The Homeless Mentally Ill

Vicki Notes

Homelessness:

A Historical Perspective

• In the 18^th century America – some believed the mentally ill were possessed & that they should be feared.
• Toward the end of the century, state mental asylums were established & evolved throughout the 19^th century & early 20^th century.
• During the great depression of the 1930s there was a surge in homeless people.
• After World War II – skid rows began to develop in major urban areas.
• This census rise was too much for state hospitals to handle (provide adequate care) à care then deteriorated à and resulted in warehousing.
• In the 1940s the media exposed deplorable mental hospital conditions.
• In 1948 the National Institute of Mental Health was established.
• In 1953 the first major tranquilizers were introduced.
• As social reform responded to deplorable hospitalization conditions, the movement towards deinstitutionalization began à this lead to mentally ill persons being discharged to nursing homes, boarding houses, hotels, single-room dwellings & low-income housing à By the end of the 1970s many of these persons were among the homeless.
• In the 1980s -1990s decreased funding for low income housing & decreased federal aid to the disabled (many who are mentally ill) increased the problem.
• Today the criminal justice system & homeless shelters are often the primary care providers for the homeless mentally ill.

Who are the homeless?

• Families (single moms with 2-3 children), schizophrenics, the elderly, people displaced by domestic violence, runaways, people on the street.
• There may be as many as 3 million homeless in the US.
• There are three defined categories of the homeless:
• Those who suffer severe economic setbacks.
• Those with personal lives & decisions complicated by crisis or series of crisis.
• Seriously disabled with mental illness or substance abuse disorders with no social support system.
• The homeless are mainly Caucasian & less than 50% have a high school diploma.

Homeless Families

• Families are the fastest growing subpopulation of homeless.
• A typical family is a single mom with 2-3 children.
• These children show developmental delays, depression, anxiety, learning difficulties & shame.

Homeless Mentally Ill People

• Account for 1/3 of the homeless population & half show symptoms of depression.
• Schizophrenia is the most common mental illness affecting homeless people. Major affective disorders & alcoholism are also higher in the homeless.
• Changes in TX philosophy & mental health law have created a rise in homelessness of chronically mentally ill young adults. They usually receive TX à leave the facility à do not follow-up & decompensate.

Factor Contributing to Homelessness in the Mentally Ill:

Discussed here is substance abuse, poverty, inadequate housing & high mobility.

Substance abuse

• Mentally ill, especially young adults may attempt to self-medicate psychiatric symptoms with street drugs or alcohol.
• Between 20% - 40% of homeless mentally ill people also have alcohol or substance abuse disorders.

Poverty

• The most seriously affected are people of color, children & the elderly.
• Unemployment, public assistance cuts, and increased domestic violence contribute to homelessness.
• High % of new jobs created in the 80s & 90s paid only minimum wage or higher à this increased homelessness.
• Those with better paying jobs are not immune.
• Americans in low paying jobs may only be a few paychecks away from homelessness.

Inadequate Housing

• People with low incomes are paying more for housing.
• In the 1980s there were twice as many low-income families as there was available low-income housing & there have been no improvements.
• The poor, the nonwhite & the elderly are victims of eviction.
• A wide range of community housing is needed for the diverse functioning levels of the chronically mentally ill.

High Mobility

• A phenomenon of restlessness affects many homeless mentally ill.
• Moving in & out of homelessness or homes & outpatient treatment facilities.
• Chronically mentally ill young adults may find a sense of autonomy in being homeless à it makes them fell independent of family/parents. However it leads to them receiving a lack of treatment, using street drugs to self-medicate & not being able to cope with their mental illness.
• 3 types of mobility are noted in the homeless mentally ill:
• Episodic or intermittent – movement in & out of homelessness.
• Seasonal-type movement – in a geographically defined area.
• Migratory-type movement – over wide geographical areas.

Critical Issues Affecting the Homeless Mentally Ill:

These include the effects of deinstitutionalization, barriers to care, the shelter system & health concerns.

• A sense of belonging & a psychological sense of a home are lost for the homeless person.
• Chronic homelessness occurs when community support is not available to prevent it or turn it around.
• To cope with losses the homeless may disaffiliate from conventional society & identify with a homeless culture à called acculturation.

Effects of Deinstitutionalization

• Taking the mentally ill out of institutions began as a positive process in support of these patients’ civil rights à but when less were put into institutions there was nowhere for them to go à they lacked community support services & housing.
• They have the right to receive TX, refuse TX & be treated in the least restrictive environment à the question is – is that therapeutic?
• It has affected about 2 million seriously mentally ill in the US/

Barriers to Care

• Barriers to care include lack of insurance, transportation, knowledge of available services, they have no identification or address (which are often required for eligibility or services), fear of leaving their things while at an appointment, missing meals, or fear of scrutiny by acre givers.
• An internal psychological barrier in accessing care is the two-way process of withdrawal that may occur between the nurse & patient à nurses should focus on the physiological causes of the clinical situation, not examining their own feelings & attitudes. Avoid the all or nothing approach with treatment à be flexible.

The Shelter System

• Are needed for homelessness but are not & never can be the solution.
• Act as a replacement for mental institutions in urban settings.
• Vary in size & service offered à may have beds, cots or only floor space, meals, reading materials, laundry facilities & clothing. Some have psychiatric & health services.
• Often staffed by professional & nonprofessional volunteers.
• Valuable opportunity to provide health education.

Health Concerns

• The chronically mentally ill have 3 times the disease morbidity & mortality rates à with the homeless being even higher.
• Chronic disease of the homeless – 1^st is mental illness à then hypertension à followed by diabetes, circulatory disorders & peripheral vascular disease à only half seek help.
• Average life expectancy of the homeless is 50 years.
• Other health problems from being homeless include – exposure, dependent positioning (being on their feet all day), poor ventilation, trauma from violence (especially in cities), high population density, heat stroke, frostbite, lice, scabies, insect bites & poor nutrition.
• Because of their anonymity, homeless people are often victims of senseless crimes à and are victims far more often than the perpetrators of such crimes.

Assessment

• Stereotypes to homeless may be a barrier to providing care, as they are widely stigmatized as, "crazy"à nurse should assess her feelings and attitudes to be able to provide effective care.
• It is not unusual for a nurse to feel uncomfortable and even fearful when beginning to work in homeless settings.
• Assess capacity to work, ADL’s, chronic treatment needs, seek out and enjoy leisure time, difficulty relating to others, lack of self confidence and self-esteem, dependency needs, affects of meds that limit motor capacity, acting out that interferes with relationships, financial resources, lack of motivations or self-direction toward defined goals.
• Assessment may be difficult due to lack of privacy and the high noise level in shelters, distractions of the street when outside a shelter. Embarrassment of having belongings inspected and frisked for weapons.
• Proceed with mental statues exam- keep in mind the most pressing problem may be securing a place to stay that night. These patients have increased likelihood of CNS impairment. Note history of head traumas and other organic damage. Screen for STD’s, toxicology, risk factors for HIV and with consent, blood testing.

Nursing Diagnosis

• Psych nurses must be familiar with the norms and necessities of street life, because some unusual behaviors actually may be adaptive mechanism (ex: patient may wear excessive clothing to keep people from sealing them or patients exhibit bizarre behaviors to keep others away).

Some Nursing Diagnoses:

• Altered Family Processes r/t recent displacement
• Social Isolation r/t new onset of homelessness
• Ineffective Individual Coping
• Powerlessness
• Self Esteem Disturbance
• Social Isolation
• Risk for Infection
• Risk for Injury

Client Outcomes:

• Should be reasonable and attainable, for example: The client controls paranoid thoughts long enough to spend a complete night in a shelter.
• Other outcome goals may include- demonstrating an increase in appropriate independent functioning, increasing contact with case management services or increasing use of clinic services.
• Evaluate outcomes in terms of small successes.
• Do not necessarily designate the end of homelessness as an outcome criterion à episodic Interventions:

Create an Alliance

• Initiate the helping relationship in a nonthreatening manner à giving patient as much control as possible.
• Avoid wanting to "fix" problems, act as an advocate but know your limits.
• Don’t make quick referralà before you establish trust.
• Discuss medical conditions before psychiatric problems to help build trust.
• May need to postpone interventions for disturbing symptoms at first to decrease negative experience.

Medication Management

• Sedating effects can put a patient in danger on the street.
• Carrying medications increase the risk of assault and robbery.
• Caution against combining meds with alcohol or other drugs.
• Involve patients in medication management.

Education

• Teach on topics such as hygiene, dealing with infestation, heat and cold temps out doors, cancer/ respiratory risks/ problems, STD’s and substance abuse.
• Teach them particulars about their mental illness, symptoms, and medication side effects.

Case Management- encompasses all needs.

• Provides a connection between patient and the community.
• Nurse ensures patient receives structure and support they need.
• Responsibilities may not be able to handle the increased caseload, nurse doesn’t trust handing it over or patient doesn’t want relationship with the nurse interrupted.

Political Involvement and Advocacy

• Nurse should address the structural problems of society and help influence policies regarding change.

Questions to consider:

1. What are the factors contributing to homelessness?

Substance abuse, poverty, housing and mobility patterns among the homeless mentally ill.

2. What are the issues specific to the homeless mentally ill?

The ongoing effects of deinstitutionalization, the impact of loss on the person, ensuring access to care, the shelter system and health concerns.

3. Who is the homeless population?

Heterogeneous, the young, elderly, families with children, victims of domestic violence, runaways, veterans, ex-prisoners, immigrants and the mentally ill. Families are the most rapidly growing segment.

4. Homelessness is a result of what?

A series of crisis, lack of community and family support, poor decision making, external economic issue and missed opportunities with the impact of these losses having physical and psychological effects.