Homelessness, Housing and Mental Illness

We all have our ideas and “assumed understanding” of homelessness based on occasional encounters with homeless people on the streets of our cities (I remember homeless people sleeping at the entrances of posh San Francisco art galleries) or in an occasional news media story. As Russell Schutt, principal author of this book, points out, the times when homelessness was front-page news are long gone—it may reappear “during the holidays in the spirit of Charles Dickens’s A Christmas Carol” (p. xiii). He adds, “Homelessness had become an expected part of community life, in cities large and small, in rural areas, throughout the United States” (p. xiii). At times, this part of community life becomes almost invisible, as in a city such as Detroit, where one barely walks and thus may see a homeless person in the corner of one’s eye while driving under an expressway bridge (the homeless sleep there) or when crossing an intersection where a homeless person walks with all his/her possessions in a shopping cart. We frequently suppress our feelings about homeless and conclude (“assumed understanding”) that those are the unfortunate people who are mostly mentally ill and who are not “our problem.” However, do we really understand the issue of homelessness, do we know how many homeless people are mentally ill and what the relationship between homelessness and mental illness is? I daresay that we mostly do not understand all these issues and that we do not have but superficial evidence (or epidemiological if you wish) about the relationship between homelessness and mental illness. Some psychiatrists have been studying this relationship and are helping us understand it. One such person is Stephen Goldfinger (probably the nation’s foremost expert in this area), who was the principal investigator of the team studying homelessness, housing, and mental illness in a project this book is based on. Homelessness and its relationship to mental illness is certainly not just a psychiatric issue; it is also societal, sociological, economical, psychological, and others. Russell Schutt, a sociologist, and a group of other investigators in this project, focused on the relationship between mental illness, homelessness, and housing from broader sociological, anthropological, psychological, and social points of view (but not so much an economic and political point of view, as he points out). This volume is a synthesis of their research results and of a lot of recent literature. In this project, “a total of 118 homeless persons moved out of shelters financed by Massachusetts Department of Mental Health (DMH) into permanent housing funded by the US Department of Housing and Urban development (HUD). Some moved into spacious multibedroom homes…. Others found themselves in an apartment building on a floor that had been converted into a set of connected residencies. About half moved into independent apartments without resident staff, albeit in buildings that already housed many elderly or disabled persons on government subsidies” (p. 2) (although HUD paid for housing for only 1½ years, the DMH guaranteed housing as long as necessary). The research team studied these two groups (persons living independently versus in a group home setting) to answer questions about their housing preferences, service satisfaction, housing retention, neuropsychological functioning, service cost, impact of mental illness, impact of substance abuse, and consumer empowerment. Dr. Shutt’s book (with the help of Stephen Goldfinger, and one chapter co-authored by Larry J. Seidman) summarizes the results of this project and puts them into a broader perspective in 11 chapters (the book also includes a large Appendix on Research Methods, Notes, and extensive References). Chapter 1, “A point of departure,” is a brief overview of the project methodology (randomized design with longitudinal follow-up, mixed methods, multisite comparisons, interdisciplinary scholarship) and of the book. Chapter 2, “Community in theory,” is a mostly sociological treatise focused on the “ideal” community and the goals of the main study. The third chapter, “From back wards to dark hallways,” reviews briefly the history of homelessness and mental illness. The analysis of state hospitals and their role in the management of mentally ill is a bit superficial. The chapter raises, in my mind, some difficult questions about the deinstitutionalization and the way it has been done. The following chapter, “Satisfying wants and meeting needs,” discusses the issue of participant preferences and clinicians’ recommendations in regards to housing selection in this project. Participants clearly preferred independent housing and viewed an assignment to it as “winning the lottery” (p. 88), whereas clinicians disagreed and recommended group homes for most participants (the randomization was done independently of the desires and opinions). Chapter 5, “Social relations,” points out that the project “succeeded in setting the stage for intense social interactions to develop among participants in the group homes …” (p. 118; including both tenants and staff). However, the initial expectations that tenants would become a smoothly functioning group, readily take over house management, or start to work or otherwise participate fully in the surrounding community were “not met.” (p. 118). The sixth chapter, “Substance abuse,” presents several very important observations: most participants had a history of abusing drugs and/or alcohol; a history of alcohol abuse seemed to connote more problems than a history of drug abuse (more negative social ties); the overall level of substance abuse changed little during the project despite housing acquisition and without regard to the type of housing; the high level of substance abuse had a corrosive effect on social processes; and substance abuse during the project added to the risk of housing loss. These are pretty discouraging facts. On the other hand, as discussed in chapter 7, “Mental illness,” “…neither psychiatric diagnosis nor self-reported depressive symptoms throughout the project were related to risk of housing loss or housing satisfaction” (p. 172). Psychotic symptoms, however, often disrupted social processes, most dramatically when a patient stopped taking medication. This chapter also contains an interesting discussion of medical and sociological concepts of mental illness. Chapter 8, “Functioning in the community,” presents another very interesting and surprising finding—“…most dimensions of neurocognition improved after the participants moved into project housing…..” and “…the type of housing received did not have a bearing on most measures of cognitive functioning” (p. 199). Living in group housing improved executive function compared with living independently (p. 199). The next chapter on “Empowerment” suggests that the path to some simple elements of empowerment such as performing chores and managing funds could be quite rocky. Expulsion became a key management strategy (p. 237). The main findings presented in chapter 10, “Housing loss,” were that African American residents were more vulnerable to housing loss, even more so if they were living independently and abused drugs and that substance abuse was a critical individual-level risk factor of housing loss (p. 252). The final chapter, “Community process in context,” provides some recommendations on how to integrate a project such as this one into the community (e.g., social support by community volunteers, community processes should be given their due in housing programs, etc.). I summarized the major points of this book and its chapters, as the text itself is a bit repetitive and wordy. The presented findings are important and interesting, confirming some notions we have about homelessness, mental illness, substance abuse, and housing. The book is clearly a sociology book that will be of main interest for sociologists. However, psychiatrists, psychologists, social workers, and policymakers will find it a useful reading that may help them to set up programs or deal with patients housed in various projects. There are not many projects available with a published summary and analysis such as this book. Nevertheless, as I mentioned earlier, reading this book raises in one’s mind some questions about the path deinstitutionalization took and whether deinstitutionalization is the answer to helping the mentally ill or just another stop on a long uncharted road. But that would be material for another book. Richard Balon, MD Wayne State University Detroit, Michigan DISCLOSURE The author declares no conflict of interest.