Homeless Mental Health: Social Work, Ethics, and Care

Introduction

Mental health is an issue that is widely considered to be under-treated and under-diagnosed within the United States. Beyond that, certain populations face far greater risk than others. One clear example is the prison population, where drug use and mental health issues are both rampant. However, another group that is highly affected and particularly difficult to treat is the homeless. Indeed, many people who are homeless find themselves in that position partly because of mental health issues. Mental health is often not the only issue involved, as comorbidity with substance abuse is common. Nevertheless, mental health will be the primary focus of this report.

The facets of homelessness and mental health that will be examined here include diversity, ethics, values, social justice, the diagnosing of patients, initiation and termination of care, aftercare, and the broader topic of social work as it pertains to treating and interacting with the homeless. While mental health challenges can be very difficult to address within the homeless population, social workers and related professionals should absolutely strive to confront and manage them.

Mental Illness and Homelessness: Scope and Context

As partially noted in the introduction, there is a high concentration of mental illness within the homeless population. This is considered to be even more pronounced in certain situations. There are, broadly speaking, two main types of homeless people. The first group experiences a short period of bad luck and is often able to secure housing again within a relatively short time. By contrast, the second group is persistently and chronically homeless over an extended period. The latter group is considered far more likely to be mentally ill and therefore in need of intervention and treatment from social work agencies. At the same time, alcohol and other drug abuse is fairly consistent across all types of homeless individuals. The length and depth of a person's homelessness has a great deal to do with how many stressors and aggravating factors they face. This in turn affects the likelihood of successfully initiating treatment, continuing it until it can reasonably be terminated, and keeping individuals on a stable path afterward (Lippert & Lee, 2015).

While some may argue that many homeless people are in their situation as a result of their own actions or inactions, this is simply not always the case. Furthermore, even if it were true, leaving the problem untreated would not be ethical, would not be consistent with proper social justice principles, and would ignore the meaningful interventions that can address the mental health needs of homeless individuals. Such interventions can be effective enough to prevent the continuation of mental illness once treatment is rendered. This was demonstrated in a Housing First program that showed a reduction in re-offending among formerly homeless adults with mental disorders. That study makes the stakes clear: those who are mentally ill are at elevated risk of arrest, as are those who are homeless. When both traits converge in the same person, the overall risk of arrest is compounded significantly (Somers, Rezansoff, Moniruzzaman, Palepu & Patterson, 2013).

Beyond the ethical and social justice dimensions, there are also significant public costs associated with failing to treat homeless individuals with mental illness. Rather than enacting laws that criminalize panhandling or sleeping in public areas, many advocates argue that resources should focus on the source of the problem — mental health itself. If the root cause is not addressed, the problem will not resolve and will likely worsen as more people go untreated and become homeless as a result. There is also a clear over-representation of mentally ill people in prison systems, and incarceration is rarely the appropriate setting for individuals whose primary need is mental health treatment rather than punishment. For those who are not violent and who genuinely seek treatment, rehabilitation in the form of mental health services can and should be funded so as to reduce suffering and the broader negative social consequences that often follow (Somers et al., 2013).

Ethics, Social Justice, and the Role of Children

When it comes to ethics and social justice, it is also worth noting that many people who are chronically or even occasionally homeless and mentally ill are also parents. Their children need protection as well, and one meaningful way to achieve that is by ensuring parents receive the mental health care they need. There are situations in which a parent is struggling despite genuine effort, and the children suffer nonetheless because there is nothing simple or easy about living in homelessness. Furthermore, homeless and mentally ill parents may be unwilling or afraid to come forward and seek help out of fear that their children will be removed by the state. This fear can create significant barriers to referral and engagement. However, intervention remains important, because research indicates that the presence of children creates new and unique factors relating to mental illness among homeless parents (Chambers et al., 2014).

An important insight is that while mental illness can contribute to homelessness, the reverse is also true. Becoming homeless can itself lead to deterioration of a person's mental state, and this dynamic can be intensified when children are present. In many ways, this presents a multifaceted problem involving homelessness, mental illness, and the welfare of dependent children. Even if temporary removal of a child from a parent's custody is not the most desirable outcome, it can sometimes be the most effective course of action, as it temporarily lifts a significant burden from the parent. So long as the parent engages in good faith with the required treatment, reunification should be the goal. Children need a stable and structured environment, and whether the parent can provide that environment depends on both their financial situation and their mental health status. If the parent is unable to provide such stability, social work agencies likely need to intervene (Chambers et al., 2014).

Structure and stability are critical components of successful treatment and recovery. It is well understood that individuals at various stages of treatment and recovery benefit greatly from having a structured daily life, even if they do not have a permanent home. This applies throughout the full arc of care — from initial engagement and diagnosis through the core treatment phase and into the planning of termination or pause of services. One major way to provide this structure for a homeless individual is to remove the housing instability from their situation. This can be accomplished through shelters or low-cost housing arrangements. Not all jurisdictions have these facilities readily available, but many use programs like Section 8 vouchers or similar mechanisms to provide housing at low or no cost while a person stabilizes financially and mentally. Experimental and quasi-experimental studies have found that individuals given at least temporary accommodations during the mental health treatment process fare significantly better than those who remain in persistent or intermittent homelessness (Stergiopoulos et al., 2015).

Conclusion

The author of this report is hopeful that there is a paradigm shift underway — away from simply jailing and warehousing the mentally ill and toward actually helping them recover. Those who persistently commit crimes and refuse engagement with treatment may ultimately require incarceration. Those who harm others without remorse or any willingness to change should be treated accordingly. However, those who genuinely want help, along with the children who are affected by the circumstances of their parents, deserve access to meaningful, effective, and dignified mental health services. The case for treatment over punishment is both ethically sound and empirically supported, and it should guide the policies and practices of social work professionals, healthcare systems, and governments at every level.

References

Belcher, J. R. (1988). Rights vs. needs of homeless mentally ill persons. Social Work, 33(5), 398.

Chambers, C., Chiu, S., Scott, A., Tolomiczenko, G., Redelmeier, D., Levinson, W., & Hwang, S. (2014). Factors associated with poor mental health status among homeless women with and without dependent children. Community Mental Health Journal, 50(5), 553–559. doi:10.1007/s10597-013-9605-7

Chen, F. (2014). Developing community support for homeless people with mental illness in transition. Community Mental Health Journal, 50(5), 520–530. doi:10.1007/s10597-013-9641-3

Chrystal, J. G., Glover, D. L., Young, A. S., Whelan, F., Austin, E. L., Johnson, N. K., & Kertesz, S. G. (2015). Experience of primary care among homeless individuals with mental health conditions. PLOS ONE, 10(2), 1–14. doi:10.1371/journal.pone.0117395

Fielding, K., & Forchuk, C. (2013). Exploring the factors associated with youth homelessness and arrests. Journal of Child & Adolescent Psychiatric Nursing, 26(4), 225–233. doi:10.1111/jcap.12056

Gadermann, A., Hubley, A., Russell, L., & Palepu, A. (2014). Subjective health-related quality of life in homeless and vulnerably housed individuals and its relationship with self-reported physical and mental health status. Social Indicators Research, 116(2), 341–352. doi:10.1007/s11205-013-0302-2

Hodge, D. R., Moser, S. E., & Shafer, M. S. (2012). Spirituality and mental health among homeless mothers. Social Work Research, 36(4), 245–255. doi:10.1093/swr/svs034

Ito, K. S., Morikawa, M., Okamura, T., Shimokado, K., & Awata, S. (2015). Factors associated with mental well-being of homeless people in Japan. Psychiatry & Clinical Neurosciences, 68(2), 145–153.

Lippert, A. M., & Lee, B. A. (2015). Stress, coping, and mental health differences among homeless people. Sociological Inquiry, 85(3), 343–374. doi:10.1111/soin.12080

Pakes, F., Shalev-Greene, K., & Marsh, C. (2014). Crisis, trauma and loss: An exploratory study into those who "come to notice" to police and health services and subsequently abscond. International Journal of Police Science & Management, 16(4), 297–307.

Payne, J., Macgregor, S., & McDonald, H. (2015). Homelessness and housing stress among police detainees: Results from the DUMA program. Trends & Issues in Crime and Criminal Justice, (492), 1–8.

Peltz, J. (2015). NYC mayor proposes millions in new mental health services. AP Top News Package.

Rayburn, R. L. (2013). Understanding homelessness, mental health and substance abuse through a mixed-methods longitudinal approach. Health Sociology Review, 22(4), 389–399. doi:10.5172/hesr.2013.22.4.389

Somers, J. M., Rezansoff, S. N., Moniruzzaman, A., Palepu, A., & Patterson, M. (2013). Housing First reduces re-offending among formerly homeless adults with mental disorders: Results of a randomized controlled trial. PLOS ONE, 8(9), 1–8. doi:10.1371/journal.pone.0072946

Stergiopoulos, V., Schuler, A., Nisenbaum, R., deRuiter, W., Guimond, T., Wasylenki, D., & Dewa, C. (2015). The effectiveness of an integrated collaborative care model vs. a shifted outpatient collaborative care model on community functioning, residential stability, and health service use among homeless adults with mental illness: A quasi-experimental study. BMC Health Services Research, 15(1), 1–12. doi:10.1186/s12913-015-1014-x