Homelessness and mental health linkages: review of national and international literature
While much has been written about homelessness over the last two decades there is no consistent definition of the term, although there is a general consensus among researchers that the term homeless refers to something more than just 'house-less-ness'. (Baum & Burnes 1993; Daly, 1996). This is reflected in the following excerpt:
"The term 'homeless' is actually a catch word, a misnomer that focuses our attention on only one aspect of the individual's plight: his lack of residence or housing. In reality, the homeless often have no job, no function, no role within the community; they generally have few social supports. They are jobless, penniless, functionless, and supportless as well as homeless." (Lipton & Sabatini, 1984, p.156)
This view of homelessness emphasises the person's alienation and lack of social support networks. (Baum & Burnes, 1993). This isolation is reflected in the high proportion of homeless people who have never been married and have little or no contact with friends or family (Lam & Rosenheck, 1999; Thornicroft & Breakey, 1990). A person alienated from society may not actively seek help or support from government and welfare agencies.
"A homeless person is without a conventional home ... She/he is often cut off from support of relatives and friends, she/he has few independent resources and often has no immediate means and in some cases, little future prospects of self support." (Council to Homeless People, 1988)
The concept of home is at the heart of the term homelessness. The term home has been used by various disciplines (sociology, anthropology, psychology, architecture, history, geography, philosophy) to define a structure, a place or dwelling, a family or group of people, a country or birthplace, an organization or building, a place within that defines a person's sense of self, a refuge from the outside world, a haven (Mallet, 2004). Within an Australian context the term home resonates as the Australian dream, a free-standing house with a backyard occupied by a single family. This is one view of home. Another view as expressed by indigenous people is not the dwelling but the land from which one comes, and from where one's ancestors camped and lived (Mallet, 2004). A phenomenological approach to understanding home acknowledges that home may be located in the physical place (house, apartment, institution) but it is also the lived experience that occurs in this space, the expression of social identity and meanings. In this frame homeless and home are not opposite terms but exists in a dynamic and dialectic relationship (Mallet, 2004).
This is encompassed in the following quote ...
"We make our homes. Not necessarily by constructing them, although some people do that. We build the intimate shell of our lives by the organization and furnishing of the space in which we live. How we function as persons is linked to how we make ourselves at home. We need time to make our dwelling into a home ... Our residence is where we live, but our home is how we live" (Ginsburg, 1998 p.31).
The relevance of this sentiment in understanding the issues faced by people who are homeless and have a mental illness will be demonstrated throughout this literature review. People are faced not only with a lack of appropriate shelter but also with the lack of social connection and opportunity for meaningful activity.
The definition of homelessness can also reflect approaches to resource allocation and program development to meet the needs of homeless people and the varying government philosophies, policies and priorities. Experience from overseas illustrates this point. In the USA, definitions of homelessness within social policies have been narrowed over time. Several decades ago homelessness encompassed all people living in substandard housing (Daly, 1996). More recent definitions refer to homelessness as a more basic lack of shelter, including people living in public and private shelters and institutions providing temporary accommodation (Daly, 1996). At the same time, public monies are being spent on large shelters and the provision of food, clothing, medical attention and other immediate needs rather than the provision of low-cost and adequate housing and providing supports to those vulnerable to becoming homeless (Rickards, Leginski, Randolph, Oakley, Herrell, & Gallagher, 1999).
In Australia, during the past decade two definitions of homelessness have emerged. One is a cultural definition of homelessness formulated from the work of Chamberlain (1999) and used by the Australian Bureau of Statistics to systematically enumerate the homeless population.
"Primary homelessness: people without conventional accommodation such as those who 'sleep out', or use derelict buildings, cars, railway stations for shelter."
"Secondary homelessness: people who frequently move from temporary accommodation such as emergency accommodation, refuges, and temporary shelters. People may use boarding houses or family accommodation just on a temporary basis."
"Tertiary homelessness: people who live in rooming houses, boarding houses on medium or long-term where they do not have their own bathroom and kitchen facilities and tenure is not secured by a lease."
"Marginally housed: people in housing situations close to the minimum standard"
The above definitions reflect an interpretation of cultural standards in Australia about what is deemed 'adequate housing'. It would be generally accepted that a single person or couple could expect to have a least a room to sleep in, private bathroom and kitchen facilities, and some sort of secure tenure (Chamberlain, 1999).
The other definition below was developed for the purposes of the Supported Accommodation Assistance Act (1994) to determine who is eligible for services.
"A person is homeless if, and only if he/she has inadequate access to safe and secure housing. A person is taken to have inadequate access to safe and secure housing if the only housing to which a person has access:
There are several ways to sub-classify homelessness. People may be transiently, episodically or chronically homeless (Arce & Vergare 1984). In other words, homelessness may comprise a series of states that exist along a continuum of time and place, and entry to or exit from the homeless state is usually part of a process rather than a single jump. This notion of a continuum has been developed further in the recent work of Mackenzie and Chamberlain (2003) who coined the phrase 'homeless career'. According to this concept the person passes through various stages before developing a self-identity as a homeless person. The first typology is the youth career that focuses on teenagers forced to leave their family home before establishing themselves financially. They usually stay with friends, 'couch surfing', without their parents' permission. They tend to still be at school when the first episode of homelessness occurs, then with time they may drop out of school and enter a homeless sub-culture. The second typology is adult homelessness. Mackenzie and Chamberlain (2003) describe three pathways to entering adult homelessness:
- housing crisis career whereby poverty and accumulating debts, lead to a loss of accommodation;
- family breakdown attributed to domestic violence; and
- transition from youth to adult homelessness.
Thus while the definition of homelessness varies, there is a growing consensus that, at least within Australia, cultural standards of adequacy and acceptability are important definitional components. Further, homelessness is not viewed as a single state, but varies as a continuum over time and place.
Prevalence estimates vary over time, and this depends at least in part on the method used in the study, and on the definition of homelessness. In Australia in 1985, the Federal Department of Housing and Construction estimated that 40,000 people slept outdoors and 60,000 people were housed inadequately (Coopers, Lybrand & Scott, 1985).
Counting the Homeless (2003) estimated the number of homeless people in Australia using 2001 Census data. The study suggested that 100,000 people were homeless across Australia on Census night and that many of the homeless people move from one form of temporary shelter to another with:
- Nearly half, 49%, staying temporarily with other households;
- 14% were in improvised dwellings, tents or sleeping out; and
- Another 23% were staying in boarding houses (Chamberlain & MacKenzie, 2003).