predictor of outcome than degree of pathology. Innovative strategies are being developed that parallel the interventions used with refugees, disaster victims, and others enduring social dislocation (Goodman et al 1991). Consequently, attention has been directed toward empowerment strategies such as building social supports, encouraging self-help and other group actions, creating large-scale preventive projects, and promoting collaborations in which homeless persons are included in the design and execution, and in the analysis of the research data (Cohen and Thompson 1992; Glickman 1988; Goodman et al 1991; Long and Van Tosh 1988). On the sociopolitical level, our perspective calls for alliances not only among subgroups of the homeless, but also among the threatened poor, or the working and middle-class populations who likewise commonly find themselves unable to afford housing and other economic necessities. There is room in this alliance for psychiatric clinicians and researchers, because research in this area can serve as a powerful vehicle to promote community interest and empowerment. Such an alliance can serve as the basis for new initiatives that will include mental health services as one constituent of a comprehensive program for improved housing, health, and economic well-being. Psychiatrists must not let the welcome growth of knowledge in biological psychiatry overwhelm their judgment, impoverish their capacity to see social context, or deflect the urge to act upon it. Carl I. Cohen I Kenneth C. Thompson 2
~State University of NY Department of Psychiatry Health Sciences Center 450 Clarkson Ave Brooklyn, NY 11203
FAitorial
BIOL PSYCHIATRY 1992;32:383-386
385
2Department oi' Psychia~, University of Pittsburgh School of Medicine Pittsburgh, PA 15213
References Baker R (1991): Hiatus in the fun. New York Times, November 12, AI5. Barrow S, Hellmdn F, Lovell A et al (1989): Effectiveness of programs for the mentally ill homeless. Final Report. New York: New York State PsychiaUic Institute. Baxter JE, Hopper K (1982): The new mendicancy: Homeless in New York City. Am J Ortho. psychiatry 52:393-408. Caton CLM, Wyatt RJ, Grunberg J et al (1990): An evaluation of a mental health program for homeless men. Am J Psychiatry 147:286-289. Cohen Cl, Onserud H, Monaco C (1991): Project Rescue: Serving the homeless and marginallyhomeless elderly. Final Report (April). Cohen CI, Sokolovsky J (1989): Old Men of the Bowery. New York: Guilford Press. Cohen CI, Thompson K (1992): Homeless mentally ill or mentally ill homeless? Am J Psychiatry 149:816-823. Dennis D (1990): Exploring myths about "street people." Access 2:1-3. Dennis DL, Buckner JC, Lipton FRet al (1991): A decade of research and services for homeless mentally ill persons. Where do we stand? Am Psychologist 46:1129-1138. Eagle PF, Caton CLM (1990): Homelessness and mental illness. In Caton CLM (ed), Homeless in America. New York: Oxford University Press. Fischer PL Breakey WR (1991): The epidemiology of alcohol, drug, and mental disorders among homeless persons. Am Psychologist 46:1115-1128. Glickman LG et al (1988): To Build A Community: Report of the Mayor's Citizens Task Force on Central City East. Goodman L, Saxe L, Harvey M (1991): Homelessness as psychological trauma: Broadening perspectives. Am Psychologist 46:1219-1225. Gruenberg EM (1967): The social breakdown syndrome: Some origins. Am J Psychiatry 123: ~4811489. Koegel P, Bumam MA, Fan" RK (1988): The prevalence of specific psychiatric disorders among homeless individuals in the inner-city of Los Angeles. Arch Gen Psychiatry 45:1085-1092. Lamb HR, Zu~man J (19"/9): Primary prevention in perspective. Am J Psychiatry 136:12-17. Long LA, Van Tosh L (1988): Program Descriptions of Consumer-Run Program for Homeless People with Mental Illness (Vol. 2 of 3). Rockville, MD: National Institute of Mental Health, Program for the Homeless Mentally 111. Man:use P (1990): Homelessness and housing policy. In Caton CLM (ed), Homeless in America, New York: Oxford University Press. Mossman D, Perlin ML (1992): Psychiatry and the homeless mentally ill: A reply to Dr. Lamb. Am J Psychiatry 149:951-957. Mulkem V, Bradley V, Spence R et al (1985): The Homeless Needs Assessment Study. Boston: Human Services Research Institute. Roper RH (1988): The invisible homeless. New York: Human Sciences Press. Rossi PH (1989): Down and out in America. Chicago: University of Chicago Press. Roth D, Bean J, Lust N et al (1985): Homelessness in Ohio. Columbus: Ohio Department of Mental Health. Struening E (1987): A study of residents of New York City shelter system. New York: NYS Psychiatric Institute.
386
BIOL PSYCHIATRY 1992;32:383-386
Editorial
Susser E, Valencia E, Goldfinger S (1991): Clinical care of homeless mentally ill individuals: Strategies and adaptations. In Lamb R, Bachrach L, Kass F (eds), Treating the Homeless Mentally Ill (in press). Tessler RC, Dennis DL (1989): A synthesis of NIMH-funded research concerning persons who are homeless and mentally ill. Washington, DC: National Institute of Mental Health. Wicker T (1991): A time for action. New Fork Times A23, (May).
383
EDITORIAL
Psychiatry and the Homeless
There are now countless thousands of homeless in our cities, living in the streets; sleeping in armories, shelters, and churches; holding out their cups for alms; and arousing guilt, fear, and shame among us. They are mostly men, but some are women, some are aged, and not infrequently family groups are seen, with or without fathers. Many are alcoholic, others are mentally ill, and well-intentioned efforts are periodically made to discover the psychiatric cases by street encounter to round them up for treatment or institutionalization. To what extent is homelessness a psychiatric problem? Is deinstitutionalization dumping these unfortunate into our streets; do many psychotics drift downward into this condition; does homelessness induce mental breakdown and disorder? An overemphasis on the psychiatric symptomatology encountered in homeless populations can create the impression that psychiatric disorder is a major cause of homelessness. Actually, it requires considerable ingenuity and adaptive skill to survive on the streets. On a number of relevant parameters those labeled mentally disturbed show no significant differences from those supposedly normal, viz, past histories, demographics, adaptive skills, substance abuse, social support (Caton et al 1990; Coh~.a and Sokolovsky 1989). Roper (1988) concluded there was no evidence to suggest that mental illness was a major cause of homelessness. Epidemiological studies show that, aside from substance abuse, about one-third of homeless persons have a DSM Ill Axis I diagnosable mental disorder (Dennis et al 1991), though the percentage with active psychotic illness may be between 10 and 13% (Fischer and Breakey 1991; Koegel et al 1988). Rates of substance abuse, mostly alcoholism, often exceed 50% (Eagle and Caton 1990). It must be realized that the severe stresses of homelessness, and accompanying malnutrition, inadequate sleep, exposure to weather, infection, and injury, can by themselves induce or exacerbate psychiatric disorders. Half the homeless are to some degree depressed (Cohen and Sokolovsky 1989; Rossi 1989) and show other psychological sequelae of chronic stress (Goodman et al 1991). Gruenberg (1967) long ago described a "social breakdown syndrome" as a state in which individuals under great and continued stress manifest withdrawal, aggressiveness, apathy, or negativism, regardless of any specific diagnosis they may acquire. Because of the many factors involved, Baxter and Hopper (1982) caution that all diagnoses must be provisional, because "were the same individuals to receive several nights of sleep, an adequate diet, and warm social contact, some of their symptoms might subside." A biomedical psychiatric approach to this hugh problem can at best provide only a modest contribution. There is no strong connection between homelessness and de~nstitutionalization (Tessler and Dennis 1989). Only 1 in 20 single adult homeless weLc,found to be in need of acute patient care (Mulkern et al 1985; Roth et al 1985; Struening 1987). The homeless themselves often resist the efforts of social workers to get them to accept psychiatric help: they do not wish to be isolated and stigmatized (or threatened) by placement in an institution, and sometimes prefer the freedom to live with their symptoms in the streets (Mossman and Perlin 1992). © 1992 Society of Biological Psychiatry
0006-3223/92/$05.00
384
BIOL PSYCHIATRY 1992;32:383-386
Editorial
Here, as elsewhere, a misplaced psychiatric emphasis can divert attention from real causes and necessary remedies. There has been a disastrous decline in affordable and available housing in recent years (more than 5 million low cost units were lost during 1973-1985), combined with a huge loss in both manufacturing and service jobs, at the same time that entitlements and other social service programs have been reduced (Cohen and Thompson 1992). One-third of American families are now shelter-poor (i.e., unable to pay for nonhousing necessities and still cover housing costs), and 60% are now living on incomes equivalent to what they had in the 1960s (Marcuse 1990; Wicker 1991). Thus, over the past two decades, the poor, the aged, the salaried worker, the mentally ill, and all powerless and vulnerable elements of the population have become increasingly impoverished, resourceless, and homeless. As columnist Russell Baker (1991) recently observed, "For the first time in 50 years people who cannot be dismissed as shiftless louts are worrying about how they are going to pay the doctor, pay the rent, and pay the butcher." In this social context remedial action will need broad alliances: in the specific area of homelessness psychiatry can make its contribution, but other forces must be mustered. At the service level, we propose a model that is more generic than clinically oriented. Programs that are open to all homeless and that offer a variety of entitlements and clinical services seem to work best (Cohen et al 1991; Susser et al 1991). As long as the client remains engaged, mental health often improves even if it is not targeted primarily. Moreover, those programs that have encouraged autonomy and individual choice have been more successful in maintaining contact (Barrow et al 1989, Dennis et al 1991; Susser et al 1991). Availability of resources that allow for a wider array of options has been found to be a better predictor of outcome than degree of pathology. Innovative strategies are being developed that parallel the interventions used with refugees, disaster victims, and others enduring social dislocation (Goodman et al 1991). Consequently, attention has been directed toward empowerment strategies such as building social supports, encouraging self-help and other group actions, creating large-scale preventive projects, and promoting collaborations in which homeless persons are included in the design and execution, and in the analysis of the research data (Cohen and Thompson 1992; Glickman 1988; Goodman et al 1991; Long and Van Tosh 1988). On the sociopolitical level, our perspective calls for alliances not only among subgroups of the homeless, but also among the threatened poor, or the working and middle-class populations who likewise commonly find themselves unable to afford housing and other economic necessities. There is room in this alliance for psychiatric clinicians and researchers, because research in this area can serve as a powerful vehicle to promote community interest and empowerment. Such an alliance can serve as the basis for new initiatives that will include mental health services as one constituent of a comprehensive program for improved housing, health, and economic well-being. Psychiatrists must not let the welcome growth of knowledge in biological psychiatry overwhelm their judgment, impoverish their capacity to see social context, or deflect the urge to act upon it. Carl I. Cohen I Kenneth C. Thompson 2
~State University of NY Department of Psychiatry Health Sciences Center 450 Clarkson Ave Brooklyn, NY 11203
FAitorial
BIOL PSYCHIATRY 1992;32:383-386
385
2Department oi' Psychia~, University of Pittsburgh School of Medicine Pittsburgh, PA 15213
References Baker R (1991): Hiatus in the fun. New York Times, November 12, AI5. Barrow S, Hellmdn F, Lovell A et al (1989): Effectiveness of programs for the mentally ill homeless. Final Report. New York: New York State PsychiaUic Institute. Baxter JE, Hopper K (1982): The new mendicancy: Homeless in New York City. Am J Ortho. psychiatry 52:393-408. Caton CLM, Wyatt RJ, Grunberg J et al (1990): An evaluation of a mental health program for homeless men. Am J Psychiatry 147:286-289. Cohen Cl, Onserud H, Monaco C (1991): Project Rescue: Serving the homeless and marginallyhomeless elderly. Final Report (April). Cohen CI, Sokolovsky J (1989): Old Men of the Bowery. New York: Guilford Press. Cohen CI, Thompson K (1992): Homeless mentally ill or mentally ill homeless? Am J Psychiatry 149:816-823. Dennis D (1990): Exploring myths about "street people." Access 2:1-3. Dennis DL, Buckner JC, Lipton FRet al (1991): A decade of research and services for homeless mentally ill persons. Where do we stand? Am Psychologist 46:1129-1138. Eagle PF, Caton CLM (1990): Homelessness and mental illness. In Caton CLM (ed), Homeless in America. New York: Oxford University Press. Fischer PL Breakey WR (1991): The epidemiology of alcohol, drug, and mental disorders among homeless persons. Am Psychologist 46:1115-1128. Glickman LG et al (1988): To Build A Community: Report of the Mayor's Citizens Task Force on Central City East. Goodman L, Saxe L, Harvey M (1991): Homelessness as psychological trauma: Broadening perspectives. Am Psychologist 46:1219-1225. Gruenberg EM (1967): The social breakdown syndrome: Some origins. Am J Psychiatry 123: ~4811489. Koegel P, Bumam MA, Fan" RK (1988): The prevalence of specific psychiatric disorders among homeless individuals in the inner-city of Los Angeles. Arch Gen Psychiatry 45:1085-1092. Lamb HR, Zu~man J (19"/9): Primary prevention in perspective. Am J Psychiatry 136:12-17. Long LA, Van Tosh L (1988): Program Descriptions of Consumer-Run Program for Homeless People with Mental Illness (Vol. 2 of 3). Rockville, MD: National Institute of Mental Health, Program for the Homeless Mentally 111. Man:use P (1990): Homelessness and housing policy. In Caton CLM (ed), Homeless in America, New York: Oxford University Press. Mossman D, Perlin ML (1992): Psychiatry and the homeless mentally ill: A reply to Dr. Lamb. Am J Psychiatry 149:951-957. Mulkem V, Bradley V, Spence R et al (1985): The Homeless Needs Assessment Study. Boston: Human Services Research Institute. Roper RH (1988): The invisible homeless. New York: Human Sciences Press. Rossi PH (1989): Down and out in America. Chicago: University of Chicago Press. Roth D, Bean J, Lust N et al (1985): Homelessness in Ohio. Columbus: Ohio Department of Mental Health. Struening E (1987): A study of residents of New York City shelter system. New York: NYS Psychiatric Institute.
386
BIOL PSYCHIATRY 1992;32:383-386
Editorial
Susser E, Valencia E, Goldfinger S (1991): Clinical care of homeless mentally ill individuals: Strategies and adaptations. In Lamb R, Bachrach L, Kass F (eds), Treating the Homeless Mentally Ill (in press). Tessler RC, Dennis DL (1989): A synthesis of NIMH-funded research concerning persons who are homeless and mentally ill. Washington, DC: National Institute of Mental Health. Wicker T (1991): A time for action. New Fork Times A23, (May).
