Athabasca University University of Calgary

ATHABASCA UNIVERSITY

UNIVERSITY OF CALGARY

UNIVERSITY OF LETHBRIDGE

A Literature Review of the Psychological Impact of Homelessness

Mandana Diba

A Final Project submitted to the

Campus Alberta Applied Psychology: Counselling Initiative

in partial fulfillment of the requirements for the degree of

MASTER OF COUNSELLING

Alberta

April 2007

DEDICATION

I dedicate this work to the memory of my father, for his continuous love, support, words of encouragement, and for being the first one teaching me the meaning and effects of power and privilege. Also, to my son Reza, for his endless help and support throughout this program.

iii

ABSTRACT

There is a reported lack of literature on the psychological impact of homelessness.

The present paper aims to fill this void. The definition of homelessness, prevalence, developmental factors associated with homelessness, and psychological impact of homelessness will be reviewed.

Interventions aimed at reducing harm and facilitating “exits” for homeless people will be presented, followed by a summary of the implications and key findings of this review.

ACKNOWLEDGEMENTS

I would like to acknowledge Dr. Simon Nuttgens for supervising my final project. I would also like to thank Dr. Sandra Collins for acting as second reader for this project. I extend my appreciation to Dr. Shelly Russell-Mayhew for her feedback on the first draft of this project and Pam Hirakata for her thoughtful questions. I would like to thank my family especially my daughter for their patience throughout my re-schooling. Much of family time was lost, but due to their patience and thoughtfulness our relationship remained strong. My appreciation also goes to many homeless individuals whom I came to contact with, for giving me the privilege of having a glimpse into their lives and see their pains as well as their survival strengths. Above all, my thank goes to God who gave me the strength to learn from my experiences and to follow my dreams.

Table of Contents

Chapter I. Introduction ...... 2 Chapter II. Procedure ...... 3 Chapter III. The Literature Review...... 4 Defining Homelessness ...... 5 Prevalence of Homelessness ...... 7 Developmental Factors Associated with Homelessness...... 7 The Psychological Impact of Homelessness...... 9 Addiction and other mental health concern ...... 10 Trauma ...... 18 Physical Illness...... 26 Human contact and relationship ...... 28 Stressful life event ...... 29 Women and Homelessness ...... 32 Interventions...... 34 Housing ...... 35 Supportive relationship ...... 36 Mental illness and addictio ...... 36 Case Management Strategies ...... 41 Counselling and Therapy ...... 43 Summary...... 51 Chapter IV. Synthesis and Implications ...... 54 References...... 60

A Literature Review of the Psychological Impact of Homelessness

CHAPTER I

INTRODUCTION

Homelessness is a debilitating condition affecting many individuals in the world and in our society. In Canada, as many as 150,000 to 300,000 individuals are thought to be homelessness (McLaughlan, 1987), and considering the lack of a current statistic, one would imagine that this number is significantly higher.

My first experience with homelessness came from delivering food baskets to individuals whose homes had been destroyed due to Iraq’s sudden military attack on Iran. I observed the food line-ups, the separation of families, and the tears in some people’s eyes.

These were people who were in enormous pain due to their losses. Many expressed their embarrassment at having to receive food donations. Owning a blanket or having money was considered wealth. These people had lost everything—their jobs and belongings, including their notes, pictures, and many items that could connect them to their past. Similarly, in my current experience with homeless individuals in Vancouver’s Downtown Eastside, many people carry, if anything, just a bag of items. They have also lost everything they may have once had, perhaps not to a bomb or missile, but to some force just as powerful as those weapons, powerful enough to cause them to leave everything behind, and become homeless.

The current literature lacks an in-depth review of the factors contributing to an individual becoming and remaining homeless and the psychological impact of such experiences. According to my investigation, a comprehensive review of interventions, such as counselling, is also lacking. There is a reported lack of an in-depth understanding of factors contributing to individuals’ homelessness and the psychological factors of living in

such a debilitating condition (Bentley, 1997; Evans & Forsyth, 2004). There is also a lack of reports on factors that may lead some individuals to remain in such a condition, or those that can empower homeless individuals to exit from it. The present paper examines the psychological impact of homelessness and factors that may reduce harm or help individuals to exit from it. Such an understanding is necessary for the development of counselling interventions (Bentley 1997; Hertlein & Kilmer, 2004; Washignton, 2002), as well as social policies, programs, and interventions that can reduce the harm to this population.

Here, I will present a definition of homelessness and review the literature on factors associated with homelessness, prevalence, and the psychological impact of homelessness.

The current literature on suggested interventions will be discussed, and a summary and discussion of the reviewed literature will be presented.

CHAPTER II

PROCEDURE

In the present literature review, I have adapted Mertens’ (1998) recommendations for reviewing secondary sources and evaluating research reports, as well as drawing from my experience working in this field. I have been working with homeless individuals for the last five years, supporting them in various transitional housings in Vancouver’s Downtown-

Eastside. There are no facts or stories gathered from individuals or agencies other than what has been reported or written elsewhere. Electronic databases that have been used for this literature review include: PsycARTICLES, PsycINFo, Medline, SocINDEX, PsychLIT,

Psychology and Behavioral Sciences Collection, Dissertation Abstracts International, and two different search engines, OVID, and EBSCOhost. The key search terms included homeless, homelessness, poverty, housing and instability, housing, and violence. The search

also included all the terms covered in the title of this project. In addition, books, government studies, reports, other organizations’ research projects and relevant information available on the Internet have been utilized. Parameters in this literature review include using English language publications and articles published from 1980 to 2006. Both qualitative studies, quantitative studies, and studies that combine these methods have been included. In addition,

I have adopted the definition of homelessness offered by the Kappel Ramji Consulting Group

(2002) that includes individuals affected by either visible or hidden homelessness. Visible homelessness includes individuals who stay in emergency hostels and shelters and those who sleep in rough places considered unfit for human habitation such as parks and ravines, doorways, vehicles, and abandoned buildings. Hidden homelessness includes those who are temporarily staying with friends or relatives, women staying with a man only to obtain shelter, individuals living in illegal or physically unsafe buildings, or those who are living in a household and are subject to violence just because they have no place to go to.

CHAPTER III

THE LITERATURE REVIEW

The present literature review offers a definition of homelessness, prevalence studies, developmental factors associated with homelessness, and the psychological impact of homelessness. Following this, I present suggested interventions aimed at reducing the harm to this population or assisting them to exit from the condition of homelessness.

Defining Homelessness

Most people have homes to go to, homeless people do not. Even if they have a roof over their heads, they will usually have little or no privacy and no right of permanent residence (Grimm & Maldonado, 1995). They are at the bottom end of the poverty

continuum, without many of the opportunities that most people take for granted (Timms &

Borrell, 2001). However, the absence of a permanent shelter, while being a widely agreed- upon definition of homelessness, cannot stand as the sole criterion. For instance, it would be hard to define members of the Kickapoo First Nation tribe living in reed huts under a bridge across the Rio Grande at Eagle Pass, Texas, as homeless for they share a rich tribal affiliation

(Walker, 1998). In addition, home is a concept with deep existential implications because it evokes a complex set of meanings for each individual. Homelessness, therefore, is more than having no fixed address or phone number; it is a disengagement from mainstream society— from friends, family, neighbourhood, and community. It is the feeling of being utterly alone.

Homeless individuals are not a monolithic and homogeneous group. Calling them simply "the homeless" is misleading; the term implies sameness and does not broaden our understanding of the complexities of contemporary homelessness (Walker, 1998). As the

Kappel Ramji Consulting Group (2002) reports, a distinction also exists between visible and hidden homelessness. Visible homelessness includes individuals who stay in emergency hostels and shelters and those who sleep in places considered unfit for human habitation, such as parks and ravines, doorways, vehicles, and abandoned buildings. Hidden homelessness includes individuals who are temporarily staying with friends or family, those performing sexual or illegal favours in exchange for shelter, those staying in illegal or physically unsafe buildings, and those living in households where they are subject to family violence yet have nowhere else to go.

Even with such distinctions there are differences that exist between homelessness in

North America and homelessness in other regions such as those in Europe, or what is considered by some as the Western world (Markland, 1990), and regions where residents are

subjected to war and its accompanying losses (Benjamin et al., 2003). These losses include the loss of family and friends in addition to the roof over their heads. In some countries individuals are subjected to torture by dictator regimes (Hillsum, 2005) or regimes considered liberal but that resort to torture behind closed doors (Amnesty International,

2006).

Some of these individuals leave their homes and their homeland behind in the hope of a better life only to end up living in refugee camps or on the streets (Burke, 2002). In addition, an increasing number of women are subjected to human trafficking. Reports from nongovernmental organizations from the Netherlands indicate an increase in the number of victims of human trafficking (Raymond, 2003).

The present paper focuses on homelessness in North America in general and in

Canada in particular, with the recognition that homelessness can reflect many of the situations I have discussed earlier in this paper. In the present paper, most of the literature reviewed, with some exceptions, has looked at visible homelessness in varying degrees, and the majority of them have been conducted in North America.

Prevalence of Homelessness

The homeless population in the United States consists of a growing number of families primarily headed by single mothers. Estimates suggest that each year 420,000 families become homeless (Burl, 1996). This places more than 900,000 children at risk of compromised developmental and behavioural outcomes (Burl, 1996). The shelter occupancy counts in Toronto revealed that in 1998, 28,800 people had used the shelters (Golden, Currie,

Graves, & Latimer, 1999). The homeless count in Vancouver in 2005 saw an increase of 33% in the number of individuals staying in shelters compared to 2002 (from 788 to 1,047)

(Homeless Count, 2005). Shelter counts, however, under-estimate the number of individuals sleeping rough, for they have not included counts of people sleeping in the streets, transitional houses, rooming houses, cars and dwellings unsafe for residency. The report on street homelessness in Vancouver shows a 238% increase in the number of street homeless in

2005 compared to 2002 (from 333 to 1,127) (Homeless Count, 2005), and proportionately more aboriginal women than men in the population. Aboriginal people were over-represented within the homeless population. While the aboriginal community comprises 2% of the general population, they make up 30% of the homeless population in Vancouver.

Developmental Factors Associated with Homelessness

An individual’s path to homelessness can differ depending on the set of factors that result in their loss of housing and support networks (Grimm & Maldonado, 1995). These factors may include lack of childhood experience of intimate care (Anderson & Rayens,

2004), lack of parental responsiveness (Tavecchio, Thomer, & Meeus, 1999), and poor educational achievement (Caton et al., 1995; North, Pollio, Smith, & Spitznagel, 1998).

Anderson and Rayens (2004) compared the childhood experiences of intimacy and autonomy in the families of origin of women who experienced homelessness and those without such an experience. They compared social conflicts as they occurred in childhood support networks and in the current support networks of the two groups of women they studied. In addition, they examined the relationship between intimacy and autonomy in the family support networks of the participants’ childhoods. Women in their sample who experienced sexual abuse in childhood yet also had a person who loved them unconditionally had lower likelihood of homelessness in adulthood than females who had been sexually abused as children and did not have a significant person who loved them unconditionally.

Similarly, Tavecchio et al. (1999), comparing homeless youth with youth from the general population, found that growing up in a family with divorced parents, and especially lack of parental responsiveness and emotional support, increased the likelihood that a youth would become homeless. However, social support systems can act as a protective factor and prevent the occurrence of homelessness in such cases. Aside from parental and support systems, studies have pointed to factors such as differences in opportunities for educational achievement as being distinct markers between those who are homeless and those who have never experienced homelessness (Caton et al., 1995; North et al., 1998).

Caton et al. (2005) studied risk factors associated with the course of long-term homelessness. Participants in this study included 225 men and 220 women who had experienced the initial loss of their living space within the two weeks prior to the assessment time. The inclusion criteria was for participants to have no fixed residence or place of night- time shelter other than accommodation at an emergency shelter or a place not meant for sleeping. The study carefully tracked participants through an 18-month period. The initial assessments were also taken during a one-year period so that they could include individuals using the shelters at different times of the year. Thereafter, the follow-up was for six months or longer. Of the participants who were followed-up (377), 19% remained homeless and the rest found housing within the community.

The findings of the study revealed that participants who experienced a shorter duration of homelessness differed in many aspects with those who remained homeless. They were in general younger, had a better psychological adjustment, a recent or current employment history and an earned income, adequate family support, and no current drug treatment.

There is a reported increase in the number of homeless individuals and families in

North America, in general, and Canada in particular. According to the studies reviewed, individuals’ path to homelessness depends on many factors such as the absence of intimacy in childhood, lack of parental responsiveness, and poor educational achievements. In addition, factors considered as linked to shorter duration of homelessness include younger age, better psychological adjustment, recent or current history of earned income due to employment, existence of adequate family support and absence of a history of receiving drug treatment.

The Psychological Impact of Homelessness

The experience of being homeless, as has appeared in many of the stories of homeless individuals interviewed by Byrne (2005), is one beyond imagination. Tom says:

I ended up having to arm myself with a knife. Had to, you didn’t know how hopeless

I looked. I thought, ‘Fuck this, there’s got to be a different side to life’ … you adapt

to it [staying in shelters]…you do it the first couple of times and you don’t feel real

good about yourself, but then it becomes second nature to you…[when on the street]

a dog’ll piss on you or a cop’ll kick you in the guts [and say] ‘get up ya mongrel’ (pp.

46-47).

The holistic view of an individual points to many factors affecting an individual’s well-being. Therefore, it is the interaction of social, environmental, spiritual, and individual factors that affect a person’s wellbeing (Broderick & Blewitt, 2006). Many factors such high exposure to trauma resulting from violence, poor physical health, lack of close and supportive relationships, and the existence of many stressors may result in mental health conditions such as depression, anxiety, and post-traumatic stress disorder (Goodman, Dutton,

& Harris, 2004; Wenzel, Leake, & Gelberg, 2001; Witbeck, Hoyt, & Yoder, 2004), or may explain the high prevalence of other diagnoses of mental illness (Ran et al., 2006), and addiction (Evans & Forsyth, 2004; Fountain, Hows, Mardsen, & Strange, 2002; Kemp,

Neale, & Robertson, 2006) among the homeless. In what follows, I review the psychological impact of homelessness in terms of addiction, mental health concerns, trauma, physical illness, human contact and relationship, and stressful life events.

Addiction and other mental health concerns. Addiction is reported as one of the primary factors associated with homelessness (Fountain, Hows, Mardsen, & Strange, 2002;

Kemp, Neale, & Robertson, 2006). In a sample of 877 drug users entering treatment in

Scotland, Kemp et al. reported that 36% were homeless, a prevalence rate that is at least 7 times higher than that of the general population. Also, compared to the never-homeless drug users in their sample, the homeless population had recently injected, had recently been imprisoned, or had recent illicit income. In addition, they had parents who were divorced, separated, or never married, and had experienced physical or sexual abuse at some point in their lives.

Fountain et al. (2002) also studied the prevalence of addiction among homeless individuals. Their criteria for homelessness included individuals who had slept rough in the streets for at least six nights within a six-month period prior to the study. They interviewed a convenience sample of 389 people, with the exception of three individuals who withdrew from the study. Interviews were conducted by members of a team who all had experience working sensitively with homeless individuals. Of the respondents, 81% were males and 19% were females. In the month before the interview, 96% of participants reported having used drugs and alcohol, and 83% reported having used a drug, but no alcohol. The high prevalence

of addiction among homeless participants in this study, however, could be due to convenience sampling.

Evans and Forsyth (2004) also reported the relationship between substance abuse and homelessness. They used unstructured interviews with 42 homeless men and women (30 and

12 respectively) and asked key issues such as the reasons they were homeless, their means of survival, history of substance abuse, mental illness, criminal record, and history of victimization. Interviews took from 1 hour to 2.5 hours in length. Their research also included the perceptions of a judge, a warden, two law enforcement officials, and the director of a homeless shelter regarding social factors contributing to the behaviour of the homeless.

In their sample, 39% had been excluded from one or more types of homeless service mainly due to physical violence toward others. A large proportion of this sample (33% of men and

27% of women) considered marital disruption as the reason for their homelessness. Of this group, all but one individual considered substance use and abuse as the main reason for their marriage falling apart. Another reason for homelessness presented by many of the women was sexual abuse. These women became homeless through escaping an abusive homelife.

The criminal activity of others (partners) was another factor that females in this study reported as being the cause of their homelessness. For males, however, their own criminal activity, their release from jail, and not having a place or a job to go to was identified as the cause of their homelessness (Evans & Forsyth, 2004).

In an attempt to find out whether homelessness increased or decreased the pattern of drug use, O’toole, Gibbon, Hanusa, and Freyder (1997) conducted a cross-sectional survey of adults 18 years of age and older, identified by their social security numbers. They excluded from their study individuals who were incoherent, abusive, psychotic, or acutely intoxicated

at the time of interview. Of the respondents 78.3% met American Psychiatric Association,

Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R,

1987) criteria for substance abuse disorders, and more than half reported that substance abuse played a major role in their becoming homeless. The majority reported no change in drug use after becoming homeless. Those who reported a reduction in their drug use named joining a treatment program as the major factor in the decrease. For those who reported an increase in drug use after becoming homeless, they reported experiencing mental health symptoms as the major reason for their homelessness. However, this study included only individuals with social insurance numbers. In my experience working with homeless individuals, many, especially those with less housing stability are not aware of their social insurance number and do not carry relevant identification to aid in finding their social insurance number. In addition, the omission of individuals who were incoherent or intoxicated at the time of their survey might have affected the results.

As Applewhite (1997) concludes, the high prevalence of drug and alcohol abuse among the homeless cannot explain homelessness. Many people abuse these substances and never become poor or homeless, but those who are addicted and are poor are at a much higher risk to become homeless. A good example is the many Vietnam veterans who were addicted to heroin and those individuals who became addicted to morphine at the hospitals and could quit their addiction after going back home (Walker, 1998). For individuals with complex addiction, however, the need for the substance is merged with their emotional state, judgment, and motivation to such an extreme degree that these are hard to separate. People with complex addiction often report having their psyches “hijacked.” Such an individual cannot introspectively tell the difference between natural feelings of joy or sorrow and the

highs and lows of the rush and withdrawal. Indeed, like colours close enough together on the spectrum, there comes a point when these feelings are no longer distinguishable (Bank,

1998). Aside from the research that directly investigated factors contributing to homelessness and the effect of homelessness on individuals, some researchers such as Byrne (2005) attempted to bring the true story of the life of those with homeless experience and let the reader have his or her view on the experiences of such individuals. Byrne’s (2005) definition of homelessness closely agrees with my own. It considers an individual as being homeless if she or he:

Currently lives on the street; lives in crisis or refuge accommodation; lives in

temporary arrangements without security of tenure, for example moving between

residences of friends or relatives; living in squats, caravans or improvised dwellings,

or living in boarding-houses; lives in unsafe family circumstances, for example,

families in which child abuse or domestic violence is a threat or has occurred; living

on very low income and facing extraordinary expenses or personal crisis (p.16).

Byrne (2005) interviewed twenty individuals with such experiences. From their stories it appears that physical and sexual violence, sexual exploitation, and drug use are common experiences among the homeless. For example, among people whom he interviewed, one individual called Mike reported that depression hit him after caring for his mother who had Alzheimer’s for two years. He had many suicide attempts and had been in a psychiatric ward for a while. He became homeless after losing his job. Of his experience, he says:

The first night I was homeless…I was shit-scared...on the streets I saw violence, I saw

theft, drug overdoses, a number of things. The hardest part was sleeping with one eye

open. You are constantly watching out for yourself. With the general public, you only

have to see the way they look at you. When you’re homeless the way they look at you

is with utter contempt. The harshest part was the long days with nothing to do but

trying to survive. It was extremely depressing. (pp. 101-103).

Applewhite (1997) blames the attempt to normalize mental illness and treat people outside of mental hospitals in the name being morally right and cost-effective as contributing factors in the increase in the number of homeless individuals. The issue of discharge from hospitals to streets and shelters has been explored by Furchuck, Russell, Kingston, Turner, and Dill (2006) in London, Ontario, Canada. They report that such discharges had occurred

194 times in London in 2002. They stress that shelters are not appropriate addresses for discharging individuals recovering from a mental illness. They add that people recovering from an addiction should not be returned to their previous rooms in unsafe neighbourhoods.

In China, the prevalence of homelessness among individuals with schizophrenia was studied by Ran et al. (2006). In their sample of homeless individuals, 7.8% had a diagnosis of schizophrenia. Comparing this prevalence with the rate of homelessness in China (which is

0.9 % per year), those diagnosed with schizophrenia were over-represented in the homeless population. Also a 10-year follow-up revealed that factors related to their being homeless were low family income, having a parent with mental illness such as bipolar disorder or schizophrenia, having no income, and being unmarried or divorced. Risk of homelessness increased substantially with exposure to multiple risk factors.

Folsom et al. (2005) studied the prevalence of homelessness over a one-year period among 10,340 patients who had been diagnosed with a mental illness such as schizophrenia or bipolar disorder. Of the population they studied, 15% were homeless. The majority of the

homeless individuals were male and African-American. In addition, in their sample, homelessness was associated with a diagnosis of schizophrenia or bipolar disorder and poor functioning coupled with the presence of addiction.

A study by McNiel, Binder, and Robinson (2005) on the history of homelessness among 12,934 incarcerated individuals also pointed to a relationship between mental illness, homelessness, and incarceration. Their findings indicated that homeless individuals with a mental disorder, although representing only a small proportion of the total population, accounted for a substantial proportion of persons who were incarcerated in the criminal justice system. In this study’s urban setting, in 16% of the episodes of incarceration, the inmates were homeless. Among this group, 30% had a diagnosis of mental illness of which

78% had a co-occurring addiction diagnoses.

As the above studies show, the likelihood of individuals becoming dependent on substances is much greater among those with a mental illness. The combination of these two factors alone can increase the chances of an individual falling to a level of poverty that may result in him or her becoming homeless (Applewhite, 1997). The phenomenon of homelessness among people with mental illness can be complicated, particularly when addiction is also present (Walker, 1998).

Researchers have pointed to gender differences in the type of mental illness (Ross,

Glaser, & Stiasny, 1988) and the type of drugs used among the homeless (Lin et al., 2004;

Ross et al.). Gender difference in drug use behaviour was investigated by Gearon, Nidecker,

Bellack and Bennett (2003). In this study participants comprised of 52 psychiatric outpatients attending an inner-city community mental health centre (28 men and 24 women) who all had a diagnosis of mental illness (schizophrenia/schizoaffective disorder, recurrent major

depression, or bipolar disorder) and co-occurring drug abuse or dependence. Diagnoses were confirmed in this study through use of the Structured Clinical Interview for DSM IV, Patient

Version (SCID-P; First, Spitzer, Gibbon, & Williams, 1994). It is worth noting that they did not assess for any anxiety disorders including post-traumatic stress disorder. The Positive and

Negative Syndrome Scale (PANSS; Opler, Kay, Lindenmayer, & Fiszbein, 1992) was also used to evaluate psychiatric symptomatology. To assess participants’ reasons for substance use, eight subscale scores representing the participants’ reasons for use were obtained. The subscales were: unpleasant emotions, physical discomfort, pleasant emotions, testing personal control, urges and temptations to use, conflict with others, social pressure to use, and pleasant times with others. All questions were rated on a 4-point Likert Scale, ranging from never to frequently, and were read to the participants to ensure their comprehension.

Their study demonstrated meaningful gender differences in the way drug habits are formed and maintained, the drugs are obtained, reasons for use, and the psychological consequences of use. Women in this study appeared to be dependent on harder habit-forming drugs such as cocaine and heroin (61%) in comparison to men (20%). Women were more likely than men to report using drugs as a way of testing personal control over drug use. Women in this sample were also more likely than men to report having drugs given to them by significant others and purchasing drugs from friends. In addition, women with severe mental illness were more likely than men with severe mental illness to report using money from prostitution for drugs and trading sex to support their drug habit. Women also reported higher lifetime sexual and physical victimization than men did. The reported rate of depression and anxiety between the two genders in the above study was found to be similar. However, as mentioned

earlier, this report on similarity could be due to the fact that the assessment of anxiety disorders was excluded from this study.

Many of the studies reviewed demonstrated a relationship between homelessness and factors such as mental illness and addiction. Such a relationship does not clearly show which one is the cause and which is the effect, whether mental illness precipitates homelessness or vice versa. As is pointed out by Alexander-Eitzman (2006), the studies such as the one by

Caton et al. (2005) base their assumption that a complex social phenomenon such as homelessness has defined personal level determinants that may be explained by personality characteristics or psychiatric illness of individuals. When a researcher looks for specific categories, then the strategies and tools chosen are those that define the problem. To understand homelessness multiple layers of analysis are required (Alexander-Eitzman, 2006;

Caton et al., 2006), including a dynamic interaction between personal, environmental, and social factors (Alexander-Eitzman, 2006). Furthermore, some of the diagnoses presented in many of the studies reviewed included bipolar disorder or schizophrenia. Since this occurred at the time when the diagnosis of complex post traumatic disorder was not available, perhaps it is reasonable to conclude the lack of DSM diagnosis of complex post traumatic disorder may have resulted in an overdiagnosis of schizophrenia and bipolar disorder. Recent literature now indicates an overlap between the three mentioned diagnosis (Haskel, 2003). In addition, the feminists’ perspective rejects the diagnosis of individual pathology for it considers symptoms as adaptative responses to environmental pressures (Haskel, 2003). The feminist perspective frames an individual’s problem in the context of social roles and oppression (Corsini & Wedding, 2000).

Literature reviewed points to addiction and mental illness as the most prevalent factors associated with homelessness. However, it is not clear whether mental illness and/or addiction precipitate homelessness, or vice versa. The link between addiction and homelessness also appears to be related to the presence of multiple factors such as parental responsiveness and physical and sexual abuse as well as the condition of homelessness itself.

In regards to mental illness, issue of the discharge from hospitals to the streets as well as the condition of homelessness itself, need to be considered. There appear to be a gender difference in drug behaviour. Females appear to abuse more hard core drugs than men do and often maintain their drug habit through prostitution.

Trauma. Homeless individuals are exposed to many violent incidents such as stabbings, murder, (Kipke, Montgomery, Simon, & Iverson, 1997), and sexual assault

(Browne, & Bassuk, 1997; Rayburn et al., 2004; Tucker, Wenzel, Elliot, Marshal &

Williamson, 2004). In considering the role of traumatic events, research repeatedly points to women who are subjected to human trafficking, prostitution, and repeated sexual assault

(Rayburn et al, 2004).

Rayburn et al. (2004) examined the relationship between trauma, coping, depression, and mental health-service seeking in a probability sample of sheltered homeless and low- income-housed women. In this study a broad definition of trauma was used (having spent the night in jail or prison or having lived in a homeless shelter). Participants were 810 women

(402 sampled from shelters and 408 sampled from low-income housing) who were sampled as part of a larger study examining the experiences of drug use, violence, and HIV risk among impoverished women (Tucker et al., 2004). The results of this study highlight the diversity of trauma. In longitudinal analysis, women who lived in shelters or experienced

major violence had a twofold increase in their risk of depression over the 6-month follow-up.

In a cross-sectional analysis, childhood sexual abuse, living in a shelter, physical violence, childhood physical abuse, and death or injury of a friend or relative, predicted avoidant coping and symptoms of depression. Active coping and depression predicted mental health- service seeking among traumatized women. It was also found in this study that violence occurring during the time interval between baseline and follow-up increased the risk of a possible diagnosis of depression at follow-up. Women who were violently assaulted in the previous six months were more than twice as likely to be clinically depressed at follow-up, than women without these experiences. In addition, the study found that women who lived in a shelter were twice as likely as those who did not to show symptoms of depression over the six-month follow up. It is however, not clear if such symptoms are due to their living situation or prior unmeasured factors that resulted in women moving to a shelter. Similarly,

Withbeck et al. (1999) found that street adaptations in youth increased the likelihood of depressive symptoms for females but not for the males they studied.

These findings support the argument that the condition of homelessness itself represents an extremely stressful and potentially traumatic condition. Sexual violence is a major problem facing homeless women. The Browne and Bassuk (1997) study on the experience of violence among poorly-housed and homeless women reported that almost one- third of their respondents had been physically assaulted by their current or most recent partner, and some had been threatened with death by their partners. The criteria for the homeless participants in their study was to have a child in custody under the age of 17, or be pregnant, and reside in a shelter for at least seven consecutive days. The poorly-housed women were low-income-housed mothers who had no history of homelessness and were

randomly selected from a welfare office. Over 60% of all the respondents reported having experienced sexual molestation or physical attack by the age 12. Similarly, Evans and

Forsyth (2004) report in their study that sexual abuse was a common theme among women who were forced to survive on the streets (10 out of 12 reported being sexually abused while homeless). Many of the individuals in their study viewed jails and treatment centres as reprieve from having to survive on the street.

Wenzel, Leake, and Gellberg (2001) studied the health of homeless women who were raped. Participants in their study included 974 homeless women who had spent one night in the month previous to the study date in non-traditional housing. These women, aged 15 to 44, were recruited from 60 shelters and 18 meal programs in Los Angeles County and were randomly sampled for this study. They all took part in a 45-minute interview in which they were asked how many times in the past 12 months a male person obliged them to have vaginal, oral, or anal sex by force or threat of harm. Current health of women was measured on a 5-point Likert Scale using self-report measures. The participants who reported rape in the previous year comprised 13% of the sample. Half of those women reported being raped more than once. The general health among women who reported rape was worse than that of those who did not. More than the non-raped group, they reported that they did not seek the attention of a physician, even though they needed to see a physician for their physical illness.

The incidence of drug and alcohol abuse was higher among those who reported rape than among those who had not experienced such incidents.

Inciardi, Surratt, and Kurtz (2006) examined the rates of HIV, hepatitis B (HBV), and hepatitis C (HCV) among female street workers with addiction. Considering that most studies on participants in the sex trade are conducted during the day, while sex trade workers

usually appear in the streets after 10 pm, these researchers interviewed their sample after 10 pm. The sample included 586 low-income sex-trade workers who were recruited in the inner city of Miami, Florida. The participants were those who solicited sex on the streets, empty lots and backyards, crack-houses, motels, behind fences, along the sidewalks of darkened streets, and in the many back alleys that are a characteristic part of the downtown Miami geography. The sample also included those who engaged in sex-for-drug exchanges in automobiles. Most of the women either considered themselves as homeless or reported being in and out of a homeless cycle. All the women in the study had extensive histories of substance use (alcohol or marijuana (95%), crack (81%), other forms of cocaine (83%), and heroin (35%). Among all women studied, 22% tested positive for HIV, 53% positive for antibodies for hepatitis B, and 30% positive for antibodies for hepatitis C.

Aside from rape, many factors place women’s health at risk. Many resort to the sex trade in order to survive the streets while others, who may have suffered from child sexual abuse, resort to sex and the sex trade to cope with their painful memories (Maltz, 1994).

A large number of women who enter the sex trade (70%) have dealt with physical and sexual violence from an early age. As many as 30% of the women in sex trade enter the trade through their boyfriends or recruiters (MacGilivary, 2006). Regardless of the way they had been recruited, as expressed by women in the sex trade who were interviewed in the

Coalition Against Trafficking Women (CATW; Raymond & Hughes, 2001), choice in entering the sex trade can only be discussed in the context of lack of other options. Moreover, using sex as a way to blot out pain is not something new. Many survivors of child sexual abuse engage in sexual acts as a way to cope with emotional pain (Maltz, 1994).

The health of women in the sex trade is at risk considering how they have to comply with a john’s request in order to survive. In one of CATW’s studies in the United States (as cited in Raymond, 2003), 47% of the women in the sex trade who had been interviewed reported that men expected sex without a condom. A majority (73%) reported that men offered to pay more for sex without a condom, and 45% expressed that they could expect to get abused if they insisted that men use condoms.

To understand homelessness and attempt to draw conclusions as to how it can affect an individual’s psyche, some investigators have studied youth homelessness or compared the newly homeless with chronically homeless individuals (Ensign & Santelli, 1997; Stewart et al., 2004). Among the newly homeless, such as the runaway youth, as Weber, Boivin, Blais,

Haley, and Roy (2004) state, the prevalence of prostitution in the United States ranges from

10% to 50% and in Canada between 12% to 32%. The variation between the estimates, however, may partially be due to the definition of prostitution offered by each investigator, from performing sex in order to receive money to performing sex in order to receive food, security, or shelter. Most studies on youth, nonetheless, have used the same age criterion of

14 to 17 years of age. Of these youth 11.1% had engaged in prostitution by the follow-up.

Also, street homeless youth in comparison to sheltered-homeless youth reported a higher incidence of exposure to violence, had been victims of forced sex, and had engaged in more sexual activity and substance abuse (Ensign & Santelli, 1997).

A similar study on runaway youth was conducted by Stewart et al. (2004). A large proportion of youth (83%) reported physical or sexual victimization after leaving home.

Approximately 18% of these youth met the criteria for PTSD. The research sought to examine the street victimization and PTSD symptoms among urban homeless adolescents

and to test whether emotional numbing and avoidance represent distinct PTSD symptoms.

Participants in the study, which took place between 1995 to 1998 in Seattle, Washington, were 374 adolescents (95% response rate), between the ages of 13 to 21, who were not physically in the custody of the state, and their places of residence were unstable. Other inclusion criteria included (1) being away from a parent, guardian or primary caregiver for more than a week, (2) not spending more than four nights at home in the previous week, (3) having no viable home in which to live in, and (4) living in temporary foster care or in a group home (only two youth who lived in foster care participated). The conclusions of the study were that physical and sexual victimization is a real threat for homeless adolescents and those who are victimized are at risk of PTSD. Nearly half of the youth (47%) were from non-dominant ethnic groups. Most youth had left home in their early teen years for the first time and many more times after their first departure. Of the participants in the study, 45% had been physically or sexually abused before leaving home and 41% were not attending school or working towards any schooling. Results of the study revealed that 44.2% of youth were physically victimized after leaving home, 31% of them were both physically and sexually victimized, and 6.4% were sexually but not physically victimized. Gender differences were found in terms of type of victimization. Males were more often found to be physically victimized, whereas females were more often subjected to sexual exploitation and rape. Victimization was more likely among those with a history of childhood physical and sexual abuse. Among those victimized (17.7 % of the population), 21.4% of females and

14.7% of males met the criteria for PTSD. Females were found to score higher than males for six of the PTSD symptoms.

PTSD may be more common among high risk populations, such as the homeless, because the risk for victimization is higher and factors associated with homelessness

(disruptive home environments) are also associated with risk for developing PTSD (Breslau,

Davis, Andreski & Peterson, 1991). In my experience of working with women who have been homeless, it is quite common to see a woman refusing to sleep in her own room (if in a shelter or transitional house), and instead choosing to sleep on a chair, floor, or any place other than her room. In a few cases, women have refused to have a bed in their rooms, because the bed reminded them of the repeated sexual assault that they experienced either as a child or as an adult.

A comparison of addiction, mental illness, and physical health among transitionally housed, chronically homeless, and housed individuals in the Boston, Massachusetts area revealed that chronically homeless individuals (22% of this sample, N = 470) had markedly worse chronic health conditions than the transitionally-housed or housed individuals. They also reported poor mental health-related quality of life over the two years after detoxification compared with transitionally homeless and housed participants. It was also reported that detoxification did not improve the mental health-related quality of life among the two groups of transitionally-housed and chronically homeless, whereas it indeed improved the mental health quality of life among housed subjects. The study sample was an urban short-term (four to six day) inpatient detoxification unit. The exclusion criteria of the study may have resulted in the under-representation of the chronic homeless condition in the sample. If a participant had a primary caregiver who visited even once in a two-year period preceding the study, they were excluded from the sample. This may have limited the numbers of the reported homeless population and their health concerns. In addition, they excluded those with a score of 21 or

lower on the Mini Mental State Exam, (Folstein et al.) and those lacking three contacts for follow-up. In my work experience, homeless people seldom have any contact numbers. For many who apply for housing, an extensive outreach is the only way to locate them when a room becomes available.

The reviewed studies demonstrated a relationship between the diagnosis of depression, post-traumatic stress disorder and trauma experiences due to homelessness.

While many homeless individuals experience physical violence, the experience of sexual violence appears to be very common among homeless female population. The findings of the studies reviewed point to a higher incidence of drug use among those with such experiences.

In addition, homeless individuals suffer from trauma experienced due to the many losses they experience, including loss of acquaintances and loss of their health due to the poor conditions of homelessness and exposure to many physical illnesses such as HIV and AIDS that increases their suffering and reduces their life expectancy.

Physical Illness. Homeless individuals suffer from many physical illnesses, including, methicillin-resistant staphylococcus (Gilbert et al., 2006) and dyspepsia, a condition that refers to a group of symptoms related to epigastric pain such as acid regurgitation, excessive burping and belching, and increased abdominal bloating (Hwang, Wong, & Bargh, 2006).

Homeless people are also more affected by Human Immunodeficiency Virus (HIV) and

Acquired Immune Deficiency Syndrome (AIDS) than the general population and therefore more prone to depression (Riley et al., 2003). As Riley et al. also report, there is a gender difference is many aspects of health including infection with HIV and or AIDS.

In their longitudinal study, Riley et al. (2003) investigated the prevalence of HIV, addiction, and mental illness among the homeless. Their findings pointed to the high

prevalence of depression among homeless individuals affected by HIV and AIDS. Riley et al. recruited 330 English-speaking individuals who all tested positive for HIV. Of these individuals, 82.5% were male and 42% were African-Americans. Those who lived in a shelter comprised 23.8% of this population, 69.5% of those studied lived in cheap hotels, and

5.7% lived elsewhere. Men in this study reported better health than women did with respect to physical functioning and overall mental health.

It should be noted that the prevalence of HIV and AIDS appears to be higher in individuals with mental illness, addiction, or both than it is in the general population, regardless of being homeless or not. The reported prevalence of HIV and AIDS in men and women with addiction or mental illness reveals that persons with a mental illness were 1.44 times more likely to be HIV-positive or have developed AIDS than persons without a mental illness (Stoskorpf, Kim, & Glover, 2001). Furthermore, women with mental illness were 1.90 times more likely to be HIV positive, or have AIDS than women without a mental illness.

Among men, however, having a mental illness did not appear to be a risk factor for HIV or

AIDS (1.09). The most prevalent mental illnesses were found to be substance abuse disorder and depressive disorder. The results of this study, however, must be taken with caution because it could be that the individuals with mental disorders, in general, are more likely to be tested for HIV than the general population.

The likelihood of homeless women and their intimate partners becoming infected with HIV was studied by Nyamathi, Galif, and Leake (1999). Women in this study scored higher for depression, anxiety and hostility, and lower on self-esteem and emotional well- being than their intimate partners. Participants in their study were 448 homeless women and their 448 partners. Women were recruited from 40 homeless shelters or by outreach workers.

Participation criteria were: aged 18-50, homeless for a week or longer, and having a significant other who was primarily involved with them in an intimate relationship and was willing to participate in the study. As the intimate partners were overwhelmingly males, intimate female partners were excluded from the study. Data were collected by means of 45- minute to 60-minute interviews conducted by research nurses and outreach workers who were extensively trained in working with homeless and drug-addicted women. In general, the study demonstrated that homeless women and their intimate partners engaged in behaviours that increased the risk of HIV or AIDS. These behaviours included unprotected sexual activity, sex with multiple partners, and drug use. The study also revealed that homeless women frequently receive support from other high-risk individuals. Nonetheless, the study appears to have some limitations which include non-random sampling and that the fact that the partner relationship was not the primary relationship.

The reviewed literature points to the prevalence of poor health conditions among the homeless. Such conditions include methicillin-resistant staphylococcus, dyspepsia, HIV, and

AIDS. Homeless men in general are reported to be in better health conditions as compared to homeless women. In particular, the incidence of HIV and AIDS is more prevalent among homeless females.

Human contact and relationship. There is a reported lack of supportive relationships among the homeless (Herrman et al., 2004; Rokach, 2004). A homeless person, Mark, expresses his longing for closeness as “When you’re a homeless man you don’t really have contact with homeless women… homelessness did affect my confidence and pride. Your esteem gets so low and it takes so long to get that back again” (Byrne, p. 103).

A high proportion of participants in the study by Herrman et al. (2004), especially

women, reported social withdrawal and difficulties socializing with others. Nearly half of

these individuals reported having no intimate relationship such as a special person, either a

friend or a caregiver, with whom they could share their thoughts and feelings. Almost one in

four said that no friends were available and, contrary to stereotypes, over half of the men and

women expressed that they needed and wanted more friends. Rokach (2004) studied the

experience of loneliness among homeless individuals. Eight hundred and sixty-one

participants, 531 men, and 330 women volunteered to answer the loneliness questionnaire.

Samples were recruited in a Canadian urban area. The average age was 34.74 with

participants’ age ranging from 16 to 83, with the range of formal education varying from 3 to

23 years. The results of the loneliness questionnaire from this sample was compared to the

results of a loneliness questionnaire gathered from a sample of individuals from the general

population, coming from all walks of life. These individuals were interviewed in community

centres, both college and adult educational settings, and special interest groups (Parents

without Partners). The results of the study indicated that homeless individuals experience

loneliness differently from the general population. Out of five subscales, homeless

individuals had higher scores on interpersonal isolation and on self-alienation, while scoring

low on growth and discovery.

Stressful life eventS. Life in the streets can be very stressful. As expressed by Ray

(Byrne, 2005):

It wakes you up a bit [being homeless]. You’ve got to fight for everything you get.

Everything I have I carry in a big black carry bag. The streets have been hard. I’ve

been in fights. Some [of the general public] are alright [to me]. Others hassle me a bit.

I’ve had to defend myself. Years ago you could walk around not watching your back.

These days there are too many junkies and young ones that hang around in gangs.

Over the past few years I have seen homeless families out on the streets - whole

families; mothers, fathers and kids. They get help quicker than single folks…all of the

funny farms [mental health institutions] have been closed down. So [you can see]

some of the ex-patients walking like zombie (P.62).

The role of stressful life events in the lives of homeless people was explored by

Munoz, Panadero, Santos, and Quiroga (2005). Their sample included 289 homeless individuals in Madrid, Spain, who literally slept on the streets. Three categories of stressful life events were found among participants. One category included 124 individuals with economic problems, a second group included 80 individuals differentiated by their health problems, drug or alcohol abuse, and death of one or both parents, and the third group comprised 50 individuals with an accumulation of stressful life events in childhood in addition to alcohol abuse. The results indicated that the group with economical struggles was the highest-functioning group and was characterized by the lack of any substance abuse, severe mental illness, or previous psychiatric hospitalizations. This group also had fewer health problems and fewer stressful life events. The second group was characterized mainly by alcohol abuse and significant health problems that could be attributed to the longer duration of homelessness and / or a higher average age compared to the other groups. The third sub-group of homeless individuals may be most alarming because of the low average age, the multiple problems, and the rapid deterioration observed in many different areas (over

40% reported a history of suicide attempts).

Grief and loss are stressors that are experienced by homeless individuals more often than the general population as the result of high mortality rate among homeless. For example, on the streets of Toronto one homeless person dies every six days (Layton, 2000). Cheung and Hwang (2004) studied the mortality rate among homeless men and women in Toronto and compared it to published mortality rates of homeless women in other cities such as

Montreal, New York, Boston, and Copenhagen. They reported that the mortality rate among homeless women over the age of 45 is much higher than of homeless men. The rate for both genders is relatively the same for younger populations. It is noteworthy that their sample of individuals who stayed in shelters in 1995 included 8,933 single men and 1,981 single women. Among women, the most common cause of death was HIV and / or AIDS, and drug overdose. The rates may still be underestimated, as the researchers did not count the deaths of those who had left Toronto. The mortality rate among homeless women in all cities reviewed was 5 to 30 times higher for those below 45 years of age and twice as high for those over the age of 45 as compared with general population. In the general population in

United States, younger women have a much higher life expectancy than young men have

(Sorlie, Backlund, & Keller, 1995).

In addition to losses suffered by the homeless population due to the high prevalence of health issues and violence, many women lose custody of their children due to mental health and addiction concerns. In my work with the homeless I have observed an increase in substance abuse among addicted women whose children have been apprehended. For those with a mental illness, such as schizophrenia, there seems to be an increase in aggression, hallucinatory, and delusional experiences when a child is apprehended. Typically the content of the impaired cognitive function is the absent child or children.

While homeless individuals are subjected to many stressful life events such as economical hardship, loss of parents, addiction and mental illness, those who are younger and subjected to multiple stressors from childhood appear to be at higher risk of physical and mental health when homeless than those without such multiple risk factors. Loss of life, due to high mortality rate among homeless in general and female homeless in particular is a common stressor amongst the homeless. In addition women suffer loss of the custody of their children due to their own addiction and diagnosis of mental illness.

Women and Homelessness

In just ten years, the percentage of homeless women has doubled in the United States to the point where there is now an almost equal number of homeless men and women

(Grimm & Maldonado, 1995). For women, homelessness usually results from eviction, domestic violence, or other family problems. Women differ from men in many aspects such as having experienced violence and abuse (40% to 70% higher than that of males), mental illness, inadequate health care (hypothermia, malnutrition, and communicable disease), type of substance abuse, inadequate childcare, lack of social support, and limited education or work experience (Grimm & Maldonado, 1995).

Caton et al. (1995) studied the interpersonal relationships of 249 women with schizophrenia. The findings of the study suggested that homeless women with schizophrenia, compared to never-homeless women with schizophrenia are more likely to have poor family support, alcohol and drug dependency, and antisocial personality disorder. However, it is hard to tell which factor is the cause and which is the effect. Poor family support does not explain whether those who were homeless were victims of family violence or of sexual or physical abuse that resulted in them becoming homeless.

High levels of lifetime and current emotional abuse, a lifetime physical abuse for women with lifetime mood disorders, and addiction were reported by Gearon, Ballack,

Rachbeisel, and Dixon (2001). The participants in their study were 80 psychiatric outpatients age 18-55 attending an inner-city community mental health centre. Of this sample, 25 had diagnoses of schizophrenia or schizoaffective disorder and co-occurring drug abuse or dependence; 25 had diagnoses of major affective disorder and co-occurring drug abuse or dependence; and 30 individuals had diagnoses of schizophrenia, or schizoaffective disorder, and no history of substance abuse or dependence. The drug habits of individuals with schizophrenia in their sample were largely financed by their immediate family members.

Friends also appeared to support their habits by directly giving them drugs, or by using with them. Stealing, prostitution, and trading sex for drugs, were used as ways of supporting substance abuse habits as well. The most common reasons for use were expressed as peer pressure (76%), boredom (56%), to alleviate positive symptoms (36%), to cope with side effects of their illness (48%), or to cope with urges and cravings (68%). The results also indicated high levels of lifetime and current emotional abuse, and lifetime physical abuse for participants with major affective disorder, and co-occurring drug abuse, or dependence in comparison to the other two groups.

For women, homelessness usually results from eviction, domestic violence, or difficult family problems. Homeless women differ from homeless men in many aspects such as the type of mental illness they may experience, higher incidence of violence and abuse, poorer health care, more pronounced lack of social support, lower levels of education, less work experience and more hard-core drug use. Also the drug habits of women are more likely to be maintained by trading sex for drugs, prostitution, or by theft.

Interventions

In viewing homelessness by adopting a multidimensional perspective, such as the one explained by Bronfenbrener and Ceci (1994), targets for change can be identified at multiple levels of social analysis, ranging from the individual to large-scale social policies and cultural norms. This perspective invites us to consider creative ways to make the best out of existing resources while also encouraging active collaboration with people who are homeless and other stakeholders in solving the problem of homelessness (Rosenberg, Solarz, & Bailey,

1991). From an ecological perspective, the assets and resources of people who are homeless, as well as the obstacles and assets in their environment, should be assessed as change in either internal or external resource domains has the capacity to improve adjustment. The multidimensional perspective is a general framework that can guide research, intervention, and policy (Haber & Toro, 2004).

The need for multiple layers of societal change in order to assist individuals to exit homelessness, or to better their life conditions, was addressed by delegates in the 1991

American Psychological Association (APA) convention, which focussed on homelessness

(Rosenberg et al, 1991). Some of the key themes that emerged following this convention included,

(a) the necessity to focus on a broader context of homelessness, (b) a concern with the

threat of institutionalizing homelessness, (c) the need to devote resources toward

prevention services and research, and (d) the care required when conducting and

interpreting research on individual variables in socially sensitive areas such as

homelessness” (p. 1240).

Also, a proposed policy initiative was offered that included developing and evaluating innovative models of housing programs suitable to house homeless individuals recovering from alcohol and other substances and evaluating the effectiveness of “one stop shopping” programs for homeless individuals with multiple barriers and needs. Such programs offer a variety of services such as drug and alcohol treatment, mental health services, income maintenance services, and medical care all in one setting. Following is a review of some of the available literature on such interventions.

Housing. Available housing provides homeless individuals with basic protection from cold and heat. Access to appropriate housing also improves service integration, and hence overall well-being, for individuals with mental illness (Rosenhecke et al. 1998).

As mentioned earlier, for many who have histories of childhood sexual and physical abuse, home can be a frightening place. Therefore, the individual’s readiness for housing, amongst many other factors such as the previous experiences of living in a housing facility and degree of clinical stability, need to be considered when arranging for appropriate housing

(Chinman, Baily, Frey, & Rowe, 2001).

When encouraging homeless individuals to reside in available housings, outreach can play a crucial role by building a safe, trusting, and respectful relationship (Cohen, 1989).

Outreach can achieve such goals by attending to many of the needs of a homeless individual such as attending to basic medical care or sharing a cup of coffee with him or her. It may take months or years before a homeless, traumatized person will trust the relationship or agree to move to a housing facility (Chinman, et al., 2001). The connection of the homeless individual with a case manger also appears to improve the chance of them residing in a community mental health setting after their discharge from hospital (Blankertz, Cnaan, & Saunders,

1992). Furthermore, improving the conditions of the housing to ensure the safety and connection between the residents can ease the psychological trauma experienced by many homeless individuals and prevent further traumatization (Goodman, Saxe, & Harvey, 1991).

Many housing facilities take the developmental needs of the homeless, such as age group, into consideration. To meet the needs of the homeless, such developmental considerations need to be expanded to include other characteristics of this population such as youth mental health (Haber & Toro, 2004) or previously homeless individuals who have recovered from addiction to reduce the chances of relapse (McCarty, Argeriou, Huebner &

Lubran, 1991).

Supportive relationship. Peers are one of the many sources of support for individuals who have lost connection with family and friends and lack the support of other individuals in life. Service providers, by arranging common areas and some in-house activities, can enhance the engagement between residents and thus create an atmosphere where supportive relationships among the homeless can develop (Cohen, 1989). Furthermore, as has been mentioned earlier, case managers and others who work closely with homeless individuals can be a valuable source of support for this population (Chinman et al., 2001).

Mental illness and addiction As the research presented in this paper reveals, there is a high prevalence of mental illness and addiction among adult populations struggling with homelessness. Treatment of mental illness has traditionally been separate from treatment for addiction (Kasprow, Rosenheck, Frisman, & DiLella, 1999). Whether relevant, or not, the current emphasis in the broad field of mental health regarding homeless people is on the diagnosis and medical management of mental illness (O’Connor, 2005). This stems from the traditional practice of clinical services in psychology and related fields that have been guided

by the “medical model.” This model, which shares many features with “deficit-based” approaches, advocates short-term interventions for problems that are conceptualized as acute and as resulting from a singular cause or pathogen (Haber & Toro, 2004). Psychotherapy is considered as an additional component in a set of approaches aimed at helping the person who is homeless and disenfranchised (O’Connor, 2005). The medical model of service delivery, and the programs guided by it, however, is insufficient (Toro & Warren, 1999).

In order for homeless individuals with mental illness to accept services that are offered in the community, a few points need to be considered. It is important to engage with the homeless through establishing a trusting relationship, offering services that meet the particular needs of individuals, and providing clear explanations of services offered. It is also important to realize that it is entirely the individual’s decision to accept or refuse such services (Cohen, 1989). Levy (2004) proposes that for such communication the development of a common language is necessary. To him, the main purpose of common language development is to identify and understand the words of the homeless, their concepts, and values. The next step is to develop a common language between the outreach worker and the homeless person, and the third is the bridge building process by which the homeless person becomes familiar with the language and terms used by the outreach worker so that they can both speak from the same frame of reference.

In the treatment of homeless individuals with addiction to substances, three services need to be considered: (1) acute intervention, which includes detoxification and emergency treatment; (2) rehabilitation, which includes evaluation and extended health; and (3) maintenance, which includes relapse prevention and after-care (Kirby & Braucht, 1993). The provision of a safe place for homeless individuals with addictions is the first step towards

recovery. For after-care and relapse prevention, the provision of comprehensive case management that includes job training and long-term drug-free housing facilities is essential

(Kirby & Braucht, 1993).

The research indicates that amongst individuals who struggle with both mental illness and addiction, interventions that target both concerns are superior to interventions aimed at only one of those conditions (Kasprow, Rosenheck, Frisman, & DiLella, 1999; Morse et al.,

2006). An analysis of survey and discharge reports gathered by Kasprow et al. (1999) gave support for the superiority of dual diagnosis treatment programs.

For homeless individuals who have been dually diagnosed with a mental illness and addiction, research by Morse et al (2006) also found that Integrative Assertive Community

Treatment (IACT) produced better results when compared to Assertive Community

Treatment (ACT) and standard care. In integrated programs the same team of clinicians offer both mental health and addiction treatments. Other features include (1) an assertive outreach worker to help encourage homeless individuals with dual diagnosis to seek treatment, (2) the use of motivational interviewing to assist addicted individuals who have not made a commitment to abstinence to develop a plan of action to pursue recovery, (3) cognitive- behavioural therapy to help individuals develop skills for an abstinence lifestyle, and (4) interventions aimed at increasing the homeless person’s supportive social network.

Assertive Community Treatment (ACT) is a team treatment approach that provides comprehensive, community-based psychiatric treatment, rehabilitation, and support to individuals with mental illness. The ACT team approach has proven successful in many services such as case management, psychiatric services, employment and housing assistance, family support and education, and substance abuse services. ACT team members provide

highly individualized treatment plans in collaboration with the clients and offer their services in the community including the person’s residence. Also, to prevent disruption in client care, their roles are interchangeable and they share offices (Morse et al., 2006).

Both IACT and ACT conditions showed higher consumer satisfaction than the standard care. However, in terms of a reduction in psychiatric symptoms or pattern of drug use no difference was observed between the conditions (Morse et al., 2006).

Research by DeLeon, Sacks, Stains, and McKendrick (2000) on 342 homeless individuals in New York supported what the authors termed the Modified Therapeutic

Community Treatment (TC2) over another condition they termed TC1 and Treatment As

Usual (TAU) in assisting the participants in maintaining treatment gains. The TC1 program—a modified TAU addiction treatment program, designed to meet the particular needs of individuals with mental illness. The modifications to the regular program (TAU) provided activities of shorter duration, more flexibility in required participation in program activities, less confrontation, fewer sanctions, more focus on psychoeducational instructions, more direct acknowledgement of achievements and sensitivity to individual differences, in addition to psychiatric medication administration. The TC2 was a variation of TC1. The difference between the two rested in more freedom for the TC2 group in coming and going from the residential facility early in the treatment. Also, the clients had to leave this program to attend a Mental Illness Community Addiction (MICA) program that was offered in the community. In terms of the shared responsibility between the staff and residents, less responsibility was placed on peers in the TC2 group. Staff offered more direct assistance in managing program interventions and directing client’s activities. The TAU received a variety

of usual treatments for homeless individuals such as housing, or residential treatment facilities for general population of individuals with addiction.

The treatment gains were measured at 12 and 24 months and at the end of the program. Dependent variables included aspects of criminality, substance use, HIV risk behaviour, prosocial behaviour (employment), and psychological dysfunction. Participants in

TC2 and TC1 showed greater improvement than TAU, while TC2 participants showed greater gains than TC1.

Reviewed literature points to the need for multiple layers of change in considering intervention and evaluation of innovative housing models aimed at assisting individuals to exit homelessness. In considering housing, two main factors need to be considered—one is the availability of the appropriate housing and the second is the readiness of an individual to move to such facility. In encouraging the individuals to reside in a housing facility when one becomes available, the outreach can play a crucial role, by building a respectful, safe and trusting relationship. In considering the suitability of housing, the literature points to the need for safe housing that considers the developmental needs of the individuals, and includes spaces that encourage interaction between the residents.

The management of mental illness has traditionally been focused more on the medical model. In addiction services three services can be recognized—the acute service for the management of addiction, rehabilitation and extended health, and maintenance. The provision of a safe place for homeless individuals with addictions is the first step toward recovery. For after-care and relapse prevention, the provision of comprehensive case management that includes job training and long-term drug-free housing facilities is essential.

For individuals with the diagnosis of both mental illness and addiction, interventions that

target both concerns are superior to interventions aimed at only one of those conditions.

Case Management Strategies. Among interventions offered to individuals who are homeless, intensive case management strategies are widely employed in assisting individuals to exit homelessness (Haber & Toro, 2004). However, to my knowledge, only two such programs have thus far been evaluated. The first evaluation by Cauce and Charles (1994) compared the effectiveness of intensive case management strategies to regular case management among homeless youth. Intensive case management includes links to services offered in the community such as financial, housing, and medical services. The second such evaluation was conducted by Toro et al. (1997) and compared the effectiveness of intensive case management strategies with regular case management on both single adults and families who were homeless. Both evaluations yielded support for intensive case management strategies. In such approaches, workers assist homeless clients with a full range of their long- term and short-term needs, including permanent housing, job training and placement, and linkages to services in mental health, substance abuse, and health care. Such strategies recognize that individual needs vary tremendously and may include the need for childcare, alcohol or drug abuse treatment, mental health services, medical care, education, and job training. Access to a full range of services is difficult for individuals at the economic margin and particularly difficult for individuals who are homeless (Rosenberg et al, 1991).

People with chaotic lifestyles, such as those living on the streets or working in the sex trade, have difficulty fitting in with the way mainstream health services are organized. They face administrative barriers such as the requirement for an address (even if they are homeless) or the requirement to call the practice at a certain time to get an appointment with

a physician. For homeless people, their own health is not a priority, and because most have very low self-esteem, they need outreach services that will go to them, rather than requiring them to turn up at a given time (McColl & Pickworth, 2006).

One such program offered to homeless people that combines outreach with residential support is the Star of Hope Counselling that serves homeless individuals and families in a transitional living centre, in Houston, Texas (Holleman, Bray, Davis, & Holleman, 2004).

This program follows a collaborative care model that includes four components: (1) a program called the Achieving Independence and Medical Empowerment Program, which is co-facilitated by a physician and family therapist; (2) a psycho-educational support group for persons with chronic illnesses and disabilities; (3) a family-of-origin class called Building

Better Families, which is taught by family psychologists, family therapists, and family practice residents; and (4) a program called Family Health Coaching in which family physicians conduct family health screenings and coaching in collaboration with case managers and family therapists. A family psychologist and family physician supervise a medication management program that is integrated with the other components. The centre has 66 family apartments and 45 apartments for single women. Other programs such as career programs and addiction and recovery programs are also offered in the centre.

Currently, there is no evidence for the effectiveness of the program except for the self- reported satisfaction of participants reported by Holleman et al. (2004).

The available literature lends support for the superiority of intensive case management strategies over simple case management. In intensive case management, the individual is provided with information regarding the available services in the community and is assisted in making a connection with those services, such as housing, health, mental,

and occupational services, if such services are desired. One such program that has combined outreach with a residential program is the Star of Hope Counselling Program in United States

. The program has gained self-reported satisfaction of the participants.

Counselling and Therapy

As described earlier, the issue of the psychological welfare of the homeless population has been largely ignored. Psychological interventions are scarce, and I was unable to find any evaluation of the suggested psychological interventions. I have therefore included the suggestions made in the literature for counselling and therapy interventions for addressing psychological concerns homeless individuals.

In conducting counselling and therapy with homeless people, flexibility in regards to the role of the professionals during counselling is essential (O’Connor, 2005). Also, to be viewed as an expert by the client may not be useful in the initial stages of establishing a service or a trusting relationship. It is by incorporating cultural sensitivity into the therapeutic approach, and by reaching out to the clients from a position of participant-observer that the optimum development of trust may be met, which may in turn facilitate therapeutic work

(Bentley, 1997).

For Bentley (1997), the need for homeless individuals to protect their physical and psychological possessions symbolizes a lack of trust in others. Bentley (1997) reports that for men she interviewed “Psychological possessions such as problems, feelings, and attachments were equally protected by being [bottled up] inside the person” (p.02). Due to the lack of a safe space in the external world, this psychological and physical existence, is maintained by the individual in isolation. This perspective impacts the perceived opportunity for personal development. The emotional withdrawal into the self also denies homeless people the chance

to be seen by others in society as distinct individuals with differing personalities and needs

(Bentley, 1997). While their human uniqueness is protected by being hidden, paradoxically, a safe psychological space where the individual could exist as a person of value was identified by the men in Bentley’s study as being in a relationship with a “significant other” such as a girlfriend or close friend who had an empathic understanding of the homeless person’s survival strategies. Such striving for connection is also noted in the articles by Herrman et al.

(2004) and Rokach (2004), reviewed earlier.

The role of such relationships in empowering individuals to exit homelessness is reflected in personal accounts of individuals who once lived on the streets. For example, one former homeless man, who now owns a mechanic shop, considers the best influence in his recovery as starting a relationship with a man (Branthoover, 2005):

...I met while holding a sign at the corner of Broadway and Speer in 1998. He took a

chance with me and thus began a great friendship...He gave me hope of something

more than an eternal life on the streets. I didn’t start doing everything right and solve

everything. John, my friend, endured a lot of my struggles during my recovery from

alcoholism and was witness to many of my falls, but he was there for me and for that

I am eternally grateful (p. 5).

A formerly homeless woman claims that she owes her recovery from addiction and her survival from homelessness to compassionate nurses and a dedicated, warm, and gentle doctor whom she could finally trust. Nothing had helped her to stop using drugs, until she came into contact with this doctor who believed in her and gave her enough self-esteem to start believing in herself and begin putting her life back together (Coleman, 2006).

Lack of trust, feelings of detachment, helplessness, and emotional withdrawal conspire to make it more challenging for service providers to obtain any more than a basic sense of who these homeless people are and, consequently, what they need from the therapeutic interaction (Bentley, 1997). Due to the dynamics of withdrawal as a survival strategy, initiation of a dialogue or relationship with homeless individuals lies in the hands of non-homeless people. Such a relationship, or form of “pre-therapeutic alliance” (Bentley,

1997, p. 204) is necessary for more in-depth psychological work. It would appear that a successful counselling approach would do well to incorporate “pre-therapeutic” work as part of the therapeutic strategy. Such an approach considers the invisibility of homeless people and, as Bently (1997) suggests, should therefore focus on fostering in clients a sense of their

“right to be” (p. 204), as individuals with valid concerns and priorities in society. For this, the components of a working alliance—unconditional positive regard and empathic understanding—are particularly important ingredients. Bentley’s (1997) study was a confirmation for such an approach. Participants in her study were able to perceive and value similar qualities in those relationships that they defined as life affirming and nourishing.

A strong counselling relationship can be a vehicle for empowering homeless individuals to use available services and can also serve to bring a component of safety and order to their otherwise dangerous and chaotic life. As Bentley (1997) points out, what matters the most is “the quality of [being] rather than [doing] for the client” (p. 205).

Furthermore, considering that people often find it difficult to deal with the pain that arises during the therapeutic process, it is essential that people have another person or persons, such as a friend, family member or a support worker, to help ease their pain. Therapeutic work can

therefore be considered as adjunctive to the wider care of the person who is homeless, rather than something that can be provided in isolation (Bentley, 1997; O’Connor, 2005).

O’Connor (2005) suggests approaching therapy and counselling for homeless individuals in terms of therapeutic frame and containment. The therapeutic frame refers to the boundaries of therapy established by the counsellor and the client; while containment is the active process of maintaining adherence to the therapeutic frame. It is by such an application that the possibility of moving from the uncertainty of a homeless position to a more settled and involved world of connection will evolve (O’Connor, 2005). O’Connor concludes that more important than the frame is the capacity of the therapist to remain open, non-judgmental, and aware, since the context of psychotherapy for some becomes like a home, their only home, “or a halfway house between sets of equally defined half-way houses” (p. 226). Homeless clients seek homes that are new and unfamiliar, though due to transference of their negative experience onto the therapist, they may find the therapeutic relationship disappointing. This kind of transference distortion of what is being offered makes it crucial that the therapist remains aware of the parameters of this work, especially when this work seems to be going wrong. O’Connor presented his counselling approach with two men experiencing homelessness at the time of the start of therapy; one client successfully exited from homelessness, while the other discontinued therapy and remained homeless.

Their interviews supported their early disconnection from their family and the relationship between the early feelings of disconnection with the family and the progression to homelessness. O’Connor concludes that the work with these two men also underlines the emotional vulnerability of many homeless people and the difficulties that the absence of adequate supports outside this work can have for its success.

One of the clients appeared to be both in and out, choosing on some days to be absent and portraying the work as “useless talk,” while arriving on other days with an apparent enthusiasm. Behind much of his anger, as explained by O’Connor (2005), was the memory of rejection from an early stage in his life. His fear of being locked in a house may be seen as representing a distortion of a fear of being locked out or excluded—a classic compulsion that it’s better to precipitate one’s own departure than to have it forced upon oneself.

O’Connor also stresses the importance of another support person or persons such as a family member, friend, or a support worker in the life of the homeless individual. He concludes that to attempt an approach without such a variety of support would be to leave the client at risk of feelings of being overwhelmed by what is aroused during counselling and therapy. Also, in the absence of other supporting frames, we may easily adopt a role for ourselves that oversteps our own areas of competence. It is essential that the therapist not be invested solely with the responsibility of the welfare of the client and to make sure that there is a set of supports for the client that can allow therapeutic work to take place (O’Connor,

2005).

O’Connor suggests that therapeutic interventions for homeless people should reflect the authentic circumstances of these people’s lives, which is usually traumatic in an on-going sense. O’Conner’s therapeutic work with homeless clients points to the importance of having a clear structure in the counselling relationship. It is important that some continuous and consistent supports are in position, that there is a fall-back position following the session—a place or a relationship with a key worker, or other person, who has his or her own support structure (O’Connor, 2005).

The absence of an early secure relationship for these clients means that they have not had a stable context in which they could explore their thoughts and express the anxieties that are associated with some of their troubled thoughts. This comes to be expressed in their response to environments that offer or stimulate thoughts around containment, including anything that seems like home. At a theoretical level, the task can be reframed in terms of providing a realistic alternative to the kind of disturbed interpersonal relationships and the absence of holding and containment that has been experienced. Any movement forward would imply an ability on the part of the individual to develop some capacity for containment. In the early stages, the main task is to be a basic holding container for all of the chaos that is relayed. As the relationship progresses, an alliance of understanding develops.

Such an alliance allows for the development of a shared sense of what the client’s underlying situation really is (O’Connor, 2005).

It seems possible that the reparative process can, in part, be developed through the creation of things in the world that appear as anchors for change and development. Such new avenues for symbolization and expression can themselves offer hope for new experiences.

O’Connor (2005) believes that creating symbols can enhance a particular resonance in people who have been placed outside the symbolic order and who feel themselves to be in a chaos of erratic thoughts and senselessness.

Another therapy suggested for individuals who are homeless is a community-based group therapy which focuses on trauma, developed by McWhirter (2006). In a pilot study based on a quasi-experimental design that involved 31 women participants staying for three months or longer in shelter and 31 women experiencing transitions such as loss of employment, McWhirter (2006) examined the effectiveness of her proposed group therapy

designed to address specific needs of women in transition as compared to a traditional, non- clinical program. The group therapy model was based on cognitive behavioural and gestalt therapeutic techniques. The psychoeducational component addressed distorted beliefs, with a chance for each group to explore their distortions (if present). Group therapy activities also included sharing experiences and meanings, cycle of abuse education, healthy relationship, education about differentiation between thoughts and feelings, problem solving, and relaxation strategies. The traditional program focus was on employment and social stability.

No opportunity for participation in therapeutic group intervention was offered for this group.

The pre and post measures of the participants on the social support variable were based on the Quality of Social Support Scale (Vandervoort, 1999) and the single question, “How much time do you spend alone when not working or going to school?” which was scored on a 4- point scale ranging from “almost no time” to “almost all the time.” Self-efficacy, the belief in one’s own ability to perform tasks, was measured on a 15-point self-efficacy measure that was developed for this study. In addition, financial stress was measured by the Family

Economic Pressure Scale (Whitbeck et al, 1997), and family conflict and bonding measures were both based on the Family Attachment Scale of the Student Survey of Risk and

Protective Factors (Arthur, Hawkins, Catalano, & Pollard, 1998). Both groups were equally effective in reducing participants’ self-reported financial stress and increasing the social network size. The therapeutic intervention group, however, showed greater increase in these measures. The therapeutic group intervention was also effective in increasing the self- efficacy in participants. This lack of difference between the two groups in some of the measures could be due to dissimilarity in maintaining housing between the control group

(housed) and the experimental group (homeless).

There are a large number of homeless individuals without any addiction or mental illness conditions. For such individuals, Hertlein and Kilmer (2004), based on the Bowen family system theory (Bowen, 1978), present a therapy approach designed after a year of observing clients residing in the Spring Valley Centre (SVC), a transitional housing facility in Northwest Indiana. This facility can house homeless individuals for up to four months to help their transition to permanent housing. Counselling at SVC is mandatory, which as the authors explain, contributed to some of the resistance experienced by residents in engaging in therapy. The observations of these authors pointed to financial and emotional impulsivity as underlying factors associated with homelessness. The treatment is then focussed on addressing the current factors that affect the decision making. The goal of the transitional housing and therapy at SVC is to empower homeless individuals and families to “reclaim responsibility” (p. 261) for making decisions that help them transition from homelessness to independent living. The therapy consisted of four phases that include connection, assessment, treatment or consolidation, and crisis intervention (Hertlein & Kilmer, 2004).

In the connection phase, as expressed by Hertlein and Kilmer (2004), it is important to become familiar with the worldview of the client. It is also important to wear less formal clothing and be aware of personal automatic patterns that may represent social class differences between the clients and the therapist.

The goal of the assessment phase is to evaluate the current level of differentiation of the homeless client and to determine what interferes with successful decision making. This can be accomplished in part by gathering the historical information that led to the client’s homelessness. The treatment plan follows the identification of the problem and results in generating solutions and blocking emotionally reactive decisions. It also includes exploring

alternative options to reactivity and reviewing the decisions the client has made in-between the sessions.

As Hertein and Kilmer (2004) explain, for many residents of The Spring Valley

Centre, living in the transitional house and facing their own life can be overwhelming.

Therefore, the clients may make an emotionally reactive decision such as to leave the centre.

As distressing as this may be, it can be looked at as an opportunity to examine emotionally reactive decision-making and practice decisions that are more constructive.

Hertein and Kilmer (2004) suggest that in observing the homeless population they recognized similar patterns of impulsivity in decision making, emotional reactions to the environmental stimuli, and a history of familial emotional cut-off. They believe that working from this perspective allows investigating an individual’s emotional patterns and their effect on his or her behaviour. It also helps generate options for an individual’s self-sufficient future in which they are enabled to make more intellectual decisions for themselves.

Reports of psychological interventions for the homeless population are scarce. The available research all point to one important factor—the necessity for a strong relationship between the counsellor and the homeless person and/or the availability of another person or persons to support the homeless while in counselling.

Summary

Homelessness is a debilitating condition that affects the lives of many men and women in our society. The present literature review suggests a high prevalence of mental illness among the homeless. These individuals comprise a variety of diagnostic groupings, including schizophrenia, bipolar-affective disorder, post-traumatic stress disorder, and personality disorders. In addition, homeless people with mental illness suffer from a high

incidence of depressive symptoms such as apathy, reduced activity, and indecisiveness.

Whether the depression is a chronic condition or an acute reaction to extreme life stressors is unclear. In addition, many suffer from unresolved grief regarding the scarcity of primary relationships in their former and present lives. Many homeless individuals have substance abuse disorders and resort to criminal activities such as theft and the sex trade to survive in the streets. Men and women differ in their routes to homelessness and the behaviours associated with factors related to their homelessness. While most of the studies reviewed point out that the number of males who are homeless is higher than the number of females, women are more dependent on hard-core drugs, exhibit more emotional trauma, and have a higher incidence of physical illnesses including HIV or AIDS. Reports also show that women are more often the victims of physical, and sexual, violence.

In general, homeless people with a diagnosis of mental illness show higher levels of positive symptoms, such as vivid hallucinations, delusional thinking, and odd behaviour than those with mental illness in the general population. From birth through adulthood they tend to have experienced greater family discord, higher prevalence of physical illness, and less sustained long-term commitment to any sort of traditional treatment interventions than their never-homeless counterparts.

Homeless individuals suffer from many experiences that impact their psychological health. Such experiences include, but are not limited to, lack of a close relationship and loneliness, high rates of violence, physical illness due to poverty, poor nutrition, poor living conditions, and grief and loss due to the high mortality rate among the homeless.

The supported interventions that can help reduce the impact of homelessness or assist individuals to exit from it focus on preventive and intensive case management strategies.

These include access to housing, treatment centres for addiction, on-site or outreach physical, and mental, health professionals, career services, and financial services. For psychological interventions to be successful it is essential that a strong alliance be built with the client and that there is the existence of a support person or persons in their lives. In addition, psychological interventions are to be considered as an adjunct to other interventions that are aimed at changing the social context of the homeless.

It should be noted that there were shortcomings in many of the research studies reviewed for this project. For example, in some of the studies presented, many individuals were ineligible to participate due to lack of coherence. This lack of coherence could be due to substance use but it could also be due to serious mental illness. Such omissions might yield inaccurate findings. Furthermore, many of the studies on homelessness were conducted with individuals staying in government-funded or non-profit organization facilities or with individuals in food lines. Such populations, as described by the Kappel Ramji Consulting

Group (2002), comprise only a part of the visible homeless population and may not be representative of the general homeless population, especially the homeless female population working in massage parlours or those subjected to violence due to the fear of losing a place to live.

CHAPTER IV

SYNTHESIS AND IMPLICATIONS

This present literature review was designed to add to the existing knowledge on homelessness, which can potentially have a positive impact on the homeless population and may therefore serve as a means of expression for the voice of this population. This has been done by a critical analysis of the current literature, my personal experience, published stories

of homeless individuals, and information available on the internet. The present paper can also serve families of individuals with a history of homelessness by helping them to understand the life of their loved ones and by instilling hope for a better future. Additionally, the present literature review could be beneficial to researchers, since it has provided a comprehensive review of the strengths, and limitations of the present research, and by doing so, may open new avenues for future research. Understanding the homelessness phenomenon can also help in developing counselling strategies that can address the specific needs of individuals dealing with such a complex, and debilitating, condition (Bentley, 1997; Hertlein & Kilmer, 2004;

Washignton, 2002). The present review can also help educate the public regarding the factors responsible for homelessness and provide a foundation for helping and advocating for this population.

When the number of people living on the street first swelled in the early 1980s, little reliable information existed on the size of the homeless population in the world. The estimates for the United States now range from 350,000 to 6 million people (Walker, 1998).

This population's growth has resulted, in part, from demographic shifts. As the number of young to middle-aged adults at risk for chronic mental illness has risen, for instance, there has been an appreciable increase in the absolute number of homeless people living with mental illness (Walker, 1998).

Contrary to common stereotypes, homelessness affects a wide range of people, including families with children. Families occupy 42% of shelter beds in Toronto, and about

35% of shelter beds in Ottawa with the average stay of 1.5 to 2 months.

The mentally disabled homeless are commonly characterized by the media as being dishevelled and dirty; wearing clothes inappropriate to the season; pushing their belongings

in a shopping cart; shouting, gesturing and talking to trees, store windows, or those passing by; or being quiet and withdrawn when approached. All, some, or none of these behavioural indicators may actually apply. Attempts to preserve one's identity under the strain of homelessness can, at times, produce bizarre behaviour. Each individual’s behaviour has some significance and its meaning must be understood within a larger social context (Walker,

1998).

While many homeless individuals have a diagnosis of mental illness and addiction, it is not clear which comes first, homelessness, mental illness, and / or addiction. Some investigators have studied how psychiatric disorders can lead to homelessness. For example, a chronic mental illness such as schizophrenia tends to interfere with a person's efforts toward economic security. These patients often lack a regular income because of unemployment, or an inability to apply for assistance and a lack of other material resources

(Caton, et al., 1995). Such deficiencies can eventually cause homelessness. Addiction may also lead to homelessness. However, there are many people with addiction who do not lose their homes (Walker, 1998). Furthermore, what brings a person to use substances and what functions the substance use serves in the lives of those who use or abuse substances needs to also be considered (Haskel, 2003).

Despite the lack of sufficient empirical evidence available to distinguish between the effects of homelessness and the more global effects of growing up in extreme poverty, it is generally agreed upon that homelessness is likely to have dramatic and long-lasting consequences for children (Rosenberg et al., 1991). It is also clear that life on the street exacerbates conditions such as addiction and mental illness in individuals (Goodman et al.,

1997).

Homelessness is not a choice. Who would willingly choose to become disengaged from every available source of social support? Who would choose to live a life estranged from family, friends, and society? It is important to understand the connection between homelessness, chronic mental illness, and other factors contributing to homelessness because by understanding we can develop the sensitivity and compassion necessary to serve this population (Walker, 1998).

Profound lack of trust, fear of closeness, and the desire for autonomy cause some people to avoid giving their real names to others and to refuse social services. The dehumanizing effects of institutional living may cause some individuals to display submissiveness and excessive dependence. In part, such characteristics may be due to the presence of mental illness. Many individuals with mental illness express their psychiatric vulnerability by becoming attached to homelessness as a way of life, one that demands minimal social expectations and few interpersonal contacts (Walker, 1998). In addition, not all homeless individuals develop a life style in which they move with ease between a home and the street and may have extreme difficulties in sustaining a home; they move repeatedly into homelessness even when a home is available—a condition that can be considered as self- sabotage (O’Connor 2005). Although many homeless individuals may share the same sidewalk and cardboard boxes, interpersonal interaction may still be limited. Homeless individuals often remain isolated from each other and from society at large (Walker, 1998).

While the emphasis of this paper is on the psychological impact of homelessness, I think the cultural and social factors underlying, as well as maintaining and exacerbating, homelessness should also be considered. There is a reported tension between social and

psychological models of homelessness (O’Connor, 2005). Each model, however, can only address part of the problem.

Long-term solutions to homelessness must begin with an accurate and complete definition of the problem (Walker, 1998). This may not be possible unless we hear the stories of the painful experiences and the survival strengths of homeless individuals. Hearing and understanding the factors that lead an individual to homelessness can be a very slow process—much more than what a short interview would allow (Bridgman, 2002). It takes time to build trust without invading someone’s privacy and to be able to hear, find the meaning of what is being heard, and get to the root of the problems—the problems that have resulted in a member of our society becoming homeless.

Interventions for homeless individuals also need to spring from a deep understanding of both individual and contextual factors, such as social and cultural factors that can lead to an individual’s homelessness and its maintenance. Through this, steps toward reducing the harm or assisting individuals to exit from homelessness can begin.

In providing housing for the homeless, emergency shelters cannot be considered as a solution because they foster instability and movement. Such emergency services, even when they become available, may only minimally make the homeless condition tolerable

(Rosenberg et al., 1991). Furthermore, although many of the services for the homeless, such as shelters, have incorporated developmental considerations including establishing separate facilities for adolescents and young mothers, they still tend to adopt a “one size fits all” approach in which adolescents who are homeless are treated similarly to adults, regardless of the cause of their homelessness or their future needs (Haber & Toro, 2004). Therefore, future research should include evaluating the implementation of programs that attend to the

developmental context of episodes of homelessness. In addition to improving services for the presently homeless, such programs could also help to prevent homelessness in the future

(Haber & Toro).

In my research, studies on the psychological impact of homelessness were scarce. For example, I could not find any research on the impact that child-rearing and the loss of children due to the Child Protection Acts in various countries may have on the mental health of homeless mothers. Also, while many psychological interventions are aimed at mental health management and / or addictions treatment (Haber & Toro, 2004), little research addresses specific counselling interventions for the homeless. The present counselling approaches emphasize building a strong alliance (Bridgman, 2002; O’Connor, 2005), addressing underlying containment difficulties, the fearful uncertainty toward others, and the consequent desire to withdraw from the world common in many homeless individuals

(O’Connor, 2005). It needs to be recognised that like everyone, people who are homeless have a desire to bring about change in their lives, however stuck they may have become

(O’Connor, 2005). More thorough, in depth, research into the causes and factors influencing homelessness or exiting from it is required to advocate for the development of proper policies, programs, and strategies to reduce harm to this neglected population and assist in their exit form homelessness. It is only then that we can advance our society towards a more egalitarian community.

REFERENCES

Alexander-Eitzman, B. E. (2006). Examining the course of homelessness: Right direction,

wrong approach. American Journal of Public Health, 96(5), 764-764.

Amnesty International (2006). Guantánamo Bay - a human rights scandal. Retrieved

November 29, 2006, from http://web.amnesty.org/pages/guantanamobay-index-eng.

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental

Disorders (4th ed.). APA: Washington, DC: Author.

American Psychiatric Association. (1987). Diagnostic and Statistical Manual of Mental

Disorders (3rd ed. Revised). APA: Washington, DC: Author.

American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental

Disorders (3rd ed.). APA: Washington, DC: Author.

Anderson, D. G., Rayens, K. M. (2004). Factors influencing homelessness in women. Public

Health Nursing, 21, 12-23.

Applewhite, L. S. (1997). Homeless veterans: Perspectives on social services use. Social

Work. 42, 19-31. Retrieved October 28, 2004, from Psychology and Behavioral

Sciences Collection database.

Arthur, M. W., Hawkins, J. D. Catalano, R. F., & Pollard, J. A. (1998). Student survey of risk

and protective factors and prevalence of alcohol, tobacco, and other drug use.

Seattle, WA: Social Development Research Group.

Bank, E. (1998). What types of addict are you? Social Policy. 29(2), 5-10. Retrieved October

28, 2004, from Academic Search Premier database.

Benjamin, E. R., Clements, C., McCally, M., Pellett, P. L., Van Rooyen, M. J., & Waldman,

R. J. ( 2003). The humanitarian cost of war in Iraq. Lancet, 361(9360), 874.

Bentley, A. (1997). The psychological effect of homelessness and their impact on

development of a counselling relationship. Counselling Psychology Quarterly, 10(2),

195-216.

Branthoover, T. (2005). Denvor stories: A letter on overcoming homelessness. Retrieved,

October 3, 2006, from

http://www.denverstories.com/townhall/html/modules.php?op=modload&name=New

s&file=index&catid=1.

Bowen, M. (1978) Family therapy in clinical practice. New York: Aronson.

Breslaue, N., Davis, G. C., Andreski, P., & Peterson, E. (1991). Traumatic events and post

traumatic stress disorder in an urban population of young adults. Archive of General

Psychiatry, 48, 216-222.

Bridgman, R. (2002). Housing chronically homeless women: “Inside” a safe haven. Housing

Policy Debate. 13(1), 51-82.

Broderick, P. C., & Blewitt, P. (2006). The life span: Human development for helping

professionals (2nd ed). Upper Saddle River, NJ: Prentice Hall.

Bronfenbrenner, U., & Ceci, S. J. (1994). Nature- nurture reconceptualized in developmental

perspective: A biological model. Psychological Review, 101, 568-586.

Browne, A., & Bassuk, S. (1997). Intimate violence in the lives of homeless and poor housed

women: Prevalence and patterns in an ethnically diverse sample. American Journal of

Orthopsychiatry, 67(2), 261-278.

Burke, A. (2002). Prisoners of Paradox: Thinking for the refugee. Social Alternatives, 21(4),

21-27.

Burl, M. (1996). Homeless families, singles, and others: Findings from the 1996 National

Survey of Homeless Assistance Providers and Clients. Housing Policy Debate. 12,

737-780.

Byrne, A. (2005). Homelessness: True stories of life on the streets. Frenchs Forest: New

Holland

Caton, L. M., Shrout, P. E., Hasin, D. S., Felix, A., Schanzer, B., Opler, L. A., et al. (2006).

Caton et al. respond. American Journal of Public Health, 96(5), 764-765.

Caton, C. L., Dominiguez, B., Schanzer, B., Hasin, D., Shrout, P. E., Felix, A., et al. (2005).

Risk Factors for long term homelessness: Findings from a longitudinal study of first

time homeless single adults. American Journal of Public Health, 95(10), 1753-1759.

Caton, C. L., Hasin, D., Shrout, P. E., Opler, L. A., Hirshfield, S., Dominguez, B., et. al.

(2000). Risk factors for homelessness among indigent adults with no history of

psychotic illness. American Journal of Public Health, 90, 258-263.

Caton, L. M., Shrout, P. E., Domingues, B., Eagle, P. F., Opler, L. A., Coumos, F. (1995).

Risk factors for homelessness among women with schizophrenia. American Journal

of Public Health, 85(8), 1153-1156.

Cauce, A. M., & Morgan, C. J. (1994). Effectiveness of intensive case management for

homeless adolescents: Results of a 3 month follow –up. Journal of Emotional and

Behavioral Disorders, 2, 219-227.

Cheung, A. M., & Hwang, S. W. (2004). Risk of death among homeless women: A cohort

study and review of the literature. Canadian Medical Association Journal, 170,1243-

1247.

Chinman, M. J. Baily, P., Frey, J., & Rowe, M. (2001). Directions in Rehabilitaion

Counseling, 2, 107-128.

Cohen, M. B. (1989). Social work practice with homeless mentally ill people: Engaging the

client. Social Work, 505-509.

Coleman, T. (2006). Surviving the streets. Retrieved September 3, 2006, from

http://www.multidx.com/articles/survivingStreets.htm

Corsini, R. J., & Wedding, D. (Eds.). (2000). Current psychotherapies. ( p. 455), Itasca, IL:

Peacock.

De Leon, G., Sacks, S. Stains, G., & McKendrick, K. (2000). Modified therapeutic

community for homeless mentally ill chemical abusers: Treatment outcomes.

American Journal of Drug and Alcohol Abuse, 26(3), 461-480.

Ensign, J., & Santelli, J. (1997). Shelter-based homeless youth: Health and access to care.

Archive of Pediatric & Adolescents Medicine, 151, 817-823.

Evans, R. D., & Forsyth, C. J. (2004). Risk factors of victimization, and survival strategies:

the impact of the structural location of men and women on their experiences within

homeless milieus. Sociological Spectrum, 24, 479-505. Retrieved October 28, 2004,

from Academic Search Premier database.

Exploring the Health Impact on Homelessness (1996). Retrieved on September 28, 2006,

from, http://www.oma.org/phealth/homeless.htm

First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. (1994). Structured Clinical

Interview for DSM-IV Axis I Disorders, New York: Biometric Research Department,

New State Psychiatric Institute.

Folsom, D. P., Hawthorne, W., Lindamer, L., Golmer, T., Baily, A., & Golshan, S. et al.

(2005). Prevalence and risk factors for homelessness and utilization of mental health

services among 10, 340 patients with serious mental illness in a large public mental

health system. American Journal of Psychiatry, 162, 370-376.

Folstein, M. F., Folstein, S. E, & McHugh, P. R. (1975). Mini-mental state: A practical

method for grading the cognitive state of patients for the clinician. Journal of

Psychiatric Research, 12(3), 189-198

Forchuk, C., Russell, G., Kingston-Macclure, S., Turner, K., & Dill, S. (2006). From

Psychiatric Wards to Streets and Shelters. Journal of Psychiatric and Mental Health

Nursing, 13(3), 301-308.

Fountain, J., Howes, S., Marsden, J., & Strang, J. (2002). Who uses services for homeless

people? An investigation amongst people sleeping rough in London. Journal of

Community & Applied Psychology. 12, 71-75. Retrieved October 30, 2004 from

Academic Search Premier database.

Gearon, J. S., Bellack, A. S., Rachbeisel, J., & Dixon, L. (2001). Drug-use behavior and

correlates in people with schizophrenia. Addictive Behaviors. 26, 51-61. Retrieved

November 4, 2004, from Academic Search Premier database.

Gearon, J. S., Nidecker, M., Bellack, A., & Bennet, M. (2003). Gender differences in drug

use behaviour in people with serious mental illnesses. The American Journal of

Addictions. 12, 229-241. Retrieved October 30, 2004, from Academic Search Premier

database.

Gilbert, M., MacDonald, J., Gregson, D., Siushansian, J., Zhang, K., & Elasayed, S., et al.

(2006). Out break in Alberta of community-acquired (USA 300) methicilin-resistant

Staphylococcus aureus in people with a history of drug use, homelessness or

incarceration. Canadian Mental Association Journal, 175(2), 149-154.

Golden, A., Currie, W. H., Greeves, F., & Latimer, F. J. (1999). Taking the responsibility for

homelessness: An action plan for Toronto. Report of the Mayor’s Homelessness

Action Task Force. Retrieved August 10, 2006, from

www.city.toronto.on.ca/mayor/homelesnesstf.htm

Goodman, L. A., Dutton, M. A., & Harris, M. (1997). The relationship between violence

dimensions and symptoms severity among homeless, mentally ill women. Journal of

Traumatic Stress, 10, 51-70.

Goodman, L. A., Saxe, L., & Harvey, M. (1991). Homelessness as psychological trauma:

Broadening perspectives. American Psychologist, Special Issue: Homelessness, 46,

1219- 1225.

Grimm, K., & Maldonado, J. C. (1995). No home of her own: Gender and homelessness.

Women and Environments, 14(2), 20-23. Retrieved October 28, 2004, from Academic

Search Premier database.

Haber, M. G., & Toro, P. A. (2004). Homelessness among families, children, and

adolescents: An ecological-developmental perspective. Clinical Child and Family

Review, 7(3) 123-164.

Haskel, L. (2003). First stage trauma treatment: A guide for mental health professional

working with women. Toronto, Ont: Centre for Addiction and Mental Health.

Haver, B. (2003). Comorbid psychiatric disorders predict and influence treatment outcomes

in female alcoholics. European Addiction Research, 9, 39-44. Retrieved October 23,

2006, from Academic Search Premier database.

Herrman, H., Evert, H., Harvey, H., Gureje, O., Pinzone, T, & Gordon, I. (2004). Disability

and service use among homeless people living with psychotic disorders. Australian

and New Zealand Journal of Psychiatry, 38, 965, 977.

Hertlein, K. M., & Kilmer, J. M. (2004). Toward differentiated decision-making: Family

system theory with the homeless clinical population. American Journal of Family

Therapy, 32(3), 255-270.

Hilsum, L. (2005). Worldview. New Statesman 134(4721), 23-23.

Holleman, W. L., Bray, J. H., Davis, L., & Holleman, M. C. (2004). Innovative ways to

address the mental health and medical needs of marginalized patients: Collaborations

between family physicians, family therapists, and family psychologists. American

Journal of Orthopsychiatry, 74(3), 242-252. Retrieved August 13, 2006, from Ovid

database.

Homeless Count 2005: On our streets and in our shelters. Retrieved August 10, 2006, from

www.gvrd.bc.ca/homelessness/pdfs/HomelessCount2005Bulletin.pdf.

Hwang, S.W., Wong, S. Y., & Bargh, G. (2006). Dyspepsia in homeless adults. Journal of

Gastroentrology, 40(5), 416-420.

Incirdi, J. A., Surratt, H. L., & Kurtz, S. P. (2006). HIV, HBV, and HCV Infections among

drug-involved, inner city, street sex workers in Miami, Florida. AIDS and Behavior,

10(2)139-147.

Kappel Ramji Consulting Group (2002, June). Common occurrence the impact of

homelessness on women’s health phase II: Community based action research final

report executive summary. Toronto, Ont: Author.

Kasprow, J. W., Rosenheck, R., Frisman, L. & DiLella, D. (1999). Residential treatment for

dually diagnosed veterans: A comparison of program types. The American Journal on

Addictions, 8, 34-43.

Kemp, P. A., Neale, J., & Robertson, M. (2006). Homelessness among problem drug users:

Prevalence, risk factors and trigger events. Health and Social Care in the Community,

14(4), 319-328.

Kipke, M. D., Montgomery, S. B., Simon, T. R., & Iverson, E. F. (1997). “Substance abuse”

disorders among runaway and homeless youth. Substance Use & Misuse, 32, 969-

986.

Layton, J. (2000). Homelessness. The making and unmaking of a crisis. Toronto, Canada:

Penguin books.

Levy, J. S. (2004). Pathways to a common language: A homeless outreach perspective.

Families in Society, 85(3), 371-378.

Lin, S. K., Ball, D., Hsiao, C. C., Chiang, Y. L., Ree, S. C., & Chen, C. C. (2004).

Psychiatric comorbidity and gender differences of persons incarcerated for

methamphetamine abuse in Taiwan. Psychiatry and Clinical Neuroscience. 58,

206-212.

MacGillivaray, C. (2006). Her name is Jennifer, Turning adversity into blessing. Retrieved

August 5, 2006, from www.angelscommunity.com/0501-article_jennifer.shtml

Maltz, W. (2005). Sexual healing from sexual abuse: Advice for adult survivors. Retrieved

August 5, 2006, from http://www.selhelpmagazine.com/articles/sex/healing.html.

Markland, S. (1990). Structures of modern poverty. Acta Sociologica, 33(2), 125-140

McCarty, D., Argeriou, M., Huebner, R. B., Lubran, B. (1991). Alcoholism, drug abuse, and

the homeless: homeless persons with alcohol, drug, and mental disorders. (1991).

American Psychologist, 46(11), 1139-1148.

McColl, K. Pickworth, S., & Raymond, I. (2006). Project: London-supporting vulnerable

populations. British Medical Journal, 332, 115-117.

McNeil, D. E., Binder, R. L., & Robinson, J. C. (2005). Incarceration associated with

homelessness, mental disorder, and co-occuring substance abuse. Psychiatric

Services, 56, 840-846

McWhirter, P. T. (2006). Community therapeutic intervention for women healing from

trauma. The Journal for Specialists in Group Work, 31(4), 339-351.

Mertens, D. M. (1998). Research methods in education and psychology. Thousand Oaks, CA:

Sages.

Morse, G. A., Calsyn, R. J., Klinkerberg, W. D., Helminiak, T. W., Wolff, N., Drake, R. E.,

et al. ( 2006). Community Mental Health Journal, 42(4), 377- 404.

Munoz, M. Panadero, S., Santoz, E. P., & Quiroga, A. (2005). Role of stressful life events in

homelessness: An intragroup analysis. American Journal of Community Psychology,

35-47.

North, C. S., Pollio, D. E., Smith, E. M., & Spitznagel, E. L. (1998). Correlates of early onset

and chronicity of homelessness in a large urban homeless population. Journal of

Nervous and Mental Disease, 186, 393-400.

Novac, S., Brown, J., & Gallant, G. (1999). Women on the rough edge: A decade of change

for long-term active women. A research Report. Ottawa, Ontario, Canada Mortgage

and Housing Corporation. Retrieved August 5, 2006, from www.cmhc.schl.gc.ca.

Nyamathi, A. Galif, E. R., Leake, B. (1999). A comparison of homeless women and their

intimate partners. Journal of Community Psychology, 27(4), 489-502.

O’Connor, J. (2005). Between the street and the consulting room: The role of therapeutic

frame in working with homeless clients. European Journal of Psychotherapy,

Counselling and Health, 7(5), 217-233.

Opler, L. A., Kay, S. R., Lindenmayer, J. B., & Fiszbein, A. (1992). Structured Clinical

Interview for Positive and Negative Syndrome Scale. New York: Multi Health

Systems.

O’Toole, T. P., Gibbon, J. L., Hanusa, H. B., Freyder, P. J., Conde, M. A., & Fine, M. J.

(2004). Self reported changes in drug and alcohol use after becoming homeless.

American Journal of Public Health, 94 (5), 830-836.

Ran, M. S., Chan, C. L., Chen, E. Y., Xiang, M. Z., Caine, E. D., & Conwell, Y. (2006).

Homelessness among patients with schizophrenia in rural China: A 10-year Cohort

study. Acta Psychiatrica Scandinavica, 114(2), 118-127.

Rayburn, N. R., Wenzel, S. L., Elliot, M. N., Hambarsoomians, K. Marshal, G. N., & Tucker,

J. C. (2004). Trauma, depression, coping, and mental health service seeking among

impoverished women. Journal of Consulting & Clinical Psychology, 73(4), 667-677.

Raymond, J. (2003). 10 reasons for not legalizing prostitution just when you thought

legalizing it may be the answer to the problems in the world of prostitution, you might

want to check this out. Retrieved March 12, 2006, from

http://www.rapereliefshelter.bc.ca

Riley, E. D., Wu, A. W., Perry, S., Clark, R. A., Moss, A. R., Crane, J., & Bangberg, D. R.

(2003). Depression and drug use impact health status among marginally housed HIV-

infected individuals. AIDS Patient Care and STDs, 17(8), 401-406.

Rokach, A. (2005). Private lives in public places: Loneliness of the homeless. Social

Indicators Research, 72, 99-114.

Rosenberg, A. A., Solarz, A. L., & Baily, W. (1991). Psychology and homelessness: A public

policy and advocacy agenda. American Psychologist, 46(11) 1239-1244.

Rosenheck, R., Morrissey, J., Lam, J., Callaway, M., Johnsen, M., Goldman, H. et al. (1998).

Service systems integration, access to services, and housing outcomes in program for

homeless persons with severe mental illness.

Ross, H. E., Glaser, F. B., & Staisny, S. (1988). Sex differences in the prevelance of

psychiatric disorders in patients with alcohol and drug problems. British Journal of

Addiction, 83, 1179-1192. Retrieved October 23, 2004, from Academic Search

Premier database.

Sorlie, P. D., Backlund, E., & Keller, J. B. (1995). US mortality by economic, demographic,

and social characteristics: The National Longitudinal Mortality Study. American

Journal of Public Health, 85(7), 949-956.

Stewart, A. J., Steiman, M. S., Cauce, A. M., Cochran, B. N., Whitbeck,L. B., & Hoyt, D. R.

(2004). Victimization and posttraumatic stress disorder among homeless adolescents.

Journal of the American Academy of Child Adolescent Psychiatry, 43(3), 325-331.

Stoskopf, C. H., Kim, Y. K., & Glover, S. H, (2001). Addiction services dual diagnosis: HIV

and mental illness, a population-based study. Community Mental Health Journal,

37(6), 469-479.

Summerlin, J. R. (1995). ‘adaptation to homelessness: Self actualization, loneliness, and

depression in street homeless men’. Psychological Reports, 78, 295-314.

Tavecchio, L.W., Thomer, M. A., & Meeus, W. (1999). Attachment, social network and

homelessness in young people. Social Behavior and Personality, 27(3), 247-262.

Timms, P., & Borrel, T. (2001). Doing the right thing-Ethical and practical dilemmas in

working with homeless mentally ill people. Journal of Mental Health, 10(4), 419-

426.

Toro, P. A., & Warren, M. G. (1999). Homelessness in the United States: Policy

considerations. Journal of Community Psychology, 27, 119-136.

Toro, P. A., Rabideau, J. M., Bellavia, C. W., Daeschler, C. V., Wall, D. D., Thomas, D. et

al. (1997). Evaluating an intervention for the homeless persons: Results of a field

experiment. Journal of Consulting and Clinical Psychology, 65(3), 476-484.

Retrieved August 21, 2006, from Ovid database.

Tucker, J. S., Wenzel, L. S., Elliot, M. N., Marshal, G. N., & Williamson, S. (2004).

Interpersonal violence, substance use, and HIV-related behavior and cognition: A

prospective study of impoverished women in Los Angles County. Aids and Behavior,

8(4), 463-474.

Vandervoort, D. (1999). Quality of social support in mental and physical health. Current

Psychology, 18, 205-222.

Walker, C. (1998). Homeless people & Mental Health: A nursing concern [Continuing

Education]. American Journal of Nursing, 98(11), 26-32. Retrieved October 23, 2004

from Academic Search Premier database.

Washington, T. A. (2002). The homeless need more than a pillow, they need a pillar: An

evaluation of a transitional housing program. Families in Society, 83(2), 183-189.

Weber, A. E., Boivin, J. P., Blais, L., Haley, N., & Roy, E. (2004). Predictors of initiation

into prostitution, among female street youths. Journal of Urban Health, 81(4), 584,

595.

Wenzel, L., Leake, B. D., & Gelberg, L. (2000). Health of homeless women with recent

experience of rape. Journal of General International Medicine, 15, 265-268.

Retrieved October 28, 2004, from Academic Search Premier database.

Whitbeck, L. B., Simons, R. L., Conger, R. D., Wickrama, K. S., Ackley, K. A., & Elder, G.

H. (1997). The effects of parents working conditions and family economic hardship

on parenting behaviors and children’s self-efficacy. Social Psychology Quarterly, 60,

291-303.

Whitbeck, L. B., Hoyt, D. R. & Yoder, K., A. (1999). A risk-amplification model of

victimization and depressive symptoms among runaway and homeless adolescents.

American Journal of Community Psychology, 27(2), 273-296.

World Health Organization (1992). International Statistical Classification of Diseases and

Related Health Problems (10th ed). WHO: Geneva.