Homelessness, Mental Illness, and the Failure of Public Agency

Introduction: Homelessness as a Public Crisis

For many Americans, the range of social crises such as domestic abuse and drug addiction, while troubling, may be easy to avoid. These, like a significant number of afflictions that plague the population quietly and persistently, occur largely behind closed doors. Until such crises affect individuals personally, those individuals may never have to encounter them anywhere outside the realm of mere theoretical consideration. This unaffordable luxury is what sets homelessness apart from a broad range of social problems. Homelessness is right out in the open and, on occasions that are familiar and frequent to urban and metropolitan communities, it tends to demand attention. Indeed, as a reflection of those living in the greatest despair in an otherwise prosperous society, the homeless problem speaks to a fundamental failure in public agency — a failure addressed in this discussion with the intent of providing recommendations for its reconciliation.

As we examine this problem, our focus falls on the set of public agencies given the responsibility of attending to the nation's homeless problem. The agency most primarily responsible for the administration of programs designed to assist the homeless — and especially those who are homeless and suffering from mental illness — is the U.S. Department of Health and Human Services (HHS). Its central role in monitoring or sponsoring all programs, services, and campaigns related to public health makes it an important vehicle through which legislation is implemented to aid the homeless.

Specific aspects of its relationship to America's homeless problem are derived through its role as the arbiter of grant funding for a variety of programs that either directly or indirectly attempt to address the issues facing this specific demographic. The groups that directly attempt to assist the homeless — and which, in this role, are recipients of HHS grant allocation — fulfill a range of distinct needs. Each of these is correlated to some aspect of public health, such as Health Care for the Homeless (HCH), which is centrally focused on helping the homeless gain access to primary health care, substance abuse consultation, or referrals for in-patient treatment. All of these opportunities directly relate to the root needs of homeless individuals suffering from mental illness. Moreover, the program attends to the inextricable relationship between these factors and the continuity of homelessness by offering counseling on housing and welfare eligibility services. That said, the prominence of homelessness, its relative recurrence among vulnerable individuals, and its affiliation with mental illness collectively render current treatment strategies in need of refinement. This points to the central problem addressed in this discussion: the need for a policy change that more effectively attends to issues of mental illness and habitual homelessness.

The Case for Action: Scope and Demographics

Efforts to address homelessness would be most productively concentrated in those urban locales most demonstrative of the problem. According to data as recent as 2001, the greatest number of homeless people is concentrated in major cities, where over 70% of America's homeless fall across a spectrum of categories. There is, notably, a particularly disproportionate number of African-American men who are homeless when compared to the percentage of this demographic in the general population (CMHS, 1). While homelessness is generally believed to be a chronic condition, this is not actually the case for the majority of homeless people. In fact, most homeless people are only temporarily without shelter, with an overwhelming 80% finding some form of temporary or makeshift housing within two to three weeks of their eviction from a residence. Though these individuals are accounted for in the estimated annual total of approximately 3.5 million homeless people, they do not represent the most vexing aspect of the problem.

While temporarily homeless individuals may find personal, communal, or legal resources to draw upon for assistance, those who are chronically homeless are most consistently sufferers of mental illness, substance abuse, or both. Those with severe mental disorders are of greatest concern due to the complexity of the topic itself. While only 4% of the American population is considered severely mentally ill, homeless individuals are approximately six times more likely to be mentally impaired. At twenty to twenty-five percent of the homeless population, this group is undeniably indicative of a larger social incapacity to handle severe mental disorders (USDHUD, 1).

By and large, the popular association between homelessness and mental illness is well-founded and fueled by routinely explicit evidence. As the likeliest candidates for habitual homelessness — and also the most visible and distressing homeless individuals — the mentally ill strike observers as those unable to help themselves. Moreover, due to the severity of their illnesses, these individuals are unlikely to retain any familial or social networks that could potentially provide support.

Mental Illness and Chronic Homelessness

Those suffering from disabilities severe enough to be classified as serious mental illness are usually people with debilitating depression, bipolar disorder, schizophrenia, or multiple personality disorders. Among the symptoms of these and other such conditions are paranoia, social dysfunction, and cognitive impairment — all of which can make it difficult or impossible to manage ordinary functions such as maintaining employment and stable housing. Lacking the proper initial resources for treatment, such individuals often find themselves on the street as a result of unraveled family structures, a background of poverty, chemical dependency, or various forms of social discrimination that single out the mentally ill. This situation is only compounded by the individuals' lack of capacity to seek assistance through the appropriate channels.

Without the ability to comprehend the legal and social services that may be available to them, disturbed individuals are extremely vulnerable to sustained, isolated homelessness. In addition to the variety of social circumstances that obstruct the disturbed individual from improving their situation, the common pitfalls associated with homelessness are likely to dramatically worsen their chances of transitioning into stable residency. Examination of the heightened susceptibility of mentally ill individuals to homelessness also reveals some alarming trends. They are substantially more likely to contract HIV/AIDS while homeless due to a compounding combination of cognitive impairment and financial desperation, both of which can lead to health-compromising behavior. They are also uniquely vulnerable to substance abuse, with 50% of all severely mentally ill homeless people simultaneously grappling with addiction. There is also a well-documented relationship between mental disorders and severe hygiene and health deficiencies. Beyond the already considerable challenge of contending with a mental disorder, an affected individual is likely to be suffering from additional health problems ranging anywhere from treatable to fatal.

Surprisingly, most of the individuals accounted for in this census of mentally disabled homeless people — derived from the National Resource Center on Homelessness and Mental Illness — have had some prior encounter with treatment or shelter. But on the whole, the most severely disturbed individuals, though on record as having been in-patients or out-patients at state or municipal mental health facilities, have maintained stable residence only for brief and fleeting periods. In many instances, individuals have been discharged after accumulating the maximum consecutive days of stay permitted by shelters that impose such limits. In other cases, the mental disorders themselves may be too disruptive for shelter environments to tolerate. Having also arrived at halfway houses and jails by way of frequent arrest, it is often the case that mentally disturbed individuals have removed themselves from those undesirable situations intentionally, opting instead for life on the street. This demonstrates both the degree to which available treatment falls short of providing tolerable living conditions and the degree to which mental illness contributes to an elusive social problem. Changes in agency approach would need to be fundamentally guided by the goal of improving mental health support services in order to prevent homeless recidivism.