According to Odell and Commander , research into the antecedents of homelessness among people with severe mental illness has been limited. Most work has been carried out in the USA, and has failed to establish the chronological relationship between hypothesized risk factors and the onset of homelessness . The only risk factors identified as predating homeless-ness are childhood adversity, problem behaviours and substance-related disorders [35, 36], although the pathways by which these might contribute to homelessness remain unclear. In a case control study carried out in the UK , individuals who had been homeless were compared with others who had never been homeless. Cases and controls were sampled from those in contact with psychiatric services, a feature which was acknowledged by the authors as a potential source of bias. Cases were identified through a dedicated mental health service for homeless people , and controls were sampled from an inner-city community mental health service.
For many homeless respondents, problems were evident in childhood when family living situations broke down and they were placed in care. However, the absence of childhood factors in the multivariate model indicates for the authors that their impact on homelessness is likely to be mediated through ensuing social difficulties and, in particular, a lack of ongoing support into adulthood. Unlike achievements in education and employment (which were uniform across cases and controls), social support appeared to be a key factor in preventing homelessness. Increased isolation from childhood carers was apparent among subjects prior to the onset of homelessness. In contrast, many of the control group continued to live with family members or, having been born locally, had family nearby. Families may provide considerable support to vulnerable people in terms of basic assistance and companionship, as well as help at times of crisis. People without such support may be severely disadvantaged and have additional needs that must be anticipated if homelessness is to be averted.
A substantial number of homeless people, as opposed to only a few controls, had behavioural problems in childhood. The authors stated that, although a complex relationship between childhood behaviour and a predisposition to homeless is conceivable (for example, through compromising childhood placements and subsequent support), there may also be a direct link, with antisocial behaviour persisting into adulthood . Since many subjects reported extensive criminal records as well as experiences of both alcohol- and drug-related problems, it was only the latter that persisted in their multivariate model. Substance abuse acts in a variety of ways to increase the risk of becoming homeless, diverting money from housing and other daily living expenses, as well as leading to a loss of social support and contributing to criminal behaviour . The latter in turn may jeopardize housing by causing conflict with family and landlords, or by leading to imprisonment. The authors add that coexistence of mental health and substance-related problems may paradoxically result in reduced support from psychiatric services, as many mental health and substance abuse services operate separately without adequate coordination between them . In addition, the range of available housing options may be severely restricted by entrance criteria excluding those with substance-related problems (and criminal records), particularly from shared or sheltered housing .
In this study, in one-third of homeless respondents, the onset of psychosis followed the first episode of homelessness, indicating that mental illness was not a contributory factor. Furthermore, contrary to a popular perception that homelessness may be linked to poor treatment compliance, most of those whose illness began prior to becoming homeless had established and maintained contact with psychiatric services. Where there was evidence of comorbidity, substance abuse and behavioural disturbance appeared to be antecedent to both homelessness and the onset of psychosis in most cases. For the authors, these findings suggest a limit to the extent to which psychiatric services may be able to prevent homelessness among people with severe mental illness.
Substance abuse and the absence of family support are key factors contributing to homelessness among people with psychotic disorders. This suggests that further services for people with comorbid psychotic and substance abuse disorders, including residential provision, are required. Additional interventions should also target patients with adverse childhood experiences and poor ongoing support. While not discounting the mental health care needs of homeless people with psychotic disorders, this aspect has arguably been overemphasized, while the similarities between homeless people who are mentally ill and their non-mentally-ill counterparts deserve greater attention . An integrated approach in which mental health services complement and support other agencies tackling homelessness is necessary.
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