Homeless Mentally Ill Individuals Share How They See Their Future in essay

Accessing Psychiatric Medical-Physical Health Care


Georgann E. Owens

MSW, Our Lady of the Lake University, 1995

BS, Our Lady of the Lake University, 1993

Dissertation Proposal Submitted in Partial Fulfillment of theRequirements for the Degree of

Doctor of Philosophy


Walden University

May 2014


Homelessness andmental illness are not new problems in the United States. The methodsemployed to mitigate these twin issues, both separately and together,have varied greatly over time. Due to the deinstitutionalizationmovement and two resulting waves of patient discharges, first in the1950s and 1960s, then in the 1970s and 1980s, many seriously mentallyill individuals left asylum treatment centers and had nowhere to go.Many among this population would later experience the shelter system,prison system, hospital system, and mental health care systems butwould often fall through the cracks because of fragmentation of care. Over the last 15 years attempts have been made to build bridgesbetween shelter care, mental health care, and even physical healthcare alternatives, focusing on care in the community. Though manyattempts have been made to improve and modify community resources forthe homeless mentally ill, what has been largely missing from thisapproach are the opinions of the homeless mentally ill on servicesthey are consuming, and how they consume them. Using consumeropinions is one of the chief avenues to improve access and service. Iwill use qualitative research grounded theory methodology

To investigate theattitudes and opinions of homeless mentally ill people regarding thesystems of which they are consumers, and how they perceive andnavigate those systems. Providing a voice to men and women who arehomeless and chronically mentally ill could improve human and socialconditions for others in similar circumstances.

Accessing Psychiatric and Medical Care

Georgann E. Owens

MSW, Our Lady of the Lake University, 1995

BSW, Our Lady of the Lake University, 1993

Dissertation Proposal Submitted in Partial Fulfillment of theRequirements for the Degree of

Doctor of Philosophy


Walden University

May 2014


This paper isdedicated to my family.


First, I want to express my gratitude to my supervisor, Dr. VirginiaSalzer, for the continued guidance and support from the time Istarted the research. His contribution has seen my excellence thisfar. Also, I want to thank my colleagues in college. They have beenan inspiration. Finally, I’d take this opportunity to thank myfamily. Their love, moral and financial support cannot be ignored.

Tableof Contents

Abstract ii

Dedication iv

Acknowledgment v

Chapter 1 8

1.1. Introduction 8

1.2. Background 8

1.3. Problem Statement 11

1.4. Purpose of the Study 12

1.5. Research Questions 13

1.6. Theoretical Foundation 14

1.6. Conceptual Framework 15

1.7. The Nature of the Study 16

1.8. Definitions 17

1.8.1. Homelessness 17

1.8.2. Consumers/Clients 17

1.8.3. Health Solutions 17

1.8.4. Housing Solutions 18

1.8. Assumptions 18

1.9. Scope and Delimitations 18

1.10. Limitations 18

1.11. Significance 19

1.12. Summary 19

Chapter 2: Literature Review 21

2.1. Introduction to Literature Review 21

2.2. Literature Search 21

2.2.1. What is Homelessness? 22

2.2.2. Background of the Problem: General Homelessness 23

2.2.3. Homelessness and Mental Illness 25

2.2.4. Changing notion of mental illness 26

2.2.5. Relevancy, Actuality and Significance of the Problem 29

2.2.6. Who are the Homeless? 30

2.2.7. How Does Homelessness Occur? 34

2.2.8. Stigma of Homelessness 36

2.2.8. Mental Illness in the Homeless Population 37

2.3. Service models and theory 44

2.4. Interventions: Service Delivery and Integration 45

2.5. Service Results 48

2.6. Opinions of the Mentally Ill Homeless 54

Chapter 3: Research Method 61

3.1. Introduction to Research Method 61

3.2. Qualitative Research Design and Rationale 61

3.3. Qualitative Methodology 62

3.4. Role of the Researcher 62

3.5. Participant Selection Logic 63

3.6. Instrumentation 63

3.7. Procedures for Recruitment and Participation 63

3.8. Data Collection 64

3.9. Interview Protocol 64

3.9.1. Obtaining Consent 64

3.9.2. Interviewing the Participants 64

3.10. Data Analysis 65

3.10.1. Coding Process 65

3.11. Evidence of Trustworthiness 65

3.12. Ethical Issues 66

3.13. Institutional Review Board Approval 66

3.13.1. Informed Consent 66

3.13.2. Privacy and Confidentiality 66

3.14. Summary 66

References 68

Appendix A: Informed Consent lxxv

Appendix B: Questionnaire lxxviii

Chapter 1

    1. Introduction

Theissue of homelessness, mental illness, and access to medicaltreatment is paramount in making positive social change. Identifyingobstacles preventing the subgroup of homeless mentally ill often themost difficult to reach could increase understanding and bridge thegap in research. Qualitative research coupled with grounded theorymethodology will be used to investigate how participants view theissues of access to shelter, as well as access to psychiatric andmedical care. A basic history of homelessness and mental illness willbe discussed, followed by the identification of barriers to accessingcommunity resources. By exploring the issues surrounding access toshelter and care, we may educate those who provide these services andultimately ameliorate the suffering of those homeless people withserious mental illnesses (SMI) who are struggling to meet their mostbasic needs and thus bring about positive social change.

    1. Background

Homelessness and mental illness are issues that have always existedin the United(Rossi, 1990 Lamberti, J. S., Weisman, R. L.,Schwarzkopf, S. B., Price, N, Ashton, R. M., &amp Trompeter, J.(2001). Treatment employed to address mental illness and reintegratehomeless persons have varied greatly throughout American history(Johnson, 1990 Grob, 1983 Luchins, 2001 Dixon &amp Goldman,2004). By the 1950s, mistreatment of patients, poor results, budgetcuts, overcrowding, and advances in drug therapy all contributed anew movement to shrink the existing system and move patients out ofasylums and into the community (Johnson, 1990). The shrinkage of theresidential system perpetuated by the factors mentioned came to betermed deinstitutionalization. Two major waves ofdeinstitutionalization took place in the United States, the firstduring the 1950s and 1960s and the second during the 1970s and 1980s(Johnson, 1990). The first wave was due to advances in psychotropicdrugs (Gronfein, 1985) and the second was due to increased socialplanning measures such as Supplemental Security Income or SSI,instituted in 1974 (Rosenheck, Firsman &amp Kasparow, 1999), andthrough integration of mental health care services in hospitals(Boardman, 2006) .

At the same time society first started to reject large-populationasylums in the 1960s, Community Mental Health Centers (CMHCs) werebeing outfitted to treat a large volume of new patients that hadpreviously been hospitalized. CMHCs were given federal funding andformed a prevailing ideology that mixed early emphasis on preventionand treatment of acute cases with the ability to deliver the servicesof a state hospital. The new model “required five services:inpatient, outpatient, partial hospitalization, emergency, andconsultation-education services” (Dixon &amp Goldman, 2004). CMHCsdid not focus on this released population, and served mostly newpatients, partially because of laws that either did not foster oractively prevented coordination between state hospitals and centers.

The effects of deinstitutionalization have been dramatic,fundamentally altering how mental care systems and homeless caresystems have functioned in America. According to registries(Markowitz, 2006), in 1960 about 563,000 beds were availablenationally with 535,400 resident patients. By 1990 there were 98,800beds available, with 92,000 resident patients (Markowitz, 2006). Deinstitutionalization and care in the community became linked in thepublic mind with a growing population of mentally ill homelesspeople, community support programs targeting the chronically illprovided them with work, housing and treatment, yet assisting anoverwhelming number of chronically mentally ill people remainedelusive. Evidence Based Practices (EBP) helped address that problem.

The implementation of EBPs resulted ultimately in the development ofAssertive Community Treatment (ACT). ACT was “best conceptualizedas a … system… to the latest, most effective and efficienttreatments, rehabilitation and support services conveniently as anintegrated package [in the community]” (Santos &amp Stein, 1998).ACT resulted from an earlier program – the Training in CommunityLiving Model – that taught patients the behaviors and strategiesthey would need in order to cope with living in society. This programmet with verifiable success. ACT programs in some areas have declinedin results since the 1990s this is perhaps due to shifts in programelements away from the classic ACT program. It also remains to beseen how much ACT services a patient may need to make or maintaingains, and whether a patient can be removed from ACT withoutregression.

We currently live in a post-deinstitutionalization world whereresidential/asylum treatment of mentally ill people is no longer thenorm. Though deinstitutionalization solved some of the problems ofthe institutional system of care, such as overcrowding, poor resultsand abuses led the public and many experts to grow unsatisfied withthat paradigm of care, and new problems came to the surface as oldones disappeared. As asylums released patients, they often becamelost in the larger society and failed to navigate correctly thetricky and often fragmented network of mental health and publicwelfare alternatives (Manderscheid, R., Ryff, C., Freeman, E.,McKnight-Ely, L., Dhingra, S. &amp Strine, T. 2010). From the 1950sto the mid-1980s, despite the development of programs, manycommunities lacked the resources, organization and infrastructure todeal with resident ex-patients (Manderscheid et al., 2010). Thestreets and prisons subsequently picked up the slack (Markowitz,2006) increasing levels of homeless mentally ill became more apparentby the early 1980s (Rosenheck, R., Frisman, L. &amp Kasprow. (1999)the potent combination of fragmentation of services anddeinstitutionalization helped to exacerbate the problem of thehomeless mentally ill, which we are still dealing with now.Concurrently, studies continued to show the prevalence of psychosis,depression, and personality disorders are considerably higher in thehomeless population than in the general population (Fazel, Khosla,Doll, &amp Geddes, 2008).

    1. Problem Statement

It is difficult for people who are homeless and mentally ill tonavigate the complex, bureaucratic social structures established tohelp them, structures they often distrust (Daiski, 2007 Rosenheck etal., 1999 Smith &amp Sederer, 2009). Little qualitativeinvestigation has been conducted that asks the consumers how theyactually access services and what difficulties they experiencein obtaining services. Furthermore, health, shelter, and mentalhealth professionals may have difficulties in coordinating care forpatients or consumers in the community (McCrea &amp Spravka, 2008).Different professionals see the homeless mentally ill from diverseperspectives–from the physical health, mental health and from theshelter (housing) perspective. However, none of these perspectivesalone fully describes the needs, hopes, and goals of the consumers.The focus of this study is to see how the consumers themselvesreconcile, or fail to reconcile these different services andperspectives and utilize them in a manner that makes sense for them.

    1. Purpose of the Study

The intent of this paper is to present the opinions and experiencesof individuals who are mentally ill and homeless concerning thenavigation of existing medical, mental health care, and housingprograms. Diverse approaches to service provision have beenimplemented by homeless shelters, mental health institutions,hospitals, and prisons. These programs have not been problem-free,and construction of holistic care remains difficult to achieve(McQuistion, Finnerty, Hirschowitz &amp Susser, 2003). One potentialpath towards improvement that has received less attention in theliterature is the examination of the opinions of the clients, takenon their own terms and in their own words.

Several studies have examined the opinions of consumers. One notablestudy was “I´m Glad You Asked”: Homeless Clients with SevereMental Illness Evaluate their Residential Care by McCrea andSpravka (2008). Another notable study was Perspectives of HomelessPeople on their Health and Health Needs Priorities (Daiski,2007). However, studies like these are relatively rare. The opinionselicited by the studies focused on the patient´s perceptions ofquality, effectiveness and/or their goals. Through theuse of client feedback, the present study will examine the concept ofaccess, with the intent of ascertaining how these consumersnavigate the existing housing, physical health, and mental healthsystems, with the intent of improving their ease of access toservices. A second aim will be to achieve a measure of positivesocial change simply by letting the consumers speak for themselves.

Paucity of previous research on a given topic is small justificationfor more research the promise of understanding the attitudes andopinions of consumers lies in the application of feedback mechanismsand in creating positive social change. The opinions of the consumersmatter because they can and will take an active role in the servicesaround them and need to be acknowledged in order to reverse theprocess of dehumanization (Ball, A., 2010) (McCrea &amp Spravka,2008 Daiski, 2007). Moreover, the discussion of points of view andidentification of potential problems through the eyes of consumers isa valuable tool for the improvement of service, access, utility andefficaciousness (Mojitabai, 2005 McCrea &amp Spravka, 2008) the aimof the present study is to provide insights that could be used toimprove outcomes for the subjects in this study and for the largercommunity. From a local perspective, understanding their points ofview will hopefully give insight into the specific user experienceof integrated housing, health, and psychological care solutions thatexist in the area (San Antonio, Texas), and can potentially tell 1)what areas need improvement, 2) what the real goals of the patientsare (as distinct from what care professionals think theirgoals are, and 3) what organizational strategies may be used in thefuture to improve results, while at the same time improving accessand decreasing bureaucratic complexity.

    1. Research Questions

These questions represent the key matters that the study aims toaddress:

1) From the perspective of the consumer, what are their experiencesaccessing a) health care solutions, b) psychiatric care, and c)housing solutions?

2) If the consumer does not use one or more of these services, whatare the barriers to their utilization and what do they think isnecessary to overcome these barriers?

1.6. Theoretical Foundation

This study will use Grounded Theory, Health Belief Model(HBM), Theory of Reasoned Action (TRA), Social Cognitive Theory andSocial Support Theory in order to evaluate experiences that couldprovide foundation to investigate factors that could help explain whymentally ill individuals suffer from the lack of access to mentalhealth physical help and safe housing in their own words.

Grounded Theory is a systematic concept applied in social sciences.The main idea of the theory is to read and re-read the textualdatabase in order to label and discover variables such as propertiesor concepts, and determine how they relate to each other. Such anability to perceive variables and determine their relationship isreferred to as theoretical sensitivity. Grounded theory is the ideathat data can first be collected, and then hypotheses can be formedfrom analysis of the data. This theory proposes a research paradigmopposite to that of the standard scientific model, which states thata theory must first be proposed and then tested against empiricalevidence (Charmaz, 2003).

Health Belief Model (HBM) is a psychological model used to predictand explain health behaviors. The method is ideal for determiningshort term and long term health behaviours. According to this model,the beliefs of people about health, self-efficacy, barriers to actionand benefits of action reflect their level of engagement towardshealth-promoting behaviours. For this to occur, there must be a cueto action or stimulus that triggers health-promoting behavior. HBMtheory framework will be used to increase understanding of the healthbehaviors and obstacles identified by persons living with mentalillness in accessing psychiatric care medical/physical care and safehousing (Green &amp Murphy, 2014).

Theory of Reasoned Action (TRA) theory focusses on the intention of aperson to behave in a certain manner. This theory postulates that thebehavior of a person is a reflection of behavioral intention that ismajorly as a result of the subjective norms and attitudes of aperson. The TRA theory is ideal for the current research as itsuggests the influence of external stimuli to the beliefs andbehavior of a person (Montano &amp Kasprzyk,2008).

The Social Cognitive Theory (SCT) holds that the knowledge of aperson can be directly linked to the observation of other people insocial contexts experiences and interactions. This model attempts tounderstand behavior and learning, as well as how a person’sbehavior is shaped by the environment (Luszczynska&amp Schwarzer, 2005).

Social Support theory shows that the actuality and perception that aperson is cared for can receive support from other social networks.This theory will be used tomeasure essential properties and their relationship to identifyingperceived barriers by the subjects interviewed in this study(Lakey &amp Cohen, 2000).

The Grounded Theory, Health Belief Model (HBM), Theory of ReasonedAction (TRA), Social Cognitive Theory (SCT) and Social Support Theorywill be ideal in the current research as they mostly relates topeople, attitude and beliefs. These provide a perfect framework forevaluating how the accessibility of psychiatric, medical care andsafe housing of homeless individuals who are mentally ill.

    1. Conceptual Framework

For the present study, data will be collected through asemi-structured interview guide with clients in one-on-oneinterviews. Once the data is collected, it will be analyzed andsorted into relevant data categories. These categories will depend onthe specifics of the data and on the relationship between theclient`s answers and the research questions. From categorized data,it will be possible to form hypotheses for improvement of care andaccess to care for this segment of clients. Grounded theorymethodology was developed by Glaser and Strauss in 1967 as apractical method for doing research that focused on participants intheir natural settings. Therefore, grounded theory is mostappropriate for this study because it allows the development ofsocial theories that use experiences, opinions and non-objectiveperceptions of the individual, which as a whole constituteunderstanding of qualitative data, not quantitative data. HealthBenefit Model will allow for the development of a psychological modelin an attempt to predict and hopefully explain how homeless mentallychallenged individuals identify health behaviors (Glan, 2002). SocialSupport theory offers emotional support that provides feedbackinstrumental to appraising supports perceived by homeless mentallychallenged individuals.

    1. The Nature of the Study

For the purpose of this study, approximately 10 homeless individualswho are identified as having an Axis I mental diagnosis Diagnosticand Statistical Manual of Mental Disorder Fourth Edition (DSM-IV-TR)by staff at local shelters will be interviewed. A semi-structuredindividual interview will be utilized to collect data and willconsist of standardized questions assessing theaccess of the homeless individual to 1)shelter, 2) mental health, and 3) medical services. Responses tothese questions will be utilized to direct follow-up questions toeach of the standardized questions. The goal of this line ofquestioning is to elicit from the participant his or her viewsregarding access to the above cited services. In the eventthat access is found to be difficult, obstructed, or lacking,questions will be asked as to their perceived reasons for this, andfinally an open-ended question will be asked as to what they would doto improve access to their own needs, as informed by theirexperiences.

    1. Definitions
      1. Homelessness

The definition of homelessness often depends on the context in whichit is applied. Herrman (2008) and Fazel,S., Khosla, V., Doll, H. &amp Geddes, J. (2008) mentioned the needfor a clear definition of homelessness in any scholarly workregarding the issue. Fazel et al. (2008) in The Prevalence ofMental Disorders among the Homeless in Western Countries: SystematicReview and Meta-Regression Analysis, found only 29 studies thatcould be included for his analysis. This was due to a lack of clarityover the definition of &quothomeless&quot enumerated by Herrman(2008), in that it “features… [a] lack of appropriate housing andthe social marginalization of the individual… also important is therecognition that people may be transiently, episodically orchronically homeless and that entry to or exit from the homelessstate is usually part of a process rather than a single jump”(Herrman, 2008).

      1. Consumers/Clients

Homeless people who want to use health, psychological, and housingsolutions provided by the institutions, either public or private.

      1. Health Solutions

Identifying the needfor mentally ill individuals to receive wellness exams and treatmentfor identified medical illnesses, engaging each individual withdignity and respect. Making positive social change is pivotal inreducing negative attitudes that perpetuate prejudice anddiscrimination against treating the homeless mentally ill.

      1. Housing Solutions

Providing safehousing for the homeless mentally ill population is complex anddeserves review to increase quality of life. Providing psychiatriccare could make the transition to housing a reality for participants.

    1. Assumptions

This study presumesthat participants dealing with homelessness have crossed all barriersthat are involved with their care. In addition, there is anassumption that all participants will be able to reflect on theirexperiences and will be able to communicate about further appropriatecare. The assumptions were critical to the study, with detailedinformation to locate the flaws of the treatments not defined bygeneral practice.

    1. Scope and Delimitations

This study explores how 10 homeless individuals who haveAxis I diagnoses and are experts on their life journeys will be ableto articulate how barriers interfere with access to psychiatric care,medical care and stable housing which could have a positive impactfor participants. Through these means the voices of the 10participants could establish clearer conversations on making positivesocial change. Grounded theory is appropriate for understanding theprocess of interviewing individuals in their environment.

    1. Limitations

Potential problemsinclude participants who may choose not to complete the interview orthose who may be eliminated from the study for various reasons. Ifparticipants present with illegal drug or alcohol additions thiscould potentially interfere with the purpose of the study. Ignoringpossible biases I fail to identify could interfere with buildingtrust with participants. The results of this study can be generalizedto persons who work with this special population. However, thisstudy is within the Central Texas communities to include the culturaland local community in San Antonio, Texas and may not be applicableto other states. In addition, cultural and socioeconomic disparitiescould provide a rich insight into experiencesof mentally ill homeless population in their own words. Takingstock of my own biases could lead to increased awareness of takingparticipants where they are and not where I personally think theyshould be.

    1. Significance

In making positive social change the lack of knowledge about client’sperceptions of access to psychiatric, medical and safe housing needsto be addressed in literature. The question is significant because itaffects the ability of professionals to improve the existing modes ofservice (physical health, psychological health and shelter) whiletaking into account the views of the clients.

    1. Summary

Homelessness and mental illness have been separate but extant socialissues for a long period of time in the United States. Thedeinstitutionalization movement, motivated by public awakening tolack of progress in asylums, budgetary concerns, and advances inpsychotropic medications resulted in the discharge of large numbersof mentally ill patients into the community. The discharge ofpatients, coupled with fragmented in-community care alternatives, fewlow wage jobs and a decline in affordable housing, all contributed increating the issue of the homelessmentally ill (NCH, 2009c). Taking the opinions of the homelessmentally ill into account may be one way of improving servicequality, effectiveness and access for this population.This qualitative study aims to identify areas for improvementby surveying the attitudes and opinions of consumers on theirperceived access and user experience of available services.

Chapter 2: Literature Review2.1. Introduction to Literature Review

Introduction treatment and rehabilitation methods for the homelessmentally ill have varied greatly over time. The institutional modelwas the primary treatment modality until at least the 1950s. Duringand following deinstitutionalization, care in the communityincreasingly became the chief method of delivery. Care in thecommunity was not always well-coordinated, which resulted in manyconsumers being lost to follow-up. These consumers swelled the ranksof the homeless mentally ill, people who found it difficult to obtainstable housing situations partially because of their mental illness,but partially due to other factors as well, such as lack ofaffordable housing alternatives (Forchuk, Russell, Kingston-MacClure,Turner &amp Dill, 2006). Lack of coordination is still a problemneeding resolution (Forchuk et al., 2006). One established method ofidentifying difficulties in access is to ask the consumers themselvesabout their access experience (Herrman, 2008). Understanding theproblem of the homeless mentally ill from the perspective of theconsumers themselves is key to solving problems of access, qualityand integration of services.

To better understand the relationship between the homeless mentallyill population and the services that they consume, it is necessary tofirst review the available research on this group, their opinions andavailable community care alternatives.

2.2. Literature Search

An electronic literature search was conducted through WaldenUniversity and access to the EBSCO article database, Yahoo andGoogle. Search terms included Homeless, Mentally ill, Questionnaire,Attitudes and Beliefs, Community Care, Deinstitutionalization andHomelessness trends. The goal was to identify as much of the researchliterature as possible that was related to the topic at hand, andfrom that maximum pool of research, select articles that were trulygermane. Much of the research that was found was not germane to thecurrent question. Other published material was germane but was notcurrent. A review of this literature reflects thinking on the topicof the homeless mentally ill over time, illustrates that there aregaps in the literature around this topic, and gives background to theexperiences of the homeless mentally ill and a view into their worldthat is valuable to approaching the topic.

2.2.1. What is Homelessness?

United States law essentially defines a homeless person asa roofless person (NCH 2009b) who does not have a fixed domicile oris about to lose his domicile within a week. This person may not beincarcerated but may be a resident inpublic or private shelters. Homelessness as (rooflessthis a word) is one basic definition that has met the color oflaw however, there are other definitions that complicate and add tothis one (NCH 2009b).

In the document, Who are the Homeless? (NCH, 2009a),The National Coalition for the Homeless reviews some ofthe known facts regarding homelessness and points out some of theproblems with the legal definition of it. For example, there is anoveremphasis on clearly visible roofless persons. In rural areas,homelessness is less visible because it is not composed entirely ofpersons living outside or in a shelter (as there usually no sheltersin rural areas) (NCH, 2009a). Rather, those in rural areas stay withrelatives or in substandard or crowded housing alternatives, and thusare undercounted (NCH, 2009a). In general, the NCH (2009b) points outhomelessness is a temporary state for many people, and consists of apopulation undercounted by conducting a census only of those usingshelter and soup kitchen services.

In order to make a more inclusive and correct definition of thehomeless, it may be said that homeless people in general are thosewho do not have stable housing solutions in their life. The homelessare people who have lost their residents and are roofless, arefloating from temporary solution to temporary solution, or are livingin unacceptable conditions that are overcrowded or substandard (dueto their inability to secure acceptable, stable housing). This willbe the working definition of homelessness in this study: homelesspeople are roofless people or people who are living in highlyprecarious circumstances (which include substandard and overcrowdedhousing).

2.2.2. Background of the Problem: General Homelessness

The National Law Center on Homelessness and Poverty estimated that 3million Americans find themselves homeless at one point or anotherduring any given year, with 1.3 million of those individuals beingchildren (National Law Center on Homelessness and Poverty [NLCHP],2012). Another estimate reported by USA Today estimates that1.6 million persons used transitional or emergency shelters&shyduring a given year (Kotch, 2009). The National Coalition to EndHomelessness estimated that on a single day 744, 313 people usedthese services (National Coalition to End Homelessness [NCH], 2009a).

These numbers evidence the difficulty of accurately calculating howmany homeless people exist in the United States at a given time,which in part may be related to the definition of homelessness thatis utilized. Some people experience acute homelessness, andmay temporarily live in their cars, drift from one friend´s house toanother, and may have short spells of being roofless (NCH, 2009b).This population is less likely to use shelter and food kitchenresources than other populations and therefore will not be fullycaptured by one-day snapshots like the National Alliance to EndHomelessness’ one-day service headcount (NCH, 2009a). Thetransitory homeless or those in very precarious living conditions maybe turned away from shelter as well (NCH, 2009a).

Other homeless people are chronically homeless, rooflesspersons who sleep outside or on streets (NCH, 2009a). The chronicallyhomeless are more likely to use shelter and food kitchen resourcesand experience high levels of severe mental illness and substanceabuse (NCH, 2009a).

However, much like the people who find themselves acutely homelessduring any given time in the year, there are also factors that makeit difficult to determine the full number of chronic homeless peopleby any of the typically utilized headcount metric strategies. Inaddition, shelters have a very limited capacity, with many sheltershaving to turn away as many as 75% ofapplicants in any given day. In addition, in shelters, there isusually a fixed maximum length of stay, and once this stay hasreached, the consumer must leave the premises (NCH, 2009a).Therefore, a consumer who was at a shelter and counted at one pointin time may find himself or herself outon the street at another point in time, and as a result be uncountedby a census of the homeless, despite the fact that the consumer washomeless before, after and during residence in the shelter. Nickaschand Marnocha (2009) reported in their research that participants’identified having an external locus of control.

Research literature indicates that since 2007, levels of homelessnessin general, and particularly levels of homeless children have beenrising one way of measuring this has been through bed capacity inshelters (NCH, 2009a Kotch, 2009). Available data regarding thehomeless indicates they represent up to or more than 1% of the UnitedStates population and that they are increasing.

2.2.3. Homelessness and Mental Illness

The true prevalence of mental illness among the homelessis a figure that is just as hard to verify as the figure of homelessin the general population. Calculating the number of mentally illhomeless is subject first to the general metric difficulties alreadymentioned, such as the establishment of a sufficiently inclusivedefinition of homelessness, then the establishment of a means oftabulation that is appropriate for that definition. Calculation ofthe mentally ill homeless is then subject to particular difficultiesof its own. As a result, available estimates of the number ofhomeless mentally ill from various sourcesdiffer significantly. In Prevalence of Mental Disordersamong the Homeless in Western Countries: Systematic Review andMeta-Regression Analysis, Fazel, S., Khosla, V., Doll, H. &ampGeddes, J. (2008) reviewed data from different surveys of thehomeless in order to report the average prevalence of mental illness.

The reported prevalence of psychosis in these studieswas 12.7% however, estimates “ranged from 2.8% to 43.0% withsubstantial heterogeneity among the estimates” (Fazel et al.,2008). Major depression was on average found to be prevalent in 11.4%of the population, with estimates ranging from 0% to 40.9%. Stergiopoulos, V. Dewa, C., Rouleau, K., Yoder, S., &amp Chau, N.(2008) in Collaborative Mental Health Care for the Homeless,reviewed clients referred to an integrated care network (mental andphysical health) and found that 55% of 73 referred patients “had aprevious psychiatric hospitalization” (Stergiopoulos, Dewa,Rouleau, Yoder, &amp Chau, 2008). The authors further estimated thatin the homeless population in general, “between one-fourth andone-third of the homeless has a serious mental illness, such asschizophrenia, major depressive disorder, or bipolar effectivedisorder” (Stergiopoulos et al., 2008). Vamvakis and Rowe (2001)estimated that psychosis and affective disorder is present in20-25% of all homeless clients. Point of prevalence countsalso tend to count more mentally ill individuals as homeless (NCH,2009a Phelan &amp Link, 1999), perhaps indicating that mentally illhomeless people tend to be more chronically homeless.

The reasons for the positive relationship between mental illness andhomelessness are not universally agreed upon, and not all scholarsbelieve that deinstitutionalization is at fault (Herrman, 2008Mojitabai, 2005 Dixon &amp Goldman, 2004 NCH, 2009a). For example,some homeless patients themselves perceive their loss of a home asthe result of common social or financial problems, not as the resultof their mental illness (Mojitabai, 2005). Dixon and Goldman (2004)state that releasing patients from inpatient care itself was not thecause of homelessness, but that the machinery to help them adjust tothe community was not adequately prepared (closing the institutionitself was not the cause).

2.2.4. Changing notion of mental illness

Goldman and Grob (2006) examined how the changing definition ofmental illness has been applied through policy in differentcircumstances across history. The authors noted that today in theUnited States, 5.4% of the general population suffers from seriousmental illness, and 2.4% of the overall population has “severe andpersistent” mental illness (Goldman &amp Grob, 2006). Applicationof the label “mental illness” has varied greatly throughouthistory, as specific policy initiatives have often had specificdefinitions of mental illness attached to them. The conflict inherentin these different definitions has always involved inclusiveness andresource allocation, with a trend to either target broad categories(all types of mental illness, including prevention measures) or use anarrow target for resources (focusing on the severely mentally ill)(Goldman &amp Grob, 2006). Over time, the trend has been towardfocusing resources on the narrow definition, targeting severely andpersistently mentally ill people. The roots of this shift originatefrom a directive issued by President Carter in 1978 to create anational plan for the care of the severe and persistent mentally illpopulation (Goldman &amp Grob, 2006).

Carter’s plan modified existing general care structures, as wellas SSI, SSDI, Medicaid and Medicare in order to form a new network ofsupport for the severely and persistently mentally ill people in thecommunity. Medicaid and Medicare bore the brunt of the costs for planmodifications, while SSI and SSDI provided income to consumers. Theproposed changes of Carter’s plan were largely implemented in the1980s, despite the change of government under Reagan. Depending onthe nature of the disease, mental services were sometimesmainstreamed with physical health programs and other times separateduntil 2005 (Goldman &amp Grob, 2006). Aggravating this problem ofpigeonholing patients by their diagnosis were laws passed in 1998,making federal payment for individual episodes of care dependent on“medical necessity,” thereby complicating the picture even more.

The addition of the “medical necessity” component was due toconcern that minor conditions such as “jet lag” would wastepublic funds (Goldman &amp Grob, 2006). The article concludes thatmanaged care may be the best alternative to diagnosis-based payment,which is “arbitrary and restrictive” (Goldman &amp Grob, 2006).Currently, mental illness has been defined by the Surgeon General asdiagnosable “conditions that are characterized by alterations inthinking, mood or behavior… associated with distress and/orimpaired functioning” (Mental Health Report of the US SurgeonGeneral, 1999). This definition, along with a focus on those withsevere and persistent mental illness, characterizes the rubric usedby the mental health organizations today in the United States.

Manderscheid, R., Ryff, C., Freeman, E., McKnight-Ely, L., Dhingra,S. &amp Strine, (2010) also review the evolving definitions ofmental illness and wellness and the role which those definitions playin public health policy. During much of the 20th century,mental illness was consistent with the existence of a mental disorderin the patient. Mental wellness was simply the absence of a disorder.Mental wellness and mental illness existed as two points along asingle continuum, with the emphasis of the medical establishmentbeing placed on the identification and treatment of illness

During the 1960s and 1970s, patients were defined by their particulardiagnoses, with little room for “broad classes of mental disorders”(Manderscheid et al., 2010). As the institutional model withered,this began to change. In the 1980s and 1990s, as patients weredischarged in the final large wave of deinstitutionalization, thehomeless mentally ill population surged and community resources wereshown to be insufficient to support their needs. The NationalInstitute of Mental Health (NIMH) determined that their definitionswere also insufficient and added the concepts of duration anddisability to that of diagnosis. Disability is defined as theinability of the patient to carry out activities (Manderscheid etal., 2010).

Duration defines the scope of a mental illness in a patient, with atime not less than one year being required for a person to qualifyfor services (Manderscheid et al., 2010). The creation of thesecategories went into the creation of what we term today as the“severely and persistently mentally ill” population (Manderscheidet al., 2010). From this point forward, the paradigm of mentaltreatment changed. Wellness and illness came to be considered asexisting in two different continua – wellness not being simply theabsence of disease but a positive feeling about life, happiness,meaning and positive but realistic feelings of personal capacity.

A lack of these feelings has been shown to be detrimental to thephysical health of the patient for example, the life expectancy ofthose suffering from mental illness and under public treatment is 25years lower than the healthy population (Manderscheid et al., 2010).The authors note that the focus of treatment has become promotion ofmental well-being while at the same time pursuing reintegration andparticipation in society. In conclusion, Manderscheid et al., (2010)recommend further research and documentation of the supposed“mind-body” link, while at the same time pursuing greaterintegration of psychological and physical healthcare services.

2.2.5. Relevancy, Actuality and Significance of the Problem

Regardless of the cause of homelessness for the mentally ill client,he or she requires a continuum of services that are different fromthe non-mentally ill client. These services may include outpatientpsychiatric care, medication, substance abuse treatment, and medicaltreatment.

A high percentage of mentally ill homeless clients experienceco-occurring substance abuse problems and subsequently may have moreserious and frequent health ailments, which often result ina higher mortality rate (Christensen, R., Hodgkin, C., Graces,L., Estlund, K., Miller, D., &amp Touchton, R. 2005 Boardman, 2006Fazel, et al., 2008 Vamvakas &amp Rowe, 2001 North, Thompson,Pollio, Ricci &amp Smith, 1997 Rosenheck et al., 1999). Furthermore, there is some evidence to support the conclusion thatthe homeless mentally ill use shelterresources more heavily than those that are not mentally ill (NCH,2009a). Finding and putting into practice successful strategies forthe creation of a continuum of care for mentally ill homeless clientscould potentially have a positive impacton a significant percentage of the homeless population. Understandinghow consumers perceive, utilize and interact with the health, shelterand psychological systems before them may help to create bettersystems of service.

2.2.6. Who are the Homeless?

In How Many People Experience Homelessness? The NationalCoalition for the Homeless (2009a) details the exact number ofhomeless individuals in the United States. Homeless populationsexperience a very high turnover, as the title of the fact sheetimplies. Many people enter and exit a period of homelessness in theirlives and never use shelter or soup kitchen services. There are twomajor strategies for counting the homeless in use today. Point intime counts and period prevalence counts measure the transitoryhomeless population. Point in time counts measure the populationwhich is homeless during a given time period, such as a week orsingle day, according to the amount of people in shelters, using soupkitchens or who are obviously living on the streets.

This approach is typically employed due to time and budgetaryconstraints. These counts are not entirely accurate because “[they]do not accurately identify… intermittently homeless people, andtherefore tend to overestimate the proportion of people who areso-called ‘chronically homeless’ – particularly those whosuffer from severe mental illness and/or addiction disorders andtherefore have a much harder time escaping homelessness and findingpermanent housing” (NCH, 2009a). Period prevalence counts measurehomelessness over longer periods of time. However, these numbers toocan be unreliable, as they do not measure the “hidden homeless”(NCH, 2009a) people who live in boxes, cars, caves, boxcars andanywhere out of public view. In short, it is very difficult to getreliable numbers regarding the amount of people who truly experiencehomelessness for any period of time.

The best estimates of homeless populations range widely because ofthe difficulties and limitations described:

  • As of 2012, The National Alliance to End Homelessness estimated 671,859 people as being homeless on any given night (National Alliance to End Homelessness [NAEH], 2012). The NAEH estimates are based on a bi-yearly one night point-of-prevalence.

  • The National Law Center on Homelessness in 2012 estimated that 3million people experience homelessness in the United States in a given year (NLCH, 2012).

  • USA today estimated 1.6 million are using shelters or transitional housing (Kotch, 2009).

The above three estimates were based on two nationalpoint of prevalence homeless service provider headcounts from 1996,taken in October and February (NCH, 2009a). These numbers were thenannualized based on the point of prevalence datum in question. Theannualized figure for February yields 3.5 million homelessindividuals in the United States yearly, while the figure for Octoberyields 2.3 million. The methodology involved was far from perfect andreflects some of the difficulty of obtaining timely and relevantdata.

According to a survey of 23 cities, 94% of homeless individualsliving on the street were single adults, 4% were part of families and2% were unaccompanied minors (US Conference of Mayors, 2008 ascited in NCH 2009a). Of shelter residents, 70% were singleadults, 29% were family members and 1% was unaccompanied minors. Ofsupportive housing members, 60% were single adults, 39.5% were familygroups, and .5% was unaccompanied minors.

The homeless population is estimated to be 42% African-American, 39%White, 13% Hispanic, 4% Native American and 2% Asian (NCH 2009a). This may vary by location in the country. Twenty six per cent of thehomeless are considered mentally ill, 13% physically disabled, 19%are victims of domestic abuse, 13% are veterans, and 2% are HIVpositive (NCH, 2009a). Nineteen percent of the homeless are employed(NCH, 2009a). The average stay at an emergency shelter was 51-70 daysfor all groups (US Conference of Mayors, 2008 as cited in NCH,2009a). In transitional housing, the average stay was between175-223 days. In permanent supportive housing, the average wasbetween 556-604 days. Single men had the shortest average residencytime in all of these settings.

Phelan and Link (1999) examined point of prevalence studies and theirpotential for bias in describing the homeless population. This paperanalyzed data from three studies, two being point of prevalence andthe third focusing on people who had previously been homeless.The first point of prevalence study was by Rossi (1990) and wascomposed of 722 individuals who were interviewed during two two-weekperiods in 1985 and 1986, either at a homeless shelter or in aspecific area of Chicago. The second point of prevalence survey byBurt and Cohen (1989) was composed of 1704 face-to-face interviewswith homeless in 20 cities. The study conducted in 1989 focused oncities with 100,000 or more residents with populations using soupkitchens and shelters. The third study was a telephone studyconducted by Link, Susser, Stueve, Phelan,Moore, and Struening in 1990 witha follow up in 1994. The 20 largest urban areas in the United Stateswere oversampled. For this study, 1507 adults were interviewed.Respondents were asked if they had ever been literally homeless forany period of time that is sleeping “in the rough” (Phelan &ampLink, 1999) or in a shelter without money to purchase housing.

Questions were repeated again in 1994 with a subset of therespondents from the first survey, and no great discrepancy inresponses was observed. Phelan and Link (1999) compared these threesets of data looking at several factors. They compared what the datarevealed about the respondents’ gender, ethnicity/race, level ofeducation, mental health status, prison history, length of timehomeless and substance abuse history. Phelan and Link (1999) foundthat the results from the telephone survey and the two points ofprevalence surveys were significantly divergent. Formerly homelessand currently homeless were not the same group (Phelan &amp Link,1999). Currently among the homeless population, it was found thathalf had graduated from high school (Rossi, 1990 Phelan &amp Link,1999). Former homeless figures included two thirds who had a historyof psychiatric hospitalization (Phelan &amp Lin, 1999).

Data on race and ethnicity was inconclusive and depended entirely onthe sampling area. All other areas showed a distorting effect whenthe telephone respondents and point of prevalence respondents werecompared. Phelan and Link (1999) concluded that extrapolating pointof prevalence data on homelessness to generalize about the entirepopulation creates considerable distortion of the facts and leads toa picture of the homeless person as a single male racial minorityinvolved in substance addiction and possessing mental problems. Thisportrait is more descriptive, they contend, of the persistentlyand chronically homeless individual, which is oversampled bypoint of prevalence studies.

2.2.7. How Does Homelessness Occur?

The National Coalition for the Homeless examined some of theroot causes for the appearance of homelessness in the life of theindividual. Poverty and homelessness are linked (NCH, 2009cMojitabai, 2005). An “illness, an accident or a [missed] paycheck”can make the difference between having a place to live and beinghomeless (NCH, 2009c). Relative poverty in this population hasoccurred within the context of an absolute raise in the cost ofhousing (NCH, 2009c). Rising costs of housing affect all groups thateither are in danger of becoming homeless or are currentlychronically or acutely homeless. Neither public welfare nor minimumwage employment covers the rising cost of housing (NCH, 2009c). In2009, a worker would need to earn $14.97 per hour in a 40-hour workweek to cover a one-bedroom apartment (NCH, 2009c). Furthermore, theNCH finds that employment has become ever more precarious andfinancially unrewarding for those at the lower end of the workforce,as many well-paying factory jobs no longer exist (NCH, 2009c).

Furthermore, prices on everyday items continue toincrease. For those who cannot work, the situation is similar.Support mechanisms such as shelters, SSI and Temporary Assistance toNeedy Families (TANF) are often not sufficient to secure stablehousing (NCH, 2009c). A person on SSI would not be able to affordthe national average price of a one-bedroom apartment at $715 USD permonth because the average SSI income is lower than this (NC, 2009c).State programs such as SSI and TANF have not kept up with the priceof housing, and at the same time, affordable housing has alsodwindled.

The Texas Interagency Council for the Homeless Annual Report andPathways Home Addendum (2012) reported thatin 2011 there were 7,919 homeless persons living with severemental illness, 21.5 percent of homeless extracted from the generalhomeless population. The report also indicates that the average costof renting a two- bedroom apartment in San Antonio was $750.00 permonth.

The NCH does not find that deinstitutionalization is a majorcomponent of the homeless population of today. As outlined above, theprimary contributing factors are seen asunaffordable housing, fragile and financially unrewardingworkplace relations and reduced public aid (NCH, 2009c). The NCHstates that approximately 16% of the homeless are mentally ill (NCH,2009a), though other sources contradict this (NLCHP, 2012). Thispopulation does not require institutionalization, according to the2003 US Department of Health and Human Services Report, and iscapable of living in the community with “appropriate supportivehousing options” (US Department of Health and Human Services, 2003as cited in NCH 2009c). The NCH further points out thatdeinstitutionalization occurred mostly in the 1950s and 1960s, butdramatic increases in the homeless population occurred in the 1980s. It is not deinstitutionalization that caused the current phenomenonof the mentally ill homeless rather, the NCH contends that it is alack of access to “supportive housing and/or other treatmentservices” (NCH 2009c).

2.2.8. Stigma of Homelessness

Phelan, J. C., Link, B. G., Stueve, A., Moore, R. E. (1997) used avignette experiment to determine if stigma was attached to the labelof homelessness, and its relative severity compared with that ofpoverty and mental illness. The vignette design was particularlyappropriate because it also allowed the researchers to modify therelationship between mental illness and homelessness in the minds ofpotential respondents. A single vignette was crafted, modified withsignificant phrases, and read to a subject who responded to 16questions. Stigma was defined as a social object that “discredits”and “spoils” the identity of an individual, “disqualifying[him] from full social acceptance” (Groffman, 1963 as cited inPhelan et al., 1997). The findings indicated that in general, thereis a tendency in Anglo-American culture to stigmatize the poor,ostracize them from the community, and blame them for their ownsituation, which itself is seen as a result of poor character, poorchoices and personal moral flaws (Phelan et al., 1997).

This attitude is reflected in the literature but also in legalprecedent and laws stretching back to colonial times in the UnitedStates. In modern times, the public has vacillated in its opinionstowards the poor, being more punitive in the 1990s than in the 1980s(Phelan, J. C., et al., 1997). Five hundred fifty four respondentscompleted the vignette experiment out of a larger sample of 1,507people who had been identified through a telephone search. Those ages25 to 54 were oversampled, as were married people and non-Hispanics.The telephone interview duration averaged about 40 minutes. Phelan,et al. (1997) found that the label of homelessness increased socialdistance between respondents and the story character “Jim,” andresulted in stigmatization by 1/4th to 1/3rd ofa standard deviation when compared with a poor domiciled man. Inconclusion, the author stated homeless people are likely to facesocial stigma, blame and discrimination in housing, employment andrelationships because of their social status – difficulties thatadd to the natural obstacle of being homeless and likely lead to theperpetuation of homelessness.

2.2.8. Mental Illness in the Homeless Population

There are numerousamounts of literature detailing the scope and nature of mentalillness in the homeless population. Iwill now proceed to review some of this information.

The mentally ill homeless: sources, numbers, and percentages.

Forchuk, C., Russel, G., Kingston-MacClure, S., Turner, K. &ampDill, S. (2006) examined how often psychiatric wards dischargedpatients to a shelter or to no address. Shelters are often notappropriate places for people who have been recently discharged onpsychotropic medications, as they may be exposed to substance abuse,lack of privacy, and a low staff-to-client ratio (Forchuk et al.,2006). The link between mental health problems and incidence ofhomelessness is one that is well represented in the literature.Goering, Tolomiczenko, Shelton, Boydell, and Wasylyna (2002) foundthat 64% of first-time shelter residents had substance abuseproblems, and 64% also had other mental health problems. In the samestudy, among multiple-time shelter users, 71% had substance abuseproblems and 69% had other mental problems.

Forchuk et al. (2006) analyzed hospital discharge and shelter intaketo determine the extent of discharge to no address in London,Ontario, Canada, a small city of approximately 350,000 inhabitantswhich features a centralized mental health authority. This studystated that research on the link between mental hospital dischargeand homelessness is relatively scarce, and though the homelessmentally ill are known to be overrepresented, homelessness is notusually associated with time to hospital discharge. Hospital datashowed there were 167 recorded instances of release to the shelter orto the street. Shelter data showed that there were 194 instances ofdischarge from psychiatric hospitals directly to the shelter. Forchuket al. (2006) concludes that of all discharges, 11.6% in the firstyear and 7.6% in the second year were directly to a shelter. Due topatient confidentiality, it was not possible to see the extent ofoverlap in these cases. It was also not possible to describedischarge by gender, as the system only accepted one variable at atime.

Limitations included the fact that the patient had to volunteer thatthey had no house, and the study also did not include patients wholost housing and did not know about it. In addition, most consumersreported themselves as self-referrals and were disinclined to statethey came from a psychiatric hospital (Forchuk et al., 2006). Forchuket al. (2006) conclude from that “all data sources … have thedifficulty of likely underestimating the extent of the problem”(p.304). In addition, the study indicated that shelters are notappropriate places for recovery from mental illness. They suggestedthat practitioners need to assess the housing stability of patients,take steps to get housing for patients if possible and acknowledgethat release from shelters to the streets is a real problem thatshould not be ignored.

Fazel, S., Khosla, V., Doll, H. &amp Geddes, J. (2008) reviewed andcompared professional literature to ascertain the percentage ofmentally ill homeless people in the larger homeless population.Meta-regression analysis was used after studies were collected andaccepted to attempt to ascertain sources of heterogeneity. In orderto be accepted, a study must (1) have had a clear definition ofhomelessness, (2) use diagnostic criteria from the InternationalClassification of Diseases: Classification of Mental and BehavioralDisorders (ICD-10) or the Diagnostic and Statistical Manual of MentalDisorders (DSM-IV), (3) have had a diagnosis of the consumer madewith recognized instruments by a practitioner, (4) have hadprevalence rates for the last six months included (except lifetimepersonality disorder) and (5) have been located in North America,Western- Europe, Australia or New Zealand. A study was excluded ifthe response rate was lower than 50%.

Twenty-nine studies were included for analysis with 5,684 homelessindividuals, published from 1979 to 2005 (Fazel et al., 2008). Eightythree percent of all individuals were men however, some of thestudies included surveyed only women, or a mixed group (Fazel et al.,2008). Subjects were selected from varied locations, such as sheltersfor the homeless, hostels for the homeless, streets, day centers,soup kitchens and missions (Fazel et al., 2008).

Twenty-eight studies reported on psychotic illness, with a “randomeffects pooled prevalence of 12.7%” (Fazel et al., 2008).Heterogeneity of results was high, ranging from 2.8% to 42.3%. In ameta-regression model, the only significant variable was that lowerparticipation rates were associated with lower prevalence ofpsychosis (Fazel et al., 2008). Nineteen percent included studiesthat examined major depressive disorder the random effects pooledprevalence was 11.4%. Estimates by these studies ranged from 0.0% to40.9% and showed high heterogeneity. In a meta-regression model,lower participation rates were associated with higher prevalence,with other identified variables becoming non-significant (Fazel etal., 2008). Fourteen surveys examined personality disorders in thehomeless, with the random effects pooled prevalence at 23.1%.Prevalence was heterogeneous, from 2.2% to 71.0%. Lowerparticipation was associated with higher prevalence in individualvariable analysis (Fazel et al., 2008).

Ten studies examined alcohol dependence, with random effects pooledprevalence of 37.9%. Substantial heterogeneity was observed inprevalence estimates, ranging from 8.5% to 58.1%. Two variablesconnected with heterogeneity were observed in single variableanalysis but were not in multiple variable analyses. Those twovariables were from (1) a study conducted in mainland Europe (higherrate of alcohol dependence) and a more recent study (chosen bydecade) (Fazel et al., 2008). Seven studies examined drug dependence.Random effects pooled prevalence was 24.4%, with a range from 4.7% to54.2%. No variable in these studies was associated with heterogeneityon examination. One study was found on drug dependence in the femalehomeless population, reporting a prevalence of 24.4% (Fazel et al.,2008).

According to the data mentioned above, the most common mentaldisorders in the homeless are alcohol and drug dependence, further,psychosis and depression in this population have comparable levels ofprevalence. Fazel et al. (2008) noted that the estimates for seriousmental disorders were high, and suggested local providers shouldestimate their local prevalence and act on this information, ratherthan use this data. Potential explanations for the considerableheterogeneity of the studies are varied.

The heterogeneity observed cannot be explained through simplecharacteristics such as “sex, study size or geography” (Fazel etal., 2008). On meta-regression, lower participation rates wereassociated with lower prevalence of psychosis (Fazel et al., 2008)and interviewers with medical training reported a lower prevalence ofdepression in their interviewees (Fazel et al., 2008). In closing,Fazel et al. (2008) recommends longitudinal studies of the mentallyill to better understand risk factors, pathways into homelessness,causes of desistence, and duration of homelessness. These authorsalso recommend heavy integration of treatment for mental illness andsubstance abuse, combined with housing interventions.

North, C., Thompson, S., Pollio, D., Ricci, D., Smith, E. (1997)first compared homeless and domiciled patient groups attending mentalhealth clinics in the same area, and then compared the homeless groupto a larger data set of all homeless people for the same area. Thepurpose of these comparisons was to show what, if any, mental illnessdiagnoses were more common in the homeless mental health clinicattendees as compared to domiciled attendees. The study populationconsisted of individuals in St. Louis, Missouri. The study possesseda number of strengths. First, diagnoses of all patients were madeover a long period, up to two years, as attendees were regularvisitors to the clinics. Second, detailed data of the generalhomeless population in St. Louis was readily available from amulti-year study that ran from 1991-1993. The DSM-III-R was strictlyused for all diagnoses. In total 166 homeless patients and 117non-homeless patients participated. The majority of all participants(83%) were women. Men and women were separated for statisticalcalculation. Results from comparison of diagnos identified 3 majorfindings.

First, prevalence of schizophrenia, somatization disorder and bipolardisorder were not statistically different between groups (North etal., 1997). Second, depression and non-antisocial personalitydisorder were more common in domiciled patients (For depression:16.7% vs. 64.7% in men 37.3% vs. 48.0% in women for personalitydisorders other than antisocial: 41.7% vs. 70.0% in men, 60.0% vs.62.2% in women) (North et al., 1997). Finally, prevalence ofantisocial personality disorder and substance abuse were more commonin homeless clients. Women displayed higher rates of drug abuse andmen displayed higher rates of alcohol abuse (North et al., 1997). Theauthors recommended in closing that practitioners examine patientsfor substance abuse and antisocial personality disorder as prioritieswhen assessing mental healthcare needs of homeless patients, despitethe fact that these disorders are generally more difficult todiagnose in single interview sessions.

In Long-term homelessness in men with a psychosis: Limitation ofservices, authors Burns, Robins, Hodge, and Holmes (2009)investigated two linked questions: (1) How should the persistentlyhomeless individual who has received intensive mental healthcaretreatment in the community, but unable to function in the community,be measured? (2) Has the number of these individuals increased from2000 to 2005 in the urban area around Melbourne, Australia? Theindividuals that were the subjects for this study were defined asthose “with a major mental illness… [with] persistent orrecurrent psychiatric symptoms over an extended period of time…unable to achieve an adequate, socially acceptable level of basicfunctioning and self-care despite… intensive psychiatric outreach…other community support services and interagency collaboration”(Holmes et al., 2006 as cited in Burns et al., 2009).

Burns et al. (2009) developed specific items to quantify thesecharacteristics and adopted known tools to measure them. InadequateSocial Function was defined as the inability to maintain significantpersonal relations with friends or family. Summary statements wereused that were based on considerations from the Life Skills Profile(LSP), which has criteria regarding social interactions. PoorRelationship with Mental Health Services, that is, adherence,was measured with the LSP, which has a section on “communicationand responsibility” (Burns et al., 2009). Persistent Psychosis wasassessed with DSM – IV criteria (assessment made by clinician andlater reviewed by psychiatrist or trainee) (Burns et al., 2009).

Accommodation Instability was based on an average of accommodationlocations in the past year. Burns et al. (2009) noted, “A previousstudy found men with a psychosis who experienced homelessness in theprevious year, had a mean of 4.1 accommodation settings compared with1.8 [in non-homeless people]”. Previous Intensive Treatment wasassessed on a case-by-case basis through review of cases withclinicians and experience. Burns et al. (2009) cited that there waslittle or no literature to guide them in establishing a moreobjective metric. [Homelessness] Present for the Majority of Time foran Extended Period was examined the study adopted two years ofpersistent homelessness as the standard of persistent homelessness.

The Waratah Area Homeless Psychiatric Service (WAHOPS) providedretrospective file referrals, and of this number, 57 individuals from2000 and 67 from 2005 were identified for inclusion because they metthe above-described criteria. The year 2005 was used because it wasthe last year with complete data. All subjects were male. The averageage of a subject in 2005 was 38 years old.

Results showed that the percentage of subjects who fit all criteriaoutlined above from the general homeless population of WAHOPS was 17%in 2000 and 23% in 2005. The key variable that changed between thosetwo dates was the number of men who participated in intensivecommunity treatment (Burns et al., 2009). Substance abuse wascomorbid in 53.1% of all men, and was the most common comorbidillness (Burns et al., 2009). In discussion, Burns et al. (2009)stated that the “documentation of these men… represents evidenceas to the limits of our current service system.” The authorsindicated that current modalities of treatment of mental illness inthe community and reintegration are not sufficient to help thisminority of men.

Furthermore, Burns et al. (2009) pointed out that these men who arementally ill and homeless for a long period of time have a complexmix of disabilities that complicates their treatment andreintegration into society, and about half reported inability tomanage their finances. The authors also reported that a minority ofmen who are homeless and diagnosed with long-term psychosis do notrespond to treatment in the community. Diverse difficulties indifferent areas of function may contribute to overall problems withreintegration and even follow-up to treatment. In closing, Burns etal. (2009) recommended that this subset of patients demands“management and supported accommodation,” as simple communityoutreach delivered on an opportunistic basis is not sufficient forthis population.

2.3. Service models and theory

The main theories that provides a model for the current researchinclude Grounded Theory, Health Belief Model (HBM), Theory ofReasoned Action (TRA), Social Cognitive Theoryand Social Support Theory. These theories relate to attitude,barriers to communication and social factors that make them ideal foruse in this research.

2.4. Interventions: Service Delivery and Integration

Muir, Fisher, Dadich and Abelló (2009) examined the performance ofan experimental housing and treatment strategy for the homelessmentally ill in Australia.

The experimental housing program in question was named the MentalHealth Housing and Accommodation Support Initiative (HASI). One ofthe founding tenants of HASI was to give consumers an opportunity tointegrate into their respective communities to the largest degreepossible through individualized housing with support. The authorscontrast this approach with that of transitional housing, which theystated often results in not only the exclusion and stigmatization ofconsumers, but also leads to suboptimal integration outcomes.

HASI was evaluated to examine if it (1) fostered participation in thecommunity while permitting patients to sustain tenancy and improvemental health, (2) had governance measures in place to make itsustainable and (3) improved access for consumers through integrationof varied services. To determine the answers to these questions, 633surveys and interviews were conducted with clients, providers,workers, family members of clients and a variety of other peopleconnected intimately with the program. The study spanned two years,with data collection at intake as well as in six-month incrementsthereafter. Some consumers opted to participate earlier on, butdropped out, with others participating in the middle or end.Fifty-five of the 91 starting patients completed all of the study.Sixty-nine out of 113 clients were available for longitudinal study.

Most patients in HASI were suffering from schizophrenia (74.3%) orschizoaffective disorder (11.9%), were male (67.3%) and were born inAustralia (93.6%). In results, 70% of clients remained in the housingprovided by the program after one year, while 15% had changedlocations but remained stably housed. The remaining 15% could not betracked. High positive housing incomes were associated with carefulselection of the premises of housing, “taking into accountlocations where social networks were accessible, social setting, andservices and resources” (Muir et al., 2008). Ninety-four clientswere “satisfied or very satisfied with their homes” (Muir et al.,2008). Clients received extensive support from workers and housingproviders and displayed care of their homes, as well as goodrelations with neighbors. Mental health for clients improved, with84% of clients spending less time in a mental hospital after HASI(Muir et al., 2008) this additional support resulted in significantcost savings.

Clients’ reported personal well-being first increased thendecreased in phase three. The authors stated that they believed thiswas due to elation associated with independence followed bymelancholy when consumers reflected on missed opportunities andlooming challenges in life ahead. Sixty percent of longitudinal studyconsumers reported improved physical health. By the mid-1990s, accessto physicians and mental health personnel increased. Socialexclusion was minimized as the study advanced through phases, asnumbers of consumers with no friends became lower (from 23 down to6), and more consumers found employment (from 8 to 26) or initiatededucation (from 2 to 26).

In general, social growth was reported to be moderate but growing.Muir et al. (2008) concluded that HASI is successful because of itsservice integration and the realization that some consumers needpermanent, not transitional, housing schemes that give them bothenough independence and access to interventions. Muir et al. (2008)deemed HASI to have been successful because it eradicated some of thebarriers of the mentally ill homeless to inclusion and participationin the community.

Nelson, Aubry and Lafrance (2007) reviewed literature regarding theeffectiveness of two housing interventions with mentally ill homelesspeople. The housing interventions reviewed were Active CommunityTreatment (ACT) and Intensive Case Management (ICM). All studiesselected for review were published in peer-reviewed journals,reported empirical and quantitative data, and included housing andsupport. The studies were also in line with the ACT or ICM standardsfor intervention, using an experimental or semi-experimental design.All programs were oriented toward increasing consumer autonomy,recovery and integration. Of the six studies that compared permanenthousing and support with standard treatment, there was a greaterincrease in housing in those who participated in permanent housingwith support programs, with an effect size margin of .67 (Nelson etal., 2007). Three studies compared case management and housing tocase management alone in these studies, case management and housingobtained superior results, with an effect size margin of .37 (Nelsonet al., 2007). In all cases when ACT was compared to standardtreatment methodologies, ACT produced superior housing suitability.Across eight directly experimental studies, the effect size was .47(Nelson et al., 2007).

Three directly comparable studies of ICM showed that thisintervention produced superior housing outcomes when compared tostandard treatment. The effect size of this was .35 (Nelson et al.,2007). Both ACT and ICM were effective in decreasing hospitalizationsfor psychiatric problems (Nelson et al., 2007). ACT consumers hadsignificantly more contact with other health services personnel thanthose in standard treatment. Nelson et al. (2007) concludes from thedata gathered from 16 studies that ACT and ICM are both successful inbringing about superior housing outcomes and other positive outcomes(such as integration, satisfaction and medical care use) for mentallyill homeless individuals when compared to standard treatment.

2.5. Service Results

The public often perceives care in the community forinstitutionalized mentally ill people as being a failure. They blamethis care paradigm for increases in crime, homelessness and thegeneral destabilization of local communities. Trieman, Leff andGlover (1999) investigated the results of resettling long-staypsychiatric patients in the community, motivated by a spate ofhigh-profile murders involving the mentally ill. Trieman et al.(1999) adopted continuity and quality of residential care,readmission to psychiatric hospital, mortality, crime and vagrancy asthe criteria for analysis. Subjects were selected if they had been ina mental hospital for longer than one year, yielding 670 patientsthat were to be resettled in the community 1985-1993 in London,England. Patients were assessed at baseline, one-year and five-yearincrements. Caseworkers were interviewed by phone every six months,with the goal of determining change over time. Of the 670 patients,128 (18.8%) died during the course of the study, and 12 (1.8%) movedaway. Five hundred and twenty-three (78.1%) participated in all stepsof the study. Of all patients, 525 (78.2%) were settled in staffedresidencies, 72 (10.8%) in independent living and 27 (4.0%) livedwith family. Results of the study showed the following: Of allparticipants after five years, 469 (86.9%) still lived in thecommunity and of those in the community, 310 (59.2%) still lived inthe same home where they were originally placed.

Two hundred and one patients were readmitted at least once to apsychiatric ward (38.4%), 124 more than once, and 160 (29.7%) werelong-term readmits. Fifty-four patients (10.3%) were inpatients againat the end of follow-up. Regarding crime, there were 15 seriousassault occurrences perpetrated by 13 individuals “nine of theseassaults were on members of the public, including three sexualassaults, one attempted murder, and two muggings. Three assaults wereon fellow residents and three were on staff or police officers”(Trieman et al., 1999). Nine patients were lost to follow-up. Triemanet al (1999) conclude that the community care paradigm of healthcarein the United Kingdom is broadly capable of generating positiveresults for most of those involved in it, including stable housingand ongoing treatment with “minimal detrimental effects tosociety.”

Leff (2001) examined reasons for the rather widespread public opinionin the United Kingdom that care of the mentally ill in the communityis a failure and a source of the homeless individuals. Leff (2001)theorizes that community care is mostly an invisible process to thosewho are not involved in it. Community care buildings look likeaverage houses, and patients and employees mostly dress and act likeregular people. No one carries “a black bag and stethoscope”(Leff, 2001).

In addition, the aggressive visual impact of the large stateinstitution is missing. After deinstitutionalization, the publicbegan to notice homeless mentally ill people on streets and blamed iton resettlement from institutions. Leff (2001) contended that this isnot the result of resettlement but rather, due to a decline inlow-income housing during the 1980s. He also indicates that themajority of the homeless population had never crossed the thresholdof a mental health hospital. Another belief that contributes to anegative attitude towards care in the community is the perception ofviolence in the homeless population. However, Leff (2001) indicatesthat acts perpetrated by mentally ill people have been falling in theUnited Kingdom (Leff, 2001) he indicates that the media can blow anisolated crime out of proportion, which then results in popularbacklash.

Finally, Leff contends that well-informed members of the public andmedia fail to grasp the dizzying complexity of modern mentalhealthcare in the community. Essentially, patients exist within a webof providers, services and centers, each of which serves differentneeds. As a result, it is possible that some needs are served whileothers are not. The diffuse nature of care in the community is quitedifferent from the very high level of centralization found in theinstitutions of yesteryear, but the population still judges withobsolete criteria. Leff (2001) recommended advocacy by mental healthprofessionals to explain the system and its positive impacts, and heencouraged mental health professionals to be promoters of greaterintegration of patients into society and workplaces.

Adults with Serious and Persistent Mental Health Illness (SPMI), whooften are homeless, have difficult or limited access to healthcare,with the result being a higher mortality rate. Boardman (2006)conducted a study of a health services intervention among those withSPMI attending an in-community psychological treatment facility inMassachusetts in the United States. The author also conducted aliterature review, highlighting known facts about those with SPMI,their physical health services needs and access to health services.

Boardman (2006) described many of those who suffer from SPMI ashomeless, or at the very least having insufficient income, therebyessentially limiting their options to care. Other barriers, such asrace, gender and geography also affect consumers (Boardman, 2006).Deinstitutionalization may also have had an unintentional negativeeffect on the physical well-being of ex-patients, as well aspotential psychological patients, since it removed an institutionthat was capable of delivering an integrated package of psychologicaland physical care in one place. Consumers now attend communityclinics that serve only the psychological dimensions of illness, andare not equipped as institutions were to deliver preventative andacute medical care (Boardman, 2006).

Numerous studies had documented the extent to which medical illnessin SPMI individuals is undiagnosed, untreated or treated only inemergency rooms. Boardman (2006) cites a number of examples: (1) in1979, in a sample of 2,090 individuals in community treatment, 46%were found to have severe physical ailments that were undiagnosed inreferral (Koranyi, 1979 as cited in Boardman, 2006). (2) In1981, 910 patients in psychiatric outpatient treatment receivedphysicals 20% of those included urinalysis examinations. Twenty fourpercent exhibited some abnormality that was previously undiagnosed.The authors of that study recommended integrating preventative carewith psychiatric care. (Mueke &amp Krueger, 1981 as cited inBoardman, 2006).

Roca, Beakey and Fisher (1987) examined 42 patients in an outpatientpsychiatric recovery program and found that 92% had “at least onemedical problem requiring assessment, treatment or follow-up”(Roca, Beakey &amp Fisher, 1987 as cited in Boardman, 2006).These studies, as well as others mentioned by Boardman (2006),generally recommend that general psychiatric evaluations shouldinclude physical evaluations as well. People with SPMI tend to dieyounger and have far earlier onset of certain serious illnesses, suchas heart disease, than the general population (Boardman, 2006).

In fact, “cardiac events in the 24-54 year-old age group were sixto seven times higher [in a Department of Mental Health Studygroup],”compared with the general population (Boardman, 2006). Useof certain neuroleptic medicines, typically used to treat psychoticdisorders, is also associated with higher morbidity and mortality.Use of such medicines has been known to cause weight gain and type 2diabetes which potentially affects compliance. Boardman (2006)randomly selected an experimental and control group of patients froman outpatient mental health clinic in Salem, MA. The goal of thisintervention was to reduce emergency room usage by 33%. Theexperimental group received medical care from a nurse practitioner atthe behavioral care setting, while the control group continued to usetheir medical care as they normally did.

Seventy-six participants completed this study, 39 in the experimentalgroup and 37 in the control group. Findings revealed that theexperimental group reduced ER visits by 42%, primary carepractitioner contact was 50% greater, and checkups occurred with 70%more frequency. Results for a broad range of services and proceduresshowed that patients had more access to doctors and more frequentlytook steps of preventative care. There were difficulties in settingup such a screening procedure in an outpatient clinic, such asensuring privacy and correct lighting. However, in conclusion,Boardman (2006) stated that embedding physical health care servicesin outpatient psychiatric care venues improves access to preventativemedicine for individuals with SPMI, as well as reducing cost byeliminating expensive ER visits.

Young, et al., in Characteristics of Individuals with SevereMental Illness Who Use Emergency Services (2005), examines whouses emergency services and why. The study summarized in this articlewas conducted within the Los Angeles County Department of MentalHealth, which manages community and residential mental health carefor a population of about 60,000 individuals. The study populationwas selected from a subset of this number who were eligible for the“partners” program, an assertive community-based treatmentprogram.

Eligible people were high-volume mental healthcare users aged 18 to64 years who used services for at least three years between 1988 and1993, with a yearly treatment cost greater than $30,000. This yielded1,241 potential candidates. Three hundred ninety six were randomlyselected. Those who consented were interviewed for the survey, whichwas completed by 45% of respondents (179 individuals). The resultsof the survey revealed some noteworthy facts. Twenty-one percent ofrespondents had a history of homelessness (41% in board and care, and15% in a residential facility), and 86 were receiving SSI. Schizophrenia was the primary diagnosis for 57%, 15% were diagnosedwith bipolar disorder, 4% were diagnosed with major depression, and2% were each diagnosed with dementia or anxiety disorder.

The authors note that persons with psychiatric disorders of greaterseverity were more likely to use services. They also note, “Ahistory of homelessness and lack of family contact were associatedwith greater use of emergency services” (Young et al 2005). Thesepatients also have worse access to outpatient care, which oftenresults in noncompliance and return visits. The authors conclude thatpersons with severe and persistent mental illness who often useemergency services tend to be homeless and have no family support.The relationship of this study to the body of literature suggeststhat mentally ill homeless people need and require medical care, andif that need is not satisfied in the community by existinginfrastructures of care, they will turn to local emergency rooms.

2.6. Opinions of the Mentally Ill Homeless

In an article Their Voices: Opinions of the Mentally Ill Homeless,McCrea and Spravka (2008) examined the opinions of severely mentallyill homeless consumers regarding housing and psychological services. The authors stated that examination of the views and opinions ofconsumers would reverse the dehumanization of this group and provideinsight into residential care alternatives and follow-up services.This dehumanization is illustrated by a common scene described at thebeginning of the study: a homeless man playing an oboe is ignored bycrowds of theatergoers leaving a performance. McCrea and Spravka(2008) speculate that he is a locus of their fears, both their ownpersonal fears of “destitution, delusion and abandonment” butalso the twin perceptions of the homeless as both targets andperpetrators of violence.

Before beginning the study, several obstacles were identified in thecarrying out of a qualitative opinion study of mentally ill homelessconsumers. One obstacle noted was how to preserve the naturalopinions of the consumers without stereotyping them. Another wasattracting consumers to participate in the study. To compensate forthese challenges, the researchers adopted a qualitative design.Respondents were interviewed with a semi-structured guide andgenerally gave free-form answers. Respondents who were illiteratecompleted the survey with a worker who wrote down answers for theconsumer. Workers administered the survey during the everydayprovision of services at residential treatment facilities for thehomeless mentally ill. This procedure was used to avoid the shock ofintroducing strangers into a setting and to avoid disruption of theeveryday routines of patients (McCrea &amp Spravka, 2008).

The study was conducted in the Midwestern United States, withinterviews stretching over four years. There were four primaryresearch questions associated with this study: (1) Are the mentallyill homeless capable of evaluating their own experiences? (2) What dothey perceive as the causes of their present difficulties? (3) Whathas been helpful in residential care in treating those difficulties?And (4), what can be helpful in the future, after release fromresidential care, in treating those difficulties? In total, 210subjects participated in this process.

The results indicated some interesting facts about how the homelessmentally ill perceive their experience in general. Regarding question(1), very few responses on any set of questions were coded as beingunclear, illegible, bizarre or otherwise useless. More generalquestions, such as “Can you tell us what you learned aboutyourself?” received a higher percentage of unintelligible responses(4.8%) than very practical ones such as “Who do you have to rely onwhen you leave the program?” (1.8%) (McCrea &amp Spravka, 2008).Thus, in general, consumers were well-prepared to furnish meaningfulanswers to questions. When asked about the source of their presentdifficulties (question 2), 63% of the homeless mentally ill indicatedthat mental illness was the cause of their current difficulties 34%mentioned housing difficulty, 19% combined relationship and familyrelationship difficulty, and 18% identified substance abuse as themain source of difficulties (McCrea &amp Spravka, 2008). Clientscould mention more than one problem.

Regarding residential care modalities (Question 3), clientsoverwhelmingly favored counseling (74%). Other services also receivedsupport, including group therapy (50%) and help with funding (48%).However, other services that clinicians view as valuable, such asfollow-up with medication, were viewed as less important (45%).Regarding follow-up treatment, patients indicated that they wouldlike to continue to develop and maintain relationships with carerepresentatives that they met in treatment 71% of patients preferredthat this be at their discretion and initiated by them. Otheralternatives were presented, including “Staff calls to touch base”(favored by 54%), “Participate in Drop-in Center” (favored by48%) and “Case Management” (favored by 36%) (McCrea &ampSpravka).

The emphasis placed by consumers on maintaining relationships issurprising, given that it was not targeted as one of the primaryproblems as described by consumers themselves. The authors suggestthe discrepancy is due to consumers no longer viewing relationshipproblems as problems because they have no significant relationshipsleft. Fifty-five percent stated that they had themselves/no one/Godto rely on once they left the shelter 36% cited a therapist ormental health staff (McCrea &amp Spravka, 2008). Only 23% mentionedfamily as support, and 12% mentioned friends. Lack of relationshipsamong the homeless and the need for homeless people to haverelationships that affirm autonomy and help them to participate insociety are among the strongest findings in this study.

Nelson, Clarke, Febbraro and Hatzipantelis (2005) conductedintensive interviews with 20 homeless severely mentally illindividuals (11 men and 9 women) in order to evaluate a supportivehousing initiative through their experience. Nelson et al. (2005)described the series of interviews conducted as the “narrativeapproach.” Eighteen of the interviews were conducted in Toronto,Canada, with the remaining two in Hamilton, Canada.

Both of those locations are heavily urban. The age of theconsumers ranged from 29 to 59 years old. Four respondents lived inindependent living arrangements, while 16 were in group housing. Allfive members of the team conducted the first 10 interviews. Privacyand setting varied from interview to interview. All interviews wereaudio taped and transcribed. Five interviewees were heavilysymptomatic on interview, and data from these interviews was notincluded. The study used data from the 15 individuals who presentedwith symptoms. The information was sorted by time (Youth vs. Adultlife before supportive housing vs. Life after supportive housing) andby basic themes (Relationships, housing, employment, etc.).

Results of these surveys revealed a number of generalcharacterizations. First, interviewees consistently describedchildhoods characterized by unfulfilling and unsupportiverelationships. Often, interviewees reported they pulled away fromsocial contact with friends and family and simply continued theirlives, in spirals of increasing isolation. Some interviewees didexperience social relationships that were fulfilling and supported,but most did not. Steady employment was also elusive in the historiesof most of those interviewed, though there were significant outlierson this account, including one man who reported being he was a salesclerk for 14 years before changing jobs (Nelson et al., 2005).

Many of the interviewed reported having experienced cycles ofvictimization, including violence, theft and rape. After supportivehousing, consumers generally reported improved quality of life.Feelings of security and safety were increased, though some still didnot feel it was safe to go out at night. Consumers felt that they hadgreater control over their lives and greater autonomy, and those withindividual living arrangements felt the greatest feelings ofautonomy. Consumers also formed valuable and supportive relationshipswith other consumers, as well as staff at the housing program.Resources available to consumers were also improved, with a fewnoting that these housing resources were the best to which they hadever had access.

Mojitabai (2005) conducted a qualitative study analyzing theperceptions of mentally ill homeless people regarding the reasons fortheir loss of housing and continuing homelessness. Qualitative datawas collected from mentally ill homeless, according to either astrict or a more open definition of mental illness, and compared withqualitative data regarding the same issues from non-mentally illhomeless people.

Mojitabai (2005) stated that there are generally two schools ofthought regarding the high levels of mental illness in the homelesspopulation and how to successfully reintegrate these individuals insociety. The first school of thought contends that intensivepsychiatric treatment and treatment of substance abuse must occurfirst before independent housing is provided (Mojitabai, 2005). Theother school of thought calls for the same strategies for thementally ill homeless as for the general homeless: increasing housingand providing it quickly as the primary goal (Mojitabai, 2005). Theauthor (2005) hoped this debate might be illuminated by the discoveryof a potentially different perceived source of homelessness bymentally ill and non-mentally ill consumers. The study used data fromthe 1996 National Survey of Homeless Assistance Providers and Clients(NSHAPC), targeting 2,974 individuals who were currently homeless.These individuals were recruited across 54 cities in the UnitedStates. Criteria for the broad definition category of mental illnesscame from the NSHAPC itself and criteria for the narrow definitioninvolved meeting the NSHAPC criteria as well as having a history ofhospitalization for mental illness. Fifty-six percent, or 1,620individuals met the broad category definition of mental illness. Sixhundred thirty-nine individuals met the narrow definition.

The results of the survey revealed that there was very littledifference in how the mentally ill and non-mentally ill homelessviewed the original and sustaining causes of their unemployment,”which were the cardinal causes for the broad- and narrow-definitionmentally ill homeless, as well as for the non-mentally ill. Mojitabai(2005) concludes that these data suggest that a general treatment ofhomelessness by provision of housing and general social services, andnot necessarily service models that link mental illness treatment tothe provision of housing, is the key to reintegration of the mentallyill homeless (Mojitabai, 2005).

Yanos, Barrow and Tsemberis (2004) examined challenges andopportunities in housing and community integration of the homelessmentally ill. They compared two differing approaches toward housingthe mentally ill homeless, the “housing first” approach, codedexperimental, and the “continuum of care” approach, codedcontrol. The continuum of care approach involves patients livingwithin a staffed facility and integrates substance abuse and/ormental health treatment. Professionals decide the independence levelof the patient, according to what they feel he or she can manage. Thehousing first approach places patients in independent living withoutintegrated treatment involvement. This approach has been shown tohave superior tenancy outcomes and no difference in clinical outcomes(Yanos, et al., 2004). The authors adopted a qualitative design tocompare these two housing approaches from the consumer’s point ofview regarding four criteria: Symptoms, Life Satisfaction, Choice andSense of Safety. Eighty subjects complied with intake, six-month andtwelve-month interviews from a larger sample. After the intakeinterview a patient was assigned to the experimental or controlgroup.

According to qualitative results from interviews aided byself-reporting, the majority of severely mentally ill people who werehoused after a period of homelessness (the experimental group)reported greater feelings of satisfaction, safety and belonging thanthey had before. A significant minority of consumers from the controlgroup felt that it was difficult to integrate into the community andhad ongoing difficulties adjusting to independent living tasks. Yanoset al. (2004) note that this supports research suggesting thatlong-term institutionalization actually retards the ability of aperson to live independently. One ethnographic study of long-staypatients compares the experience to “culture shock” (Yanos etal., 2004). In the control group, consumers reported frustration withrules and lack of privacy, which may lead to consumers quittingprograms altogether. In addition, patients in this control groupwaited longer for housing, which may have affected their feelingstoward housing (Yanos et al., 2004). These authors. (2004) closed bysaying that housing in the community has been successful, but mentalhealth professionals realize that the physical location of a place ofresidence may have a large impact on the consumer’s ability to feelcomfortable as they may see the area as not diverse or tolerantenough.

Chapter 3: Research Method3.1. Introduction to Research Method

The purpose of thisstudy is to research and examine opinions of homeless mentally illsubjects on their views of barriers that keep them from accessinghousing, psychiatric, and medical care. Studying and gathering firsthand experiences could improve gaps in literature that do notconsider this populations concerns as valuable this study could lenditself in making positive social change. Qualitative research modelis required for first hand interviews and personal interactions togain subjects’ trust. Qualitative methods produce information onthe why and how subjects trust and how individuals make decision.

Thecurrent study is guided by the following research questions:1) From the perspective of the consumer, what are the experiencesaccessing a) health care solutions, b) psychiatric care, and c)housing solutions? 2) If the consumers does not use one or more ofthese services, what are the barriers to their utilization and whatdo they think is necessary to overcome these barriers. Qualitativeresearch is an approach most important for listening to voices ofhomeless, mentally ill person gaining insight into how each subjectview barriers in accessing safe housing, psychiatric and medicalcare. Exploring subjects’ quality of life on the streets I haveselected grounded theory methodologies to meet the goal ofinvestigating why and how each subject views their lives.

3.2. Qualitative Research Design and Rationale

Qualitative researchis appropriate to use in this research because the intention is togarner an understanding of a paradigm where little is establishedabout the problem or variability prior to the study (Creswell, 2005). According to Flick, Kvale and Angrosino (2007) qualitativeresearch is a method that elicits an understanding of the phenomenonby generating meanings from the experiences, feelings, and theperceptions of an individual or group.

3.3. Qualitative Methodology

Qualitativemethodology research includes five types: case study, ethnography,biography, phenomenology, and grounded theory. A biography methodfocuses on an individual’s life without any focus on any particularphenomenon (Flick, 2007). According to Yin (2009) a case study methodindividuals are studied with a focus on a specific topic. Accordingto Creswell (2009) ethnography is a method that describes andinterprets a social group or culture within a system. Phenomenologymethod is appropriate when applied by collecting informationregarding the experiences of participants in the study (Creswell,2009).

Nancy Charmaz (2014)states the grounded theory methods include systematic and flexibleguidelines for the collection and analyzing qualitative data in orderto construct theories from the data. Grounded theory will allow me tofocus and flexibility necessary to stay involved with my interviews.Gathering the lived experiences of study participants, as well astheir subjective perceptions, thoughts, and feelings about the topicof interest enables an understanding of one or more phenomena (Flick,Kvale, &amp Angrosino, 2007).

3.4. Role of the Researcher

My role as aresearcher will be clear. I will remain neutral and ensure anon-judgmental attitude putting all biases aside. I will help myparticipants in achieving a level of comfort throughout theinterview. I will maintain all ethical standards. I will seek theopinion of my chair and committee members and individual persons whowork directly with my participants’. I have to keep all mypersonal opinions, experiences and prejudices dormant to prevent anynegative influence on the study. I will provide support as I do in myprofessional practice.

3.5. Participant Selection Logic

All participants willidentify themselves as homeless. I will ask each participant fortheir age and their housing status prior to enrolling them in thestudy. Their names will not be recorded however, a number will beassigned to protect their identity. Diversity in the sample isrelevant to reflect differences.

3.6. Instrumentation

Under the supervisionof my committee members and the directors at the individual studysites I will develop an interview guide. This will ensure the goal ofthe study and clarity of the questions. I will work with some of theexpert clinicians and the volunteers at the sites to ensureappropriateness of the questions. This will be done after I receiveapproval from the Institutional Review Board (IRB).

3.7. Procedures for Recruitment and Participation

I intend to recruit10 participants through staff with the Salvation Army homelessproject as well as local churches and soup kitchens that feed thehomeless. I will highlight the objectives of the study, criteria toparticipant, and offer $5.00 at the start of the interview theremaining $10.00 at the end of the interview or if a participantwithdraws from the interview early. I will conduct a semi-structured,face to face interview with my follow-up contact information forafter the interview. The questions will be sampled on twonon-participants for validity and clarity.

3.8. Data Collection

The results will be analyzed and sorted into relevant datacategories. These categories will depend on the specifics of the dataand on the relationship between the clients’ answers and theresearch questions. From categorized data, it will be possible toform hypotheses for improvement of care and access to care for thissegment of clients.

3.9. Interview Protocol

The interview willbegin with the reading of the consent information. Each participantwill be made comfortable by offering a drink and hold a briefconversation about their day. At the end of the interview,information regarding support systems and housing information will begiven.

3.9.1. Obtaining Consent

The form of consentdetailed the participants’ right to confidentiality. The numericidentifier will be placed on each signed consent form which indicatesthe participant accepts the terms of the study, understand theobjective of the study, the research process, and the willingness toparticipate.

3.9.2. Interviewing the Participants

The interview willbegin with a relaxed atmosphere by starting with a casualconversation. This will develop a rapport and ultimately build acomfort zone for both the interviewer and the interviewee. Some basicinformation such as age, place of birth, cultural background, andeducational level will be collected.

3.10. Data Analysis

My goal is tounderstand the reasons for homelessness. Verifying the responses withthe participant will confirm the accuracy of the questions.

3.10.1. Coding Process

The pivotal step inthe data analysis is line by line coding which is the central task ofgrounded theory. The coding process yields highly organized andusable data set. The data will be given to a coding team who istrained in open and axial coding system of grounded theory togenerate categories and themes from the data. Open coding is theprocess of selecting and naming categories from the analysis of thedata. This will be the primary level of acquiring and describinggeneral features of the phenomenon under study (Strauss &amp Corbin,1999).

3.11. Evidence of Trustworthiness

In any researchstudy, the questions of quality, namely validity, reliability, anddependability are likely to emerge. Ethical issues as reported inProtecting Confidentiality Rights the need for an Ethical PracticeModel (Fisher, Alice, 2008). All psychologists must uphold the sameethical standards about confidentiality even though each stateimposes different legal limits on their ability to protect clients’confidence. Boundaries of Competence 2.01. APA Ethic Code 2002Principle E: Respects for People’s Rights and Dignity states thatpsychologists are to respect the dignity and worth of all people,

Working with a vulnerable population I will ensure eachparticipant understands the nature and extent of their participation.Personal experience working with individuals diagnosed withschizophrenia bipolar posttraumatic stress disorder (PTSD) as a casemanager with The Center For Health Care Services in San Antonio,Texas working with clients’ from San Antonio State hospitals,jails, and prisons providing support for 10-14 individuals 24/7provided a first-hand experience into the lives of persons diagnosedwith chronic serious mental illnesses.

3.12. Ethical Issues

Gaining the trust andsupport of the participant is crucial to the study. All informationin the study and the informed consent will be kept confidential in anundisclosed location for a specified time period, to be determined.

3.13. Institutional Review Board Approval

Prior to the study anapproval will be obtained from the IRB. This approval will ensureethical procedures are maintained for all participants.

3.13.1. Informed Consent

The informed consentwill introduce the research process, provide contact information, theintent of the study, and the request of voluntary participation bythe recipients. Nothing can be done outside of what the consententails.

3.13.2. Privacy and Confidentiality

The participants willbe informed of their rights to privacy and confidentiality of the useof the information of the study. This is part of the informedconsent. Restricted access will be based upon a need to know status.

3.14. Summary

The purpose of thestudy is to investigate how homeless, mentally ill individuals viewtheir access to mental health, physical wellness and obtaining a safeplace to live. Navigating the complex, bureaucratic social structureshomeless mentally ill individuals often distrust will be identified(Daiski, 2007 Rosenheck et al. 1999 Smith &amp Sederer, 2009). Thefocus of my study will be to discover how individual participantsview conciliation of gaps in obtainable access to community services.


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Appendix A: Informed Consent

You are invited to take part in a research study exploring howmentally ill and homeless men and women in San Antonia navigategetting help from the public system. This form is part of a processcalled “informed consent” to allow you to understand the natureof this study before deciding whether or not to take part.

This study is being conducted by researcher Georgann Owens,who is a doctoral student at Walden University, under the supervisionof Dr. Virginia Salzer.

Background Information:

The purpose of this study is to explore how mentally ill and homelessmen and women in San Antonia, Texas navigate their way in using thepublic health system.Complexities of this issue include thedifficulty in getting medical care and housing.


If you agree to be in this study, you will be asked to:

  • Participate in an interview with the researcher the interview will take 60-90 minutes and will be audiotaped to ensure the data are captured accurately.

  • I will review questions with Participants to ensure the researcher’s interpretation of responses, and provide feedback to confirm the interpretations, correct misinterpretations, and/or clarify any of the interview data. (estimated time: 30-45 minutes)

Voluntary Nature of the Study:

This study is voluntary. I will respect your decision whether or notyou choose to be in the study. No one will treat you differently ifyou decide not to be in the study. If you decide to join the studynow, you can still change your mind later. You may stop at any time.

Risks and Benefits of Being in the Study:

Being in this type of study involves some risk of the minordiscomforts that can be encountered in daily life, such as stress,frustration, or fatigue. Being in this study would not pose a riskto your safety or well-being.

The benefit to you for participating in this study is the opportunityto add to the literature regarding the complexities ofdifferentiating between healthy and unhealthy religious/spiritualbeliefs and experiences in psychotic patients.


There will be a minimal payment of $15 to participating in thisresearch.


Any information you provide will be kept confidential. Theresearcher will not use your personal information for any purposesoutside of this research project. Also, the researcher will notinclude your name or anything else that could identify you in thestudy reports. Data will be kept secure by using pseudonyms ratherthan your name in the transcribed and published work. Data will bestored in a locked cabinet in the researcher’s office. Data willbe kept for a period of at least 5 years, as required by theuniversity.

Contacts and Questions:

You may ask any questions you have now. Or if you have questionslater, you may contact the researcher Georgann Owens at1-210-422-1504. My Walden University’s approval number for thisstudy will be added upon approval.

The researcher will give you a copy of this form to keep.

Statement of Consent:

I have read or had the information read to me regarding the aboveinformation and I feel I understand the study well enough to make adecision about my involvement. By signing below, I understand that Iam agreeing to the terms described above.

Printed Name of Participant

Date of consent

Participant’s Signature

Researcher’s Signature

Appendix B: Questionnaire


Participant`s Number:

DOB/Age: _

Place of Birth: __

Last Place of Residency___

Race: _

Educational level:

Some High School _

High School Graduate___

Trade School__

Some College_

Undergraduate Degree__

Graduate Degree___


Interview Questions

  1. Mental Health

    1. Can you tell me about how you were first diagnosed with a mental illness?

    2. Do you think this is still a problem for you? Why or why not?

    3. How does your mental illness affect your activity of daily living (ADL) in caring for yourself? Are you able to change clothe as needed brush your teeth, or just rest for a while? Can you give me some examples? Note: if only negative examples are given, can they offer any positive examples?

    4. Are you aware of the programs available to help people with mental illness? Can you describe them to me?

    5. Have you ever participated in such a program? Why or why not?

    6. If you know about programs but didn’t participate, what kinds of things would have made it more likely for you to participate?

    7. What kinds of things kept you from participating?

  2. Physical Health

    1. Do you have any other ongoing medical issues? How long have these been an issue for you?

    2. Do you feel comfortable navigating the healthcare system? Why or why not? Can you give me an example of when you were successful? Can you give me an example of when you were not successful?

    3. Are you aware of the programs available to help people with their physical health? Can you describe them to me?

    4. Have you ever participated in such a program? Why or why not?

    5. If you know about programs but didn’t participate, what kinds of things would have made it more likely for you to participate?

    6. What kinds of things kept you from participating?

  3. Homelessness

    1. When did you first become homeless? Can you tell me how that happened?

    2. How many time have you been homeless?

    3. During those times when you were not homeless, where did you live?

    4. Do you think your mental illness cause your homelessness

    5. Explain on a daily basis do you have access to a bathroom?

    6. Are you aware of the programs available to help people who are homeless? Can you describe them to me?

    7. Have you ever participated in such a program? Why or why not?

    8. If you know about programs but didn’t participate, what kinds of things would have made it more likely for you to participate?

    9. What kinds of things kept you from participating?