Homelessness and Mental Health Linkages: Review of National and International Literature
Executive summary
This literature review was funded by the Commonwealth Department of Health and Ageing and builds on a previous project which was funded by the Commonwealth Departments of Health and Ageing and Family and Community Services. It concentrates on evidence relating to linkages between the Supported Accommodation Assistance Program, mental health and other service sectors as they respond to the needs of people who are homeless and living with a mental illness.
Definitions of homelessness and mental illness are contentious. However, there is general agreement that homelessness is more than houselessness (Baum & Burnes, 1993; Daly, 1996) and includes concepts such as isolation (Lipton & Sabatini, 1984), the adequacy of facilities (Chamberlain, 1999) and marginalisation (Scott, 1993). The face of the homeless person has changed over time. It is no longer only the face of the older man, drunk and a loner. Now young people, women, families and indigenous people are among the homeless. Researchers have coined the term the 'homeless career' suggesting that there is a typology and a career trajectory among young people ending in chronic homelessness (MacKenzie & Chamberlain, 2003). Among the elderly, there is a new term 'the new homeless'. This term describes people who had previously never had a homeless episode in their lives, having led conventional lives although close to the poverty line. These people now find themselves in older age more vulnerable to the changes in availability of low cost housing and consequently experience homelessness for the first time (Lipmann, Mirabelli & Rota-Bartelink, 2004).
Definitions of mental illness may cover a broad concept such as mental health care problems (National Community Advisory Group on Mental Health, 1994) or clinical definitions such as psychosis, depression and substance use disorders (American Psychiatric Association, 1994).
The estimated prevalence of mental disorders among people who are homeless varies, reflecting the area in which the research was conducted, the definition of mental illness and the methodological approach. Despite these limitations there is consistent evidence that people who are homeless have a much higher prevalence of mental illness than the general population.
Current research highlights the interaction between individual and structural factors as contributing to the high rate of mental illness among people who are homeless. However, the direction of causality between risk factors and homelessness varies and may be unclear. Drug abuse, social isolation and mental disorders are plausible consequences as well as causes of homelessness. The constant fear, danger and victimisation may contribute to people becoming emotionally distressed and the development of ongoing depression and anxiety. There is also evidence that severe mental disorders, such as psychotic illnesses, are a risk factor for, rather than a consequence of homelessness. Hallucinations, thought disorder, paranoia, anxiety, loss of motivation or interest in their own welfare, and other disability may contribute to an increased vulnerability to homelessness (Herrman & Neil, 1996). Research evidence also indicates that effective treatment for people with psychosis early in their illness can prevent homelessness.
This review highlights the importance of effective collaboration between treatment and support agencies of various sorts in responding to the needs of homeless people living with mental illness. It also reveals how little information we have about approaches to intersectoral collaboration or the factors that inhibit or promote collaboration. The World Health Organisation (1997) has provided a framework for promoting intersectoral collaboration. This includes the willingness of sectors to work together, a capacity to undertake the proposed action, well-established existing relationships, and a well-planned activity that can be implemented and evaluated.
Research findings indicate that homelessness among people with mental illness is preventable. Studies reveal that if community psychiatric services or primary health care services are accessible, homeless people will both use and gain benefit from clinical treatment and clinical support services (Herrman, 1996; Bachrach, 1995; Buhrich & Teeson, 1996). Accessible treatment options for substance abuse are critical but are often not available or sufficiently flexible. Services most likely to be used by homeless people with mental illness are those that have adapted service delivery and treatment approaches to reflect the experiences and reports of their homeless clients (Herrman, 1996, Goldfinger & Schutt, 1999).
Evaluation of various intersectoral approaches in responding to the needs of homeless people with a mental illness demonstrates that residential stability is an attainable goal when service systems are well-integrated, substance abuse treatment is part of a comprehensive treatment approach and there is a range of housing choices with flexible support available (Herrman, 1999). This then highlights the need for a systemic approach to facilitate greater collaboration between agencies that deliver mental health services, drug and alcohol rehabilitation and housing services. The key government policy documents all recognise the need for collaboration, but further work is needed to translate this into initiatives that will make a difference at the service delivery level.
Evaluations of consumer preferences for housing demonstrate that most adults with a mental illness prefer to live independently rather than in a group home (Schutt & Goldfinger, 1996). Australian research has confirmed this finding with the least preferred housing options being shelters, crisis accommodation and hospitalisation (Browne & Courtney, 2004; Freeman, Malone, & Hunt, 2004; Owen, Rutherford, Jones, Wright, Tennant & Smallman, 1996). Within the international literature there are a number of models proposed for providing housing for people with severe mental illness: these include supported housing and a continuum of care model. In a comprehensive review of proponents for both approaches, Rog (2004) found that once housed people with severe mental illness who were homeless stay housed with supports and are less likely to be hospitalised regardless of the specific housing model. The key was having access to affordable housing (Rog, 2004). For people who are homeless and mentally ill as well as other groups in the community such as families, any stable housing has a dramatic improvement on outcomes, such as residential stability, use of institutional settings, such as hospitals, detoxification facilities, the criminal justice system and so on (Rog, 2004).
There are a number of challenges for research to contribute further to the understanding of homelessness and mental illness. Research into homelessness and mental illness will benefit from collaboration between researchers from a diversity of disciplines and a wider use of ethnographic and other qualitative methodologies. As well as further research to understand the nature and extent of the problem, there is a need for more evaluative research that can identify the impact of innovative programs related to homelessness and mental illness.