Literature Search
Complex trauma and PTSD
Literature reviews
(Bassuk, Melnick et al. 1998)
US
(Kim and Ford 2006)
US
(Tischler, Edwards et al. 2009)
UK
Americans have started to recognize interpersonal violence as a major health care issue.
Increasingly, clinicians are beginning to recognize both the high rate of victimization among
extremely poor women and its health consequences. However, most clinical responses focus
on the immediate effects of child abuse, partner abuse, and rape. The long-term medical and
mental health consequences and the relationship between early victimization and adult
problems are still largely ignored. This article focuses on medical and mental health needs of
extremely poor women survivors of interpersonal violence. It begins by documenting the
extent and nature of violence against low-income women. Special attention is focused on the
long-term sequelae of childhood abuse and on identifying and managing complex trauma
responses in these women. The article concludes by discussing obstacles to care and the
necessity of advocating for increased resources to respond to women living in extreme
poverty.
As the prevalence of homelessness among men increases, the impact of trauma and posttraumatic stress disorder in the lives of homeless men warrants attention. We will review
research and clinical reports on the impact of traumatic event exposure, the antecedents and
consequences of traumatic events, and homelessness among males in order to begin to
develop scientific, public health, and social policy answers to several questions. The nascent
clinical and scientific literature provides evidence of the need for prospective studies of the
etiology, epidemiology, course, and prevention of post-traumatic stress disorder among
males who are at risk for or in the early stages of homelessness. We attempt to summarize,
categorize, and suggest important variables and causal relationships that can inform future
research studies and interventions in order to contribute to the growth of this
underdeveloped and important knowledge base
Homelessness is recognised to be a traumatic event in itself and is often preceded by the
experience of violence. More recent research has indicated that homelessness can function to
enact growth and resilience in women with dependent children. This review paper draws
together findings from a series of studies involving women with dependent children who
experience homelessness. It identifies key psychosocial and health priorities in this
population and how findings related to resilience and growth can be harnessed in therapeutic
1
(Thompson and Carll 2007) -youth homelessness
including why youth become homeless and trauma
and homeless youth
US
work. Pragmatic service developments and examples of good practice in therapeutic and
multi-agency interventions from the domestic violence and homelessness literature are
described and recommendations are made for developing services and working
therapeutically with marginalised and transient populations. Therapists need to work in a
flexible and integrated way with other key services, so that the crisis and long term needs of
this population are met
Homeless adolescents are some of this nation's most vulnerable and underserved youth and
comprise approximately one-quarter of all people who are homeless (Cauce et al., 2000).
Homelessness among youth populations has serious consequences for public health. Topics
discussed in this chapter include why youth become homeless; homeless youth victimization;
trauma and homeless youth; homeless youth case vignettes; intervention options and
recommendations; and social policy implications.
Research Articles suggesting link between complex trauma/ PTSD and homelessness
Reference
n
Country
Population
Method/measures
type
(AndresLemay,
Jamieson et
al. 2005)
3760
Canada
adolescent
Survey
Age of
homelessness
correlated with
child trauma
(Bassuk,
Dawson et al.
2001)
425
US
Women
Longitudinal study
Homeless vs
poor
Shelter
Outcome
Respondents who reported physical abuse only, sexual
abuse only, and physical abuse with sexual abuse
were 2 to 4 times more likely to report running away
from home before age 16 years. Parental psychiatric
disorder, respondent psychiatric disorder, respondent
age, and income were also significant correlates of
running away.
We found that extremely poor women with lifetime
PTSD were more likely to have grown up in family
environments of violence, threat, and anger than
those without PTSD. The strongest risk factor for
PTSD was childhood sexual abuse with threat. Many
low-income women have difficulty using medical care
appropriately because of childhood histories of
physical and sexual abuse, the subsequent
development of post-trauma responses, and structural
barriers to care. Given these factors, it is critical that
2
(BearsleySmith, Bond
et al. 2008)
H- 137
a-r
766
n-r
4844
Australia
adolescent
Chamberlain and
Mackenzies selfreport scale
Homeless (H)
vs at-risk(a-r)
vs students (nr)
(Belcher,
Greene et al.
2001)
(Blankertz,
Cnaan et al.
1993)
US
US
Adults, dual
diagnosis
Risk factors
(Browne
1993)
US
women
prevalence
health care clinicians routinely screen for histories of
violence and PTSD and develop treatment plans that
ensure safety, link current symptoms with prior
experiences, and provide support as necessary. A
team approach coordinated by a case manager may
be the best strategy. Without routine screening for
PTSD and sensitive treatment, many extremely poor
women will receive compromised health care and may
even be retraumatized.
In multivariate analyses, homeless and at risk
adolescents reported equivalent levels of family
conflict, early problem behaviour and low
opportunities and rewards for family involvement.
Compared to adolescents not at risk, at risk
adolescents were more likely to be female and to
show poorer social skills/assertiveness and depressive
symptoms. Compared to at risk adolescents, homeless
adolescents showed additional family, school, peer
and individual risks, but lower depressive
symptomatology.
No abstract
This article examines the prevalence of these five
childhood risk factors among dually diagnosed
(mentally ill and substance abusing) homeless adults
in rehabilitation programs. It further assesses the
impact of each risk factor individually and in
combinations of two on the social functioning skills
and rehabilitation progress of these multiply
disadvantaged clients.
Higher lifetime rates of childhood physical and sexual
abuse. This can increase vulnerability to
homelessness Some of the manifestations of traumatic
3
(Browne and
Bassuk 1997)
h-220
p-216
US
Women
(Buhrich,
Hodder et al.
2000)
157
Australia
(Cauce,
Paradise et al.
2000)
364
US
adolescents
(Craig and
268
UK
Young people
Prevalence
abuse
homeless (h) vs
poor
Composite
International
Diagnostic
interview
prevalence
Diagnostic
interview and selfreport measures
reasons
Homeless vs.
victimization can be systematized in terms of
posttraumatic stress disorder (PTSD).
nearly two-thirds reported severe physical violence by
a childhood caretaker, 42% reported childhood sexual
molestation, and 61% reported severe violence by a
male partner. Comparisons of homeless and housed
women are presented, and implications for prevention
and intervention are discussed in light of recent
welfare reform legislation
All women and over 90% of men reported at least one
event of trauma in their life. Fifty-eight per cent
suffered serious physical assault and 55% witnessed
someone being badly injured or killed. Half the women
and 10% of men reported that they had been raped.
CONCLUSION: The experience of at least one lifetime
event of trauma is almost universal among homeless
people in Sydney and is considerably higher than for
the USA general population. Reasons for such high
prevalence rates are discussed. Depression and
posttraumatic stress disorder are associated with a
history of trauma. Health professionals need to be
aware of past events of trauma among individuals
who are homeless.
Results of analyses suggest that homeless youth come
from generally troubled backgrounds and have
elevated rates of psychiatric disorders. For boys, their
histories typically include physical abuse during
childhood, physical assault on the street, and elevated
rates of externalizing disorders. For girls, histories are
more often marked by sexual abuse during childhood,
sexual victimization on the streets, and elevated rates
of internalizing disorders. Implications of these results
for service delivery are discussed.
The evidence presented in this paper supports the
4
Hodson 1998)
(under 22 years)
domiciled
Women, severe
mental illness
prevalence
(DaviesNetzley,
Hurlburt et al.
1996)
120
US
(Goodman,
Saxe et al.
1991)
(Goodman
1991)
n/a
US
50 each
US
mothers
(Gwadz, Nish
et al. 2007)
85
US
Youth
Risk factors
Drop-in Centre
Homeless vs
housed
Structured
interview
prevalence
hypotheses that characterize the young homeless
population as experiencing higher rates of childhood
adversity and psychiatric disorder than their domiciled
contemporaries. A tentative model is suggested
whereby childhood experiences, educational
attainment and the prior presence of psychiatric
disorder all independently increase the likelihood of
homelessness in a youthful population
The prevalence of childhood abuse in this sample of
women was substantially higher than among homeless
women in general. The experience of childhood abuse
was related to increased suicidality, and resulted in
symptoms of posttraumatic stress disorder for some
women. Women who had suffered abuse were also
much more likely to become homeless during
childhood and it is suggested that this is an important
precursor to homelessness for many homeless women
with chronic and severe mental illness.
Homelessness is a risk factor for psychological trauma,
including implications of trauma theory improving
psychosocial conditions of homelessness.
The only between-group difference was that a
significantly higher proportion of housed mothers had
experienced sexual abuse in adulthood. However, both
groups had high lifetime prevalence rates for all forms
of abuse. Data suggest that mental health services are
urgently needed for both populations because of the
traumatic psychological effects produced by
homelessness and abuse.
Rates of childhood maltreatment were substantial.
Further, almost all youth experienced at least one
traumatic event, with most experiencing multiple types
of trauma. Gender differences were found in the
types, but not prevalence or magnitude, of childhood
5
(Feitel,
Margetson et
al. 1992)
150
Youth
Interview DSM-IIIR
prevalence
Shelter
(Heffron,
Skipper et al.
1995)
(Herman,
Susser et al.
1997)
US
US
Homeless vs 2
other groups
Health clinic
h-92 nh395
US
adult
Structured
interview including
scale for lack of
care from parents
Risk factors
Homeless(h) vs
non-
maltreatment and traumatic events experienced.
Partial symptomatology of PTSD was common for
females but not males. Symptoms of depression and
anxiety were found to co-occur with PTSD for females,
which may complicate treatment efforts.
Most of the respondents came from backgrounds
characterized by severe emotional deprivation and
physical or sexual abuse. Of the 140 who completed
the full interview, 90 percent fulfilled DSM-III-R
criteria for an emotional or behavioral disorder. Fiftynine percent had conduct disorder, three-quarters
were depressed, 41 percent had considered suicide,
and more than one-quarter had attempted suicide
Significant differences in families of origin among
these three groups were identified. On univariate
analysis, homeless persons were found to have an
increased prevalence of alcoholism in the family of
origin, earlier departure from the home, minority
status, a self-described negative childhood,
experiences of abuse as a child, high birth order in
large families, less parental education, less-skilled
parental occupations, less feeling of love in the
childhood family, less likelihood of the father being in
the home, more risk of the father having been in jail,
and less identification with a religious group.
Multivariate analysis revealed that compared to the
study groups, the following family of origin factors
were associated with homelessness: ethnic group,
alcoholism, feeling loved as a child, and having one's
father in jail.
Lack of care from a parent during childhood sharply
increased the likelihood of subsequent homelessness
(odds ratio [OR] = 13), as did physical abuse (OR =
16). Sexual abuse during childhood was associated
6
(Hyde 2005)
(Jainchill,
Hawke et al.
2000)
50
US
Young people
US
Adult
Shelter-based
therapeutic
community
and single items for
abuse Validated
scale
homeless(nh)
with a nonsignificant trend toward homelessness (OR
= 1.7). The risk of subsequent homelessness among
individuals who experienced both lack of care and
either type of abuse was dramatically increased
compared with subjects reporting neither of these
adversities (OR = 26). CONCLUSIONS: Adverse
childhood experiences are powerful risk factors for
adult homelessness. Effectively reducing child abuse
and neglect may ultimately help prevent critical social
problems including homelessness.
Life history
interviews
Why became
homeless
In professional discourses, homeless young people are
often portrayed as victims of physical abuse and
emotional neglect. Although participants' narratives
reveal that abuse and neglect play a central role in
their decisions to leave home, many maintain a sense
of agency in the recounting of how they became
homeless.
The sample presents with extensive psychopathology
and a history of physical and sexual abuse. Gender
differences indicate that, except for antisocial
personality, females yield higher rates on measures of
both psychiatric disturbance and abuse. The
relationship between psychopathology and abuse also
appears to be much stronger for females than for
males. However, the relationship between abuse and
adult homelessness appears to be similar for men and
women. The gender differences in the relationship
between histories of abuse and manifestations of
psychiatric disturbance support a hypothesis that has
been proposed elsewhere: Females internalize the
trauma associated with abusive experience, while
males externalize it. The findings suggest that,
although there may be a need for gender-specific
prevalence
7
(Janus,
Archambault
et al. 1995)
195
Canada
(Kaufman and
Widom 1999)
1196 each
US
(Khurana,
Sharma et al.
2004)
adolescents
Documented
cases of abuse
India
Children
Child
observation
home
Descriptive
investigation
prevalence
Interview + followup
Cases of
neglect vs
matched
controls
hopelessness scale
for children by
Kazdin, Beck
depression
inventory,
Psychological
prevalence
targeted interventions, treatment providers must also
recognize that the impact of abuse seems to
transcend gender within this population.
In this sample, 86% of the population (74% of the
males and 90% of the females) reported at least one
physically abusive experience. The data reported
suggest that this population of adolescents have been
the victims of chronic, extreme abuse, experienced at
a young age, often perpetrated by the biological
parent (most often the mother), and was initiated
prior to the first runaway episode. Female runaways
were at greater risk than males for all types of abuse
experience. Once youths left home, the physical abuse
experiences decreased in frequency, but grew in
severity, particularly for males
Results indicate that: (1) being abused or neglected in
childhood increases the likelihood of running away
from home; (2) both childhood victimization and
running away increase the risk of juvenile arrest; and
(3) chronic runaway youths are at greater risk of
arrest. Running away increases the risk of juvenile
arrest for both childhood victims and nonvictims, and
therefore does not mediate the relationship between
childhood victimization and delinquency. The effect of
running away is stronger for non-abused and nonneglected youths. This unexpected finding suggests
that all runaways are at risk for delinquency regardless
of childhood victimization
20.7% of children were found to have high
hopelessness and 8% of children had depression. 2%
of children revealed that they had attempted suicide
at any point of time in life. Among children with high
hopelessness, 3.2% had ever attempted suicide. 8.3%
of the depressed children gave history of suicidal
8
(Kim and
Arnold 2004)
99
(Martijn and
Sharpe 2006)
35
(McManus
and
Thompson
2008)
n/a
(MorrellBellai, Goering
29
US
Men
5 substance
abuse agencies
Australia
Age 14-25
survey
questionnaire and
RUTTER-B2 scale
were used to
assess various
mental health
problems.
Stressful Life
Events Screening
Questionnaire,
Trauma Symptoms
Checlist-40
Quasi-qualitative
adolescents
Canada
Chronically
homeless
prevalence
Pathways to
homelessness
Abuse-skills
and
homelessnes
Multimethod –
qualitative
Reasons for
homelessness
attempts. 38% of children gave history of physical
abuse, 14.6% of sexual abuse and a large number
reported substance abuse. 69.33% were found to
have behavioral problems (i.e. scored above the
recommended cut off score of 9). 81% of children had
antisocial behavior, 7.8% were neurotic and 10.5%
remained undifferentiated.
Analyses revealed that the number of stressful life
events and the presence of a co-occurring mental
health disorder were both significant predictors of the
severity of trauma symptoms. Findings suggest that
treatment professionals working with this population
should assess for stressful life events and trauma
symptoms as part of a comprehensive approach to
substance abuse treatment for homeless men.
Discuss 5 trajectories into homelessness. More
psychological disorders than average, trauma is
common prior to homelessness
The detrimental effects of traumatic experiences often
inhibit homeless youths' ability to employ the
psychosocial skills necessary to a transition out of
homelessness. Consequently, interventions targeting
the mitigation of post-traumatic stress symptoms
among this population are crucial. This article aims to
address the symptoms and needs of unaccompanied
homeless youth who experience post-traumatic stress
disorder symptomatology and offers a strength-based
intervention framework for understanding, identifying,
and beginning to address trauma-related mental
health needs within the cultural context and
experience of youth homelessness
The findings suggest that people both become and
remain homeless due to a combination of macro level
9
et al. 2000)
(adults)
component
(Mounier and
Andujo 2003)
25
US
youth
Interview, Defense
Mechanism Rating
Scale
Relationship
between
homelessness,
coping
strategies and
victimization
(North and
Smith 1992)
900
US
adult
Diagnostic
Interview ScheduleHomeless
Supplement (PTSD)
prevalence
factors (poverty, lack of employment, low welfare
wages, lack of affordable housing) and personal
vulnerability (childhood abuse or neglect, mental
health symptoms, impoverished support networks,
substance abuse). Chronically homeless individuals
often reported experiences of severe childhood trauma
and tended to attribute their continued homelessness
to a substance abuse problem. It is concluded that
both macro anal individual level factors must be
considered in planning programs and services to
address the issue of homelessness in Canada.
Relationships were demonstrated between use of
defenses and specific as well as cumulative
victimization experiences. All levels of defenses
became more pervasive in response to victimization,
but this was not a predictor of overall immature
defensive functioning. CONCLUSIONS: Clinical and
program interventions to engage homeless youth need
to incorporate an understanding of the relationship
between defenses and victimization in order to be
effective in maximizing upon the strengths of this
population.
Most subjects with PTSD had an additional lifetime
psychiatric diagnosis. No consistent pattern of
association was apparent, however, between
individual diagnoses and either traumatic events or
PTSD. In almost three-fourths of both men and
women, the onset of PTSD had preceded the onset of
homelessness. Childhood histories of abuse and family
fighting were predictive of both traumatic events and
PTSD. The results suggest that factors leading to
PTSD in the study sample began long before the onset
of homelessness and may overlap with factors
operative in the genesis of homelessness.
10
(North, Smith
et al. 1994)
900
US
(Nyamathi,
Wenzel et al.
2001)
507+
partners
US
women
History of adult
victimization yes/no response
format,. revised
version of the
Coopersmith SelfEsteem Inventory
(SEI). Brief
Symptom Inventory
(BSI), Drug History
Form.
prevalence
US
Youth (13-17
years)
Questionnaires,
behavioural
indicators
prevalence
(Powers,
Jaklitsch et al.
1989)
Abuse and
other illness
Sought services
Many subjects had experienced a traumatic event, and
post-traumatic stress disorder was very common.
Substance abuse and other Axis I disorders were
associated with a history of a traumatic event. The
majority of men and a substantial proportion of
women also had a history of physically aggressive
behaviors, often beginning in childhood. Aggressive
adult behavior was associated with substance abuse
and major depression. The aggressive behaviors
usually predated homelessness, and about half
continued after the individual had become homeless.
Thirty-nine percent of the women reported being
physically and/or sexually assaulted as adults.
Controlling for potential confounders, victimized
women were more likely than others to have a history
of childhood sexual and physical abuse, lifetime
substance use, greater mental health
symptomatology, and current risky sexual activity.
Thus, homeless women with mental health and
substance abuse problems ought to be screened for
violent experiences and encouraged to obtain
treatment appropriate to their problems to reduce
their ongoing risk of victimization.
Results indicate that clear behavioral indicators of
maltreatment can be observed among runaway and
homeless youth, which varied as a function of gender,
type of maltreatment, and the reason the youth
sought services from the program. One of the most
common behavioral indicators of maltreatment
observed had to do with school failure. Data showed
several gender differences including the fact that girls
tended to engage in victim type behaviors while boys
tended to be more anti-social. All of the behavioral
11
(Rayburn,
Wenzel et al.
2005)
US
Women
Shelter
(Rew 2002)
s-96, f-32,
i-10
US
youth
(Rew, TaylorSeehafer et
al. 2001)
96
US
adolescents
Longitudinal
analysis
Homeless vs
low-income
Survey, focus
groups and
interviews
prevalence
prevalence
indicators pointed to a high degree of psychological
pathology and dysfunction.
Results highlight the diversity of trauma. In a
longitudinal analysis, women who lived in shelters or
experienced major violence had a twofold increase in
their risk of depression over the 6-month follow-up. In
a cross-sectional analysis, childhood sexual abuse,
living in a shelter, physical violence, childhood physical
abuse, and death or injury of a friend or relative
predicted avoidant coping and symptoms of
depression. Active coping and depression predicted
mental health service seeking among traumatized
women. Modifying coping strategies may ameliorate
some of the negative impact of trauma and potentially
enhance mental health service use among at-risk
women.
Sixty percent of the sample reported sexual abuse,
which was significantly related to loneliness and
inversely related to connectedness and perceived wellbeing. Subjects felt lonely and disconnected. They
perceived their well-being in terms of current health
status.
Over 60% of the sample reported a history of sexual
abuse; the majority were under the age of 12 years
when they first tried alcohol, marijuana, and cocaine;
56.3% had injected drugs, and 46.9% had tried
inhalants. A disproportionate number of Hispanics
(95% of the sample) reported a history of sexual
abuse. Participants with a history of sexual abuse
were significantly more likely than those who did not
have a history of sexual abuse to have used alcohol
and/or marijuana (chi square = 9.93, p < .01) and to
have considered suicide in the past 12 months (F =
14.93, p < .001). We found that sexual abuse history
12
(Rosenheck
and Fontana
1994)
1460
US
(Rosenthal,
Mallett et al.
2006)
692
(Ryan, Kilmer
et al. 2000)
329
US
Adolescents
(Shelton,
14,888
UK
Young adults
is greater in this sample than in the general population
and is particularly prevalent among Hispanic/Latino
subjects. As in other studies, sexual abuse was more
common among females than among males.
Postmilitary social isolation, psychiatric disorder, and
substance abuse had the strongest direct effects on
HML, although substantial indirect effects from
stressors related to being in the war zone and from
premilitary conduct disorder were observed. Several
premilitary factors (e.g., year of birth, childhood
physical or sexual abuse, placement in foster care
during childhood) also had direct effects on HML.
Conflict with parents was the only reason reported as
important by at least two-thirds of respondents. Desire
for independence and/or adventure was rated as
important by nearly one-half of young men and
women.
veterans
Structural Equation
modelling
Causes of
homelessness
Young people
(12-20yrs)
trained interviewers
using Questionnaire
Delivery System,
importance of each
of 22 reasons for
leaving home on a
four-point scale
interviewed over a
year-long period.
Ss also completed
standardized
clinical interviews
and symptom
checklists to assess
mental health
status. Psychosocial
status was
assessed using
standardized, selfreport scales.
Causes of
homelessness
Prevalence and
abuse and
internalizing
Results show significant differences across groups for
rates of assault, rape, depression/dysthymia, and
attempted suicide; and significant differences in
severity of internalizing problems and cognitive
problems. Without exception, the group with histories
of both physical and sexual abuse exhibited the most
severe symptomatology and was at greatest risk for
revictimization. Multiple regression analyses suggested
that abuse histories were predictive of internalizing
problems while family characteristics were more
predictive of externalizing problems.
survey
Causes of
Several factors related to childhood experiences of
13
Taylor et al.
2009)
(Spence, Lee
et al. 2006)
(Stein, Leslie
et al. 2002)
(682 had
been
homeless)
581
US
Surveyed
population
homelessness
poor family functioning, socioeconomic disadvantage,
and separation from parents or caregivers were
independently associated with ever being homeless.
Other significant independent factors included current
socioeconomic difficulty, mental health problems, and
addiction problems. involvement in crime and
addiction problems with gambling and alcohol were
not independently associated with homelessness. The
findings underscore the relationship between specific
indicators of adversity in childhood and risk of
homelessness and point to the importance of early
intervention efforts. mental health problems also
appear to be associated with homelessness,
highlighting the potentially complex service needs of
this population
No abstract
Women
Trauma and
homeless,
substance
abuse
Childhood abuse directly predicted later physical
abuse, chronic homelessness, depression, and less
self-esteem. Parent substance use directly predicted
later substance use problems among the women.
Recent physical abuse predicted chronic
homelessness, depression, and substance use
problems. Greater self-esteem predicted less
depression and fewer substance use problems.
Childhood abuse also had significant indirect effects
on depression, chronic homelessness, and drug and
alcohol problems mediated through later physical
abuse and self-esteem.CONCLUSIONS: Although there
was a strong relationship between childhood abuse
and parent drug use, childhood abuse was the more
pervasive and devastating predictor of dysfunctional
outcomes. Childhood abuse predicted a wider range of
problems including lower self-esteem, more
Shelters or sober
living centers
14
(Sumerlin
1999)
(TaylorSeehafer,
Jacobvitz et
al. 2008)
146
US
Men, chronicity
US
adolescents
Placement
abuse and
homeless
Adult attachment
interview
victimization, more depression, and chronic
homelessness, and indirectly predicted drug and
alcohol problems. The mediating roles of recent
physical abuse and self-esteem suggest salient
leverage points for change through empowerment
training and self-esteem enhancement in homeless
women.
significant with longer periods of time since first
homeless and greater lengths of a current episode of
homelessness associated with childhood out-of-home
placement. Homeless men who had experienced
abuse as a child had more episodes of homelessness
than those who had not experienced abuse. Mean
Brief Index of Self-actualization scores were not
different for those with out-of-home placement or
abuse; however, self-actualization scores were
minimally lower with greater number of homeless
episodes but not with total time homeless. Case
histories supported the quantitative findings that loss
of feelings of belonging in childhood were preparatory
for chronic homelessness
While it has been established that attachment is a
salient factor with regard to childhood maltreatment
and later psychosocial problems, there is a dearth of
information on how homeless youths' thoughts and
feelings about attachment may also be linked to
behavioral risks including alcohol and substance use.
This exploratory study examines older homeless
adolescent's perspectives on attachment, trauma, and
substance use via the semistructured Adult
Attachment Interview and survey data. The findings
illuminate the relationship between these factors and
implications for future research and work with this
population.
15
(Taylor and
Sharpe 2008)
70
(Thompson
2005)
400
Australia
Age 18-73
Randomly
sampled through
8 homeless
services
US
Composite
International
Diagnostic
Interview
Adolescents
Prevalence
The majority of the sample had experienced at least
one traumatic event in their lifetime (98%). Indeed,
the mean number of traumas per person was six. The
12 month prevalence of post-traumatic stress disorder
was higher among homeless adults in Sydney in
comparison to the Australian general population (41%
vs 1.5%). But 79% of the sample had a lifetime
prevalence of post-traumatic stress. In 59% of cases,
the onset of post-traumatic stress
disorder preceded the age of the first reported
homeless episode. CONCLUSIONS: Homeless adults in
Sydney frequently experience trauma and posttraumatic stress disorder. The study found that
trauma and post traumatic stress disorder more often
precede homelessness, but re victimization is
common. These findings highlight the high mental
health needs among homeless people and have
implications for services for homeless people.
Prevalence
Ninety-eight percent of participants had elevated
PTSD symptom scores. Although use of inhalants and
LSD was associated with PTSD symptoms, only
depression, anxiety, and dissociation, mother's ecstasy
or LSD use, youth's worry about family relationships,
and poor family communication predicted higher PTSD
scores. Runaway/homeless youth entering emergency
shelters services must be evaluated concerning
trauma and associated comorbid symptoms
Findings indicate that adolescents exposed to neglect
(beta=-.20) and sexual abuse (beta=-.16) ran away
sooner and were more likely to be victimized on the
street. Rural adolescents who experienced higher
levels of physical abuse relied more heavily on deviant
subsistence strategies (beta=.15) and remained in
Youth
emergency
shelters
(Thrane, Hoyt
et al. 2006)
602
US
Adolescents
Convenience
sample
Interviews, multiple
regression
Abuse and ran
away sooner,
rural vs urban
16
(Tiwari, Gulati
et al. 2002)
40
India
Boys
Characteristics
of runaways
(Tyler 2006)
372
US
youth
Qualitative
interview
pathways
(Tyler and
Cauce 2002)
372
US
Adolescents
interviews
Prevalence and
perpetrators of
abuse
Child
observation
home
Systematic
sampling
Streets and
shelter
abusive homes longer (beta=.15) than their similarly
situated urban counterparts.
The most common reason for running away was;
beating by parents/relatives, followed by a desire for
economic independence (28.5%). Other reasons were
maltreatment by step parent/s, being both parents
dead argument with parent etc. The factors emerging
can be useful for identifying high-risk families with
children in pre adolescent age and hence for
prevention and rehabilitation
Multiple forms of child maltreatment, family
alcoholism, drug use, and criminal activity
characterized early family histories of many youth.
Leaving home because of either running away or
being removed by child protective services often
resulted in multiple transitions, which regularly
included moving from foster care homes to a group
home, back to their parents, and then again returning
to the streets
Approximately one-half of these young people
reported being physically abused and almost one-third
experienced sexual abuse. Females experienced
significantly higher rates of sexual abuse compared to
males, and sexual minority youth experienced
significantly higher rates of physical and sexual abuse
compared to heterosexual youth. Average duration of
physical and sexual abuse was 5 and 2 years,
respectively. Both types of abuse were rated as
extremely violent by more than half of those who
were abused. The average number of different
perpetrators of physical and sexual abuse was four
and three, respectively. Biological parents were the
majority of perpetrators for physical abuse whereas
non-family members most often perpetrated sexual
17
abuse. Average age of perpetrators was late 20s to
early 30s and the majority of perpetrators were male
for both types of abuse. CONCLUSIONS: The pattern
of exploitation and victimization within the family may
have serious and cumulative developmental
consequences for these youth as they enter the street
environment. Early intervention programs are needed
to break the cycle of exploitation and abuse that
adolescents experience within the family. Without
intervention, many of these youth may be at risk of
future exploitation and re-victimization out on the
street.
(Warren, Gary
et al. 1994)
(Weinreb,
Buckner et al.
2006)
(Whitbeck,
Hoyt et al.
1997)
120 +
parents
US
mothers
Prevalence in
1993 vs 2003
US
adolescents
Parent vs
runaway
The authors provide data in this descriptive study to
suggest that physical and sexual abuse within the
family system frequently expedites youths' decisions
to leave home. The role that drugs and alcohol play in
runaway youths' lifestyles is also explained
Homeless families taking part in the 2003 study were
poorer than those taking part in the 1993 study, and
female heads of household in that study reported
more physical health limitations, major depressive
illness, and posttraumatic stress disorder.
Both the parents/caretakers and their runaway
adolescents reported lower levels of parental
monitoring and warmth and supportiveness and higher
levels of parental rejection than comparison groups of
nonrunaway families. Parents/caretakers and runaway
adolescents reported high levels of family violence and
sexual abuse. Similarly, they concur regarding conduct
problems for the adolescents. The findings suggest
that runaway and homeless adolescents accurately
depict the troubled family situations that they choose
18
(Zozus and
Zax 1991)
to leave. The policy implications for recent debates
involving criminalization and mandatory return to
parental custody of homeless and runaway youth are
discussed.
No abstract
US
PTSD/complex trauma in relation to other factors
(Goodman, Rosenberg et al. 1997)
References
(Bassuk, Buckner
et al. 1998)
n
h-220
p-216
Country
US
Population
mothers
Measure/Method
aim
Homeless (h)
vs poor(p)
(Bebbington,
Bhugra et al.
2004)
8580
UK
adults
structured
assessment,
Respondents were
asked whether they
had experienced
selected events
displayed on
cards.(n=8540)
Trauma and
later
disorders
(Bebout, Harris et
al. 2001)
US
(Carroll and Trull
1999)
US
Trauma and
others
African
American
Phenomenological
procedures
Abuse and
substance
Outcome
Homeless and housed mothers had similar rates of
psychiatric and substance use disorders. Both
groups had higher lifetime and current rates of
major depression and substance abuse than did all
women in the National Comorbidity Survey. Both
groups also had high rates of posttraumatic stress
disorder and two or more lifetime conditions
In people with psychosis, there is a marked excess
of victimising experiences, many of which will have
occurred during childhood. This is suggestive of a
social contribution to aetiology.
Describes the measures that residential programs
might want to consider in order to respect the needs
and vulnerabilities of survivors of physical and
sexual abuse.
This study examined how homeless African
American women who have been professionally
19
Women
(Goodman, Dutton
et al. 1995)
99
US
Women, serious
mental illness
(Johnson, Rew et
al. 2006)
371
US
Adolescents
(16-23 years)
Street outreach
centre
Professionally
assessed
use
Abuse and
victimisation
Computer assisted self
interview (A-CASI)
Abuse and
sexual risktaking,
support and
future time
perspective
assessed and who self-report to be dependent on
alcohol and other drugs make sense of their
becoming chemically dependent. The data were
analyzed using phenomenological analysis
procedures. The results show that interviewees
perceived childhood physical, sexual, and
psychological abuse and neglect to be among the
biopsychosocial antecedents to their becoming
chemically dependent.
Three aspects of physical and sexual assault were
assessed: lifetime prevalence; severity, cooccurrence, and recency; and associations between
levels of this victimization and specific
characteristics of the women. Results indicate that
the life-time risk for violent victimization was so high
(97%) as to amount to normative experiences for
this population
Sexually abused participants had significantly less
future time perspective (p = .05), fewer sexual selfcare behaviors (p = .04), and less social support
than non-abused participants (p = .01) and almost
significantly more sexual risk-taking (p = .08).
However, no significant differences were found
between abused and non-abused participants on
sexual self-concept, self-efficacy or intention to use
condoms, safe sex behaviors, AIDS knowledge,
assertive communication, or self-efficacy to perform
testicular/ breast self-exams. Overall, participants
who did not report a history of sexual abuse had
significantly more sexual health resources and
engaged in fewer sex-risk behaviors than those who
reported having been abused. These differences
have notable implications for screening adolescents
for a history of sexual abuse. Adolescents who
20
(Johnson, Rew et
al. 2006)
US
adolescents
(Kim and Ford
2006)
US
Men
Trauma Symptom
Checklist-40, Stressful
Life Event Screening
Questionnaire
Trauma and
mental health
(Kim and Ford
2006)
US
Men
Qualitative interview
Trauma and
mental healt
US
women
qualitative
Substance
abuse and
trauma
(Nyamathi, Bayley
et al. 1999)
414
239
gender
report sexual abuse should receive risk counseling
and be screened regularly for the development of
sexual risk behaviors
We found that male and female abuse victims differ
in terms of their cognitive-perceptual and behavioral
factors associated with sexual health practices. Early
identification of those who have been abused is
critical so that interventions can be developed.
Effective short-term interventions are needed for
the adolescent victims of Child Sexual Abuse (CSA),
particularly those who are homeless and prone to
further sexual victimization.
Analyses revealed that the number of stressful life
events and the presence of a co-occurring mental
health disorder were both significant predictors of
the severity of trauma symptoms. Findings suggest
that treatment professionals working with this
population should assess for stressful life events and
trauma symptoms as part of a comprehensive
approach to substance abuse treatment for
homeless men
reported a high prevalence of depression, family
dysfunction, trauma, and a pattern of several
previous treatment experiences for substance abuse
and/or mental health. Findings imply that in order to
promote long-lasting positive outcomes in substance
abuse recovery, mental health stability, and quality
of life, treatment professionals need to address
complex and interrelated issues that often surround
this underserved population
homeless women who currently used drugs and
alcohol, homeless women who currently used drugs
only, and to a lesser extent current alcohol users
only, had suffered traumatic childhood events and
21
(Nyamathi,
Longshore et al.
2001)
223
US
women
Abuse and
substance
abuse
(Robert, Fournier
et al. 2004)
130
Canada
Adolescents
(12-17yrs)
Behavioural
problems
family dysfunction and had to cope with low selfesteem, emotional distress, and poor physical
health. The initiation of drug and/or alcohol use was
strongly affected by the social influence of other
users. In comparison, homeless women who did not
use drugs or alcohol reported a positive self-image,
few traumatic events, and chose partners who did
not use drugs or alcohol. Common among current
drug and/or alcohol users were the reported social
benefits of drug use. Quantitative analyses revealed
homeless women who were current drug users were
significantly more likely to have experienced
childhood and adult victimization as compared with
women in the other groups
Physical abuse and parental drug abuse predicted
daily drug use in the whole sample and selected
subgroups, whereas parental alcohol abuse
predicted daily alcohol use in the whole sample.
Teen self-esteem was also found to have a
protective effect on daily alcohol use for the sample
and for African American women. Negative peer
influence in adolescence predicted daily drug use
among high-acculturated Latinas. In summary,
childhood abuse, parental substance use, and
negative peer influence affect important roles in
homeless women’s daily substance use.
Therefore, the members of Group B have a higher
probability of being diagnosed as having a conduct
disorder, being male, and associating with
delinquent peers. This group had not experienced a
higher level of parental violence. The opposite is
true for the members of Group A. Conclusion: Our
study demonstrates that parental violence and
behavioral problems are variables that are
22
(Stump and Smith
2008)
50
US
women
(Tam, Zlotnick et
al. 2003)
397
US
Adults
(Tyler, Hoyt et al.
2001)
372
County-wide
probability
sampling
US
Youth (1220yrs)
Streets +
Substance
use and PTG
Interviewed 3 times
over 15 months
Trauma and
substance
use/labour
participation
Abuse and
street sexual
victimization
independently related to the defined categories of
runaways. Therefore, these variables do not
constitute, as some thinkers have claimed, the
components of a unique dynamic able to explain the
phenomenon of the runaway. Our results vitiate the
doubts sometimes expressed by researchers about
the importance of parental violence to the
phenomenon of adolescent runaways.
In line with predictions, more current substance use
was related to less PTG, more reliance on avoidant
coping once approach coping was accounted for,
and greater PTSD symptomatology. Levels of
growth were comparable to those found in samples
with less trauma exposure.
Adverse childhood events were precursors to
adulthood alcohol and drug use. Consistent
substance use was negatively associated with longterm labor force participation and with social service
utilization among homeless adults. Adverse events
at childhood, however, were positively associated
with service use. Conclusions: Adverse childhood
events may contribute to negative adulthood
consequences, including consistent substance use
and reduced labor force participation. Agencies that
are involved in halting the abuse or neglect also
should participate in more preventive interventions.
Job-related assistance is particularly important to
facilitate employment and labor force participation
among homeless adults.
Results show that high rates of both childhood
sexual abuse and street sexual victimization were
reported, with females experiencing much greater
rates vs their male counterparts. Early sexual abuse
23
shelters
(Tyler, Hoyt et al.
2000)
361
US
Female
adolescents
Risk amplification
model
Abuse and
victimisation
(Whitbeck, Hoyt et
al. 1997)
120 +
parent
Us
adolescent
interviews
Abuse and
victimization
(Whitbeck and
1-156
US
Adolescents(1)
interviews
Age and
in the home increased the likelihood of later sexual
victimization on the streets indirectly by increasing
the amount of time at risk, deviant peer affiliations,
participating in deviant subsistence strategies, and
engaging in survival sex. These findings suggest
that exposure to dysfunctional and disorganized
homes place youth on trajectories for early
independence.
early sexual abuse in the home had a positive direct
effect on sexual victimization of adolescents on the
streets. Early sexual abuse also increased the
likelihood of later sexual victimization indirectly by
increasing the amount of time at risk, deviant peer
associations, and incidents of survival sex. Young
women who leave dysfunctional and disorganized
homes often characterized by abuse continue on
negative developmental trajectories once they reach
the streets. The social context of street life puts
these adolescents in close proximity to potential
offenders and exposes them to crime and criminals.
The combination of a negative developmental
trajectory and the high-risk street environment
increases these young women's chances of being
sexually victimized
Data on levels of physical and sexual abuse within
family of origin, participation in deviant subsistence
strategies, and levels of victimization while on the
streets were collected. Path analysis indicated that
abusive family backgrounds had a positive direct
effect on victimization of adolescents on the streets,
and indirectly increased the likelihood of
victimization by increasing the amount of time at
risk, deviant peer associations, and risky behaviors
Homeless adolescents were more likely to be from
24
Simons 1993)
2-319
and adults(2)
Streets +
shelters
trauma
abusive family backgrounds, more likely to rely on
deviant survival strategies, and more likely to be
criminally victimized. A social learning model of
adaptation and victimization on the streets was
hypothesized
Research looking at Mental Health
Reviews/chapter
reference
(Buckner, Bassuk et al.
1993)
country
US
(Minkoff, Drake et al.
1992)
US
(Driessen and Dilling 1997)
German?
(Eagle, Caton et al. 1990)
US
(Fazel, Khosla et al. 2008)
UK
outcome
A review of the relevant literature is followed by an exploration of the complex relationship, especially for
women, between homelessness and mental health. Various mental health and gender-related concerns that
have implications for the design of interventions for homeless women are explored
psychiatry's awareness of the problem of substance use disorder among people with severe mental illness-often referred to as dual diagnosis--has grown rapidly over the past 10 years / individuals with HDD
[homelessness and dual diagnosis] constitute a subgroup defined by three major problems--homelessness,
severe psychiatric disorder, and substance use disorder / for this particular subgroup, homelessness operates
metaphorically as a third diagnosis; all of the difficulties that attend dual diagnosis are amplified by a third set
of complicating factors related to homelessness / review current thinking regarding HDD in several domains:
epidemiology, barriers to care, philosophical issues related to treatment, emerging clinical models, phases of
treatment, and research issues
The state of Anglo-American research on psychiatric disorders among homeless persons is summarised. Several
authors reported on life-time prevalence (50-75%) and present prevalence rates (30-50%) of psychiatric
disorders in this population. Alcohol-related and drug-related disorders were most frequent. Most studies,
however, only included single and male subjects, while there is little information on homeless persons living
with a partner or in a family. Up to now, no representative studies exist. Some recent investigations evaluated
classic single case models versus case management approaches. Short-term programmes only yielded shortterm effects, but linking psychiatric and social services seems to improve health service utilization by the
homeless
focus on a subpopulation of the homeless, those who are mentally ill (from the chapter)
explore who they are and how they came to be homeless
We undertook a systematic review of surveys of such disorders in homeless people. The most common mental
25
(Folsom and Jeste 2002)
(Fischer and Breakey
1991)
US
US
(Kamieniecki 2001)
Australia
(McQuiston, Gillig et al.
2006)
US
(Philippot, Lecocq et al.
2007)
Belguim –
review
focused on
Europe
(Scott 1993)
UK
disorders were alcohol dependence, which ranged from 8.1% to 58.5%, and drug dependence, which ranged
from 4.5% to 54.2%. For psychotic illness, the prevalence ranged from 2.8% to 42.3%, with similar findings
for major depression. CONCLUSIONS: Homeless people in Western countries are substantially more likely to
have alcohol and drug dependence than the age-matched general population in those countries, and the
prevalences of psychotic illnesses and personality disorders are higher. Models of psychiatric and social care
that can best meet these mental health needs requires further investigation
This article systematically reviews studies of prevalence of schizophrenia in homeless persons.
Describes recent research on the prevalence of alcohol, drug, and mental (ADM) disorders and the
characteristics of homeless substance abusers and persons with mental illnesses. Methodological problems in
homelessness research are reviewed, particularly in relation to definitions of homelessness and sampling- and
case-ascertainment methods. Prevalence rates of ADM disorders are much higher in homeless groups than in
the general population.
Reviewed literature on psychological distress and psychiatric disorders among homeless youth in Australia, and
compared these rates with Australian youth as a whole. 14 separate studies were located. Homeless youth in
Australia have extremely high rates of psychological distress and psychiatric disorders. As homeless youth are
at risk of developing psychiatric disorders and possibly self-injurious behavior the longer they are homeless,
early intervention in relevant health facilities is required
We have set out to assemble a practical clinical guide for work with homeless people who have mental illness,
written by clinicians, for clinicians. It approaches treatment and rehabilitation from the vantage point of the
treatment environment, from street to housing--and, we hope, almost everything in between. The ideas in this
book reflect what we believe is the evolution of consensus on a clinical approach to the homeless mentally ill
person, developed over more than two decades by many experts but until now not assembled in a detailed,
practical format.
The rapidly growing, but still small, research literature on homelessness in Europe has often been provided by
non-academics, using qualitative methods, and has been published in sources that are not widely available.
This article summarizes definitions employed, observed prevalence, the socio-demographic characteristics, and
the physical and mental health status of the homeless in Western Europe. Research pertaining to the causes of
homelessness and the societal response to the problem are also reviewed, and the ethical and methodological
questions raised by European researchers are debated. A critical analysis of the largely descriptive European
research is provided, and some noteworthy exceptions are described. We also discuss a number of promising
theoretical models, including those that focus on learned helplessness, social strain, and social stress
Significant mental illness is present in 30-50% of the homeless: functional psychoses predominate; acute
distress and personality dysfunction are also prevalent. Co-morbidity of mental illness and substance abuse
occurs in 20%, and physical morbidity rates exceed those of domiciled populations. The homeless mentally ill
26
also have many social needs. Pathways to homelessness are complex; deinstitutionalization may be only one
possible cause of the increase in the number of homeless people. This review outlines the research, highlights
current views on the definition and classification of homeless populations, and offers some guidelines on
avenues which need to be explored
This paper reviews 18 surveys of mental health problems among homeless adolescents and reports on a pilot
study of the same topic conducted in Amsterdam. Sampling methods and measures of mental health are
discussed. The reported estimates of mental health problems vary greatly, very probably because of
methodological differences. Despite the different methods used, there seems to be considerable research
evidence to support a high prevalence of mental disorders among homeless adolescents. The results of the
pilot study of 50 homeless adolescents in Amsterdam are consistent with the surveys reviewed. A highly
structured interview was conducted at all four services sites for homeless adolescents in Amsterdam. Of the
homeless adolescents interviewed, 78% had at least one lifetime DIS/DSM-III-R diagnosis, and 64% had at
least one 1-month diagnosis
Research on the mental health and service needs of homeless seniors has been scant. This paper reviews the
available literature and presents findings of a Toronto survey in an effort to describe the demographics of
homeless seniors, their level of impairment, and their mental and physical health needs. Although seniors
represent a small percentage of the homeless population, their numbers are growing. The available literature
suggests a high prevalence of psychiatric disorders and cognitive impairment in this population, with a greater
proportion of older women than men having severe mental illness.
(Sleegers, Spijker et al.
1998)
Netherlands
(Stergiopoulos and
Herrmann 2003
Canada
(Vázquez and Muñoz
2001) Vázquez and Muñoz-
Spain
In the present article, the authors synthesize the main data on this topic available in Spain, first, by presenting
preliminary results of a project investigating the sociodemographic characteristics of the homeless in Madrid
and, second, by examining the complex relationships among homelessness, mental health, and stressful life
events.
(Wallace, Struening et al.
1993)
US
what are the causal relationships between the recent environmental blight of urban homelessness and
psychopathological symptoms / the complex feedback loops involved in these processes are discussed / stress
the importance of social networks for the development of coping strategies of individuals threatened by the loss
of their regular domiciles, a loss that is viewed by the authors as a "slow disaster" (from the introduction)
the rigorous experience of IFD [irregular forms of domicile] itself may exacerbate, or even trigger, behavioral
and other symptomatology / argue that the often observed relationship between psychopathology and
homelessness has led to a misidentification of the causal process, and that a larger perspective is required if
proper interventions are to be designed and effectively implemented
27
Research articles(mental health)
Reference
(Aichhorn,
Santeler et al.
2008)
n
40
Country
Austria
Population
Young people (14-23
years)
Shelter/counselling
centre
Method/measures
Structured Clinical
Interview for DSMIV (SKID-I)
longitudinal
type
prevalence
(Barak and
Cohen 2003)
2567
Israel
elderly
Structured Clinical
Interview for DSMIV
Prevalence
(Bassuk, Rubin
et al. 1984)
78
US
All ages
interviews
Prevalence
Emergency shelter
Outcome
The results show that 58% of the homeless
adolescents were exposed to continuous violence in
their families and that violence was a major reason
for them to leave home. The overall prevalence of
diagnosed psychiatric disorders was 80% in the
whole sample; the leading disorder was substance
abuse/dependence (65%), followed by mood
disorders (42.5%), anxiety disorders (17.5%) and
eating disorders (17.5%). Duration of homelessness
had the greatest influence on the prevalence of
mental disorders. Longer duration of homelessness
was associated with a higher risk of psychiatric
disorder or self-harm. These results demonstrate the
urgent need for early psychosocial and psychiatric
help for homeless adolescents
In 44/98 (44.9%), a formal DSM-IV axis I psychiatric
disorder was diagnosed, most common being
dementia (15/44) and schizophrenia (15/44). A
significant minority of 13/44 (29.5%) were
diagnosed and treated prior to becoming homeless.
Physical co-morbidity was found in nearly 2/3
subjects. Following intensive case-management by
social workers, 35/44 (79.5%) subjects were
successfully placed in permanent housing.
The vast majority were found to have severe
psychological illnesses that largely remained
untreated. Approximately 91% were given primary
psychiatric diagnoses: About 40% had psychoses,
29% were chronic alcoholics, and 21% had
personality disorders. Approximately one-third had
been hospitalized for psychiatric care. The authors
28
(Booth and
Zhang 1996)
219
US
Adolescents and
children
(Breakey,
Fischer et al.
1989)
298 men
and 230
women then
subsample
of 203
subjects
was
randomly
selected
US
(Caton, Shrout
et al. 1995)
100 each
US
Women with/without
schizophrenia
(Chen, Tyler et
al. 2004)
361
US
Adolescent female
missions, shelters,
and jail
Diagnostic
Interview Schedule
for Children
baseline interview
that provided
extensive
sociodemographic
and health-related
data In the second
stage, systematic
psychiatric and
physical
examinations.
Standardized
research
instruments
Prevalence and
relationships
Schizophrenia
and other
diagnoses
Abuse and
substance use
discuss the relationship of mental health policy to the
homeless and suggest that shelters have become
alternative institutions to meet the needs of mentally
ill people who are no longer cared for by
departments of mental health
Although these constructs were related to each
other, a third of the subjects met criteria for only
one. Childhood sexual abuse was associated with
conduct disorder, while living in a home where drugs
were used was associated with aggression. Severe
aggressive behavior was associated with other
problem behaviors, including attempted suicide,
behavior that precipitated residential psychiatric
treatment, pregnancy, arrests, and convictions.
Data from the clinical examinations demonstrate the
high prevalence of mental illnesses and other
psychiatric disorders and of a wide range of physical
disorders and confirm the high prevalence of alcohol
abuse disorders. The high rates of comorbidity of
these conditions is demonstrated and data are
provided on the subjects' needs for mental health
and substance abuse services
Findings adjusted for ethnicity revealed that
homeless women had higher rates of a concurrent
diagnosis of alcohol abuse, drug abuse, and
antisocial personality disorder. Homeless women also
had less adequate family support.
the current study revealed a high prevalence of drug
use, especially use of cocaine among youths with
sexual abuse histories. Path analyses showed that
early sexual abuse indirectly affected drug use on
the streets via running away at an earlier age,
29
(Chen, Thrane
et al. 2007)
US
Adolescent
(conduct disorder)
Interview
Conduct
disorder and
other
(Commander,
Davis et al.
2002)
UK
Young people
Survey
Homeless vs
non-homeless
(Commander
and Odell
2001)
UK
Psyhiactiric disorders
– compares needs of
homeless vs nonhomeless
Matched controls
Homeless vs
non-homeless
spending more time on the street, and use of deviant
strategies to survive
compared with those who exhibit adolescent-onset
conduct disorder, youth with childhood onset are
more likely to engage in a series of antisocial
behaviors such as use of sexual and nonsexual
survival strategies. Second, youth with childhoodonset conduct disorder are more likely to experience
violent victimization; this association, however, is
mostly through an intervening process such as
engagement in deviant survival strategies.
The homeless sample were younger and more likely
to be male than their domiciled counterparts. They
had more often spent time in institutional child care
and had worse educational records and lower levels
of employment. Young people who were homeless
had greater involvement with the police, more
frequently used illicit drugs and reported worse
physical and mental health than those in private
households. They were equally likely to see a general
practitioner and more often consulted for 'nerves' as
well as having a higher rate of contact with mental
health professionals
Homeless patients were more symptomatic and
behaviorally disturbed than controls. They were
significantly more likely to have a criminal history
and to be identified by key workers as having
problems related to substance use. Homeless
patients were less likely to have been born in
Birmingham and to have ongoing contact with
childhood carers but despite being less aware of the
need for treatment, uptake of psychiatric care was
comparable with that of controls. The implications
for the development of dedicated mental health
30
(Connolly,
CobbRichardson et
al. 2008)
60
US
(Cougnard,
Grolleau et al.
2006)
104
France
(Crane 1998)
255
UK
(DeMallie,
North et al.
900
US
Structured Clinical
interview (DSM IV
axis I &II
disorders), Positive
and Negative
syndrome Scale
Personality
disorder
prevalence
ICD-10 diagnosis
Prevalence and
comorbidity
Older adult
Semi-structured
interviews
Cause of
homelessness
Older vs younger
National Instiutue
of Mental Health
Prevalence
Drop-in clinic
Emergency
psychiatric serivces
services for this population are discussed.
Very high rates of all personality disorders were
found for Cluster A (73% paranoid, 65% schizoid,
43% schizotypal), B (57% antisocial, 62%
borderline, 20% histrionic, 57% narcissistic) and C
(50% avoidant, 25% dependent, 57% obsessive
compulsive). Axis I mood, anxiety, and substance
use disorders were each diagnosed in over half the
sample. At least one Cluster A disorder was
diagnosed in 92% of the sample, and these disorders
were distinguished from Axis I psychotic disorders
(20%) with regard to prevalence, patterns of
association, and constellation of symptoms. Cluster A
disorders were not associated with any Axis I
disorder, suggesting diagnostic independence in this
sample.
Nearly one out of three homeless subjects (32.7%)
presented with a psychotic disorder, a higher
proportion than that found in non-homeless subjects
(15.7%). Compared to non-homeless subjects with
psychosis, homeless subjects with psychosis were
more likely to be male and to present with drug use
disorder.
There was a high prevalence of mental illness among
the Ss and this was a factor in the entry to
homelessness in many cases. There were indications
that some Ss with mental health problems became
homeless because their needs had been neglected or
undetected. Mental health problems also had an
impact on the circumstances of older homeless
people and affected their ability to seek and accept
help.
Compared with their younger counterparts, older
subjects were more likely to be male and white, to
31
1997)
Diagnostic
Interview Schedule
(Fichter,
Koniarczyk et
al. 1996)
271
Germany
men
. The Diagnostic
Interview Schedule
(DIS) was used for
diagnostic
classification
according to DSMIII in the main
interview
Prevalence
(Fichter and
Quadflieg
2005)
265
Germany
men
Interview
Differences over
3 years
(Fischer,
51
US
Survey, diagnostic
Prevalence
report lower incomes and poorer health, and to
meet criteria for lifetime alcohol-use disorder. Fewer
older than younger subjects met criteria for lifetime
drug use disorder and post-traumatic stress
disorder. These findings suggest that older and
younger individuals have different vulnerabilities to
homelessness.
the following lifetime prevalence rates were
obtained: 91.8% for substance use disorder (82.9%
alcohol dependence), 41.8% for affective disorders,
22.6% for anxiety disorders and 12.4% for
schizophrenia. Of the homeless males in Munich,
94.5% had at least one DIS/DSM-III axis I diagnosis.
Six-month prevalence data is also presented. Results
are compared with those of a very similar study on
homeless individuals in Los Angeles, which also used
DIS/DSM-III diagnoses. In comparison with
representative community samples in the United
States and in Germany, mental illness was much
more frequent among homeless individuals in Munich
as well as in Los Angeles. Implications for health
care planning are discussed.
Rates of mental illness decreased from 79 % to 66%
over 3 years possibly due to an improved housing
situation and increased medical/psychiatric attention
and service. The prevalence of mood disorders,
substance use disorders and anxiety disorders was
significantly lower at 3-year follow-up while psychotic
disorders showed a slight increase over time. A high
rate of use of general medical inpatient services was
found. Considering the very high prevalence of
mental illness, the use of psychiatric services was
very low with some increase over time.
bout one-third of the homeless scored high on the
32
Shapiro et al.
1986)
interview schedule
Mission usrs
(Greifenhagen
and Fichter
1997)
32
Germany
women
Diagnostic
Interview Schedule
for DSM-III
(Haugland,
Siegel et al.
1997)
201
US
Have mental illness
intake assessment
semistructured
interview
(Koegel,
Burnam et al.
1988)
379
(Kovess and
Mangin
Lazarus 1999)
838
France
(McGilloway
and Donnelly
401
UK
(Northern
shelter
US
Sheltered +
unsheltered
Single people
Prevalence
Diagnostic
Interview Schedule
Prevalence
Composite
International
Diagnostic
Interview
Prevalence
Institutional history
Prevalence
General Health Questionnaire which measures
distress. A similar proportion had a current
psychiatric disorder as ascertained by the Diagnostic
Interview Schedule (DIS), with the homeless
exhibiting higher prevalence rates in every DIS/DSM
III diagnostic category compared to domiciled men
Results point to very high prevalence rates of mental
disorders among homeless women. The most
frequent diagnostic groups were alcohol and drug
abuse (lifetime prevalence rate 90.6%), affective
disorders (50.0%), anxiety disorders (43.8%) and
schizophrenia (21.9%).
Twenty-one percent of the cohort was classified as
having mental illness. Seventy-two percent had a
diagnosis of drug abuse or dependence, and 51
percent had alcohol abuse or dependence. Persons
with mental illness also experienced homelessness of
some kind over a significantly longer period
Analyses indicated that Ss' lifetime and current rates
of major mental illnesses were disproportionately
high when compared with a household sample for
the city. 12% of the Ss had dual diagnoses of
chronic major mental illness and chronic substance
abuse.
The lifetime prevalence of psychiatric disorders was
57.9%, while the 1-year prevalence was 29.1%. For
definite psychotic disorders, prevalence was 16%
(lifetime) and 6% (1 year). Generally, this Parisian
homeless population had some access to care: in the
preceding 6 months 57.7% of them had been
medically attended and 14.2% of these had been
hospitalised.
41% were identified as having a mental health
problem. 59% of Ss in this target' group had an
33
2001)
Ireland)
(Mundy,
Robertson et
al. 1990)
(North,
Thompson et
al. 1997)
96
US
h-166
nh-107
+ h-900
US
(North, Smith
et al. 1993)
900 each
US
adoloescents
Prevalence
DSM IIIR
Homeless (h) vs
non-homeless
(nh)
National Institute
of Mental Health
Diagnostic
Interview
Schedule.
Homeless vs
non-homeless
Outpatient clinic
(n=900 from survey)
institutional history. Almost 25% of residents had
high deviant behavior scores. Mean general behavior
scores indicated that, overall, the group was
comparable with the worst 15% of patients in an
average day hospital, although half were rated as
having sufficient skills to "survive" in the community
with minimal or no formal support.
No abstract
Rates of schizophrenia, bipolar disorder, and
somatization disorder were not significantly different
between homeless and non-homeless groups. Major
depression was about four times as prevalent in nonhomeless men as in homeless men. Homeless men
were significantly more likely than non-homeless
men to qualify for a diagnosis of alcohol use
disorder, and homeless women were more likely
than other women to qualify for a diagnosis of drug
use disorder. Both homeless men and women were
significantly more likely than their domiciled
counterparts to meet criteria for antisocial
personality disorder. Personality disorder other than
antisocial was more prevalent in nonhomeless men
than in homeless men. Combined rates of personality
disorder were significantly higher among homeless
than non-homeless women, but not men.
In this sample of homeless men and women, most,
but not all, adult symptoms of antisocial personality
disorder were significantly associated with number of
childhood conduct disorder symptoms. The onset of
symptoms of antisocial personality disorder usually
preceded the onset of homelessness. The rates of
antisocial personality disorder were not significantly
34
(O'Reilly,
Taylor et al.
2009)
25 homeless
young
people, 5
Mental
Health
Coordinators
and 12
homeless
shelter staff.
UK
young people
(Pollio, North
et al. 1997)
60 each
US
Mental illness
(Reinking, Wolf
et al. 2001)
150
Netherlands
Adult
living in homeless
shelters in 5 large
geographical areas (
6 centres for
homeless
discourse analysis
of semi-structured
interviews,
Perceptions of
mental health
Housed vs not
housed
the depression
screener from
Schrijvers et al.,
the schizophrenia
section from the
Composite
International
Diagnostic
Interview (CIDI) a
Prevalence
affected by discounting the antisocial disorder
symptoms thought to be confounded with
homelessness. CONCLUSIONS: Overall, the data
support the appropriateness of the diagnosis of
antisocial personality disorder among homeless
populations. It cannot be said from these data that
homelessness often leads to antisocial behaviors
They report negative and stigmatising descriptions of
mental health despite their involvement with a
mental health service. Four key interpretative
repertoires are identified; denial of problems, mental
health as negative, the need to talk, and challenging
prejudice. It is concluded that the term 'mental
health', which appears in the title of the service (of
which they are clients), presents barriers for usage
but works to challenge prejudice and educate young
people.
Use of eight types of services over a 26-month
period was examined. Individuals whose primary
presenting problem was subsistence needs were
more likely to be housed than those whose primary
problem was mental, illness or substance abuse.
Those with a diagnosis of personality disorder used
fewer services. Housed individuals were more likely
to use services than those who were homeless
32% had a more narrowly defined form of
depression, 15% a schizophrenic disorder (DSM-IIIR-codes 295.00-295.70) and 52% an antisocial
personality disorder. In the case of depression and
schizophrenia it concerned a 6-month prevalence
and in the case of antisocial personality disorders it
concerned the lifetime prevalence.
35
(Slesnick and
Prestopnik
2005)
226
Us
Youth (13-17 years)
Runaway shelters
(Smith, North
et al. 1993)
300
US
Women
modified
questionnaire from
Schrijvers, related
to the DSM-III-R,
about aggressive
behaviour and the
Addiction severity
index, European
variant, version III.
DSM-IV based
computerized
diagnostic
interview schedule
for children
Diagnostic
Interview schedule
Prevalence
Prevalence
shelters
(Taylor,
Stuttaford et
al. 2006)
150
UK
Young people
18 foyers in 5
regions
history
The majority of the youth in our sample met criteria
for dual or multiple diagnosis (60%) with many
having more than one substance-use diagnosis
(56%). The severity of mental-health and
substance-use problems in this sample of substanceabusing runaways suggests the need for continued
development of comprehensive services. The range
and intensity of diagnoses seen indicates a need for
greater focus on treatment development and
strategies to address their multiple areas of risk.
Schizophrenia and bipolar affective disorder account
for only a small portion of the mental illness in these
women. Nearly one in three has a history of
substance abuse, with drug abuse being more
prevalent than alcoholism. One third of the sample
met lifetime criteria for posttraumatic stress disorder.
One fourth of the women have received inpatient
psychiatric care, and the majority with a
nonsubstance Axis I diagnosis have received some
mental health treatment.
Young people reported multiple needs such as use of
illicit drugs, experience of physical or sexual abuse,
and self-harm. lengthy and recurrent mental health
problems from childhood, with intermittent and
usually fragmented contact with services. There was
36
(Timms and
Fry 1989)
UK
Men
interviewed
prevalence
The Family Crisis
Oriented Personal
Evaluation Scales
(F-COPES) the
General Health
Questionnaire
(GHQ) a semistructured
questionnaire
identified their
goals.
Coping
strategies and
mental health
Salvation Army
hostel
(Tischler and
Vostanis 2007)
72, 44 at
follow-up
(Tolomiczenko,
112
mothers
a subset of the
a range of mental complaints, predominantly
depressive, anxiety and post-traumatic stress
symptoms Conclusions: The young homeless people
referred to the mental health service reported a
range of complex mental health needs, the majority
of which could not be met by statutory specialist
services. Young people's lower to medium level
mental health needs could be met by services
operating on the interface with specialist services, if
these are jointly planned and co-coordinated.
Thirty-one per cent fulfilled the diagnostic and
statistical manual (DSM: 111R) criteria for a
diagnosis of schizophrenia and more than half were
not in contact with psychiatric services. This
suggests that a significant number of male
schizophrenics are lost to follow-up and become
homeless.
Lower use of problem-focussed coping was
associated with poorer mental health at the time of
homelessness. Mental health problems improved
over time, but levels of psychopathology remained
high at follow-up. Most women had achieved their
primary goal of resettlement, and this was associated
with use of problem-focussed coping. Lower use of
problem-focussed coping, in particular, acquiring
social support, was associated with continuation of
mental health problems at follow-up, however the
greatest predictor of mental health at follow-up was
mental health status whilst homeless. Despite
exposure to major stressors and poor mental health,
mothers experiencing homelessness can maintain
their ability to cope effectively, in order to achieve
their goals.
The psychiatric status of homeless adults has been
37
Sota et al.
2000)
Personality
Assessment
Inventory, this
study tests the
feasibility and
usefulness of a
brief, selfadministered
questionnaire
(Torchalla,
Albrecht et al.
2004)
17
Germany
women
Structured Clinical
Interview for DSMIV (SKID-I).
Prevalence
(Whitbeck,
Hoyt et al.
2007)
428
US
16-19years
Interviews
Prevalence
described primarily in terms of Axis I disorders. By
adding Two of these were characterized by extreme
scores on pathological dimensions of personality
(borderline features, antisocial traits, and
aggressivity) and differed primarily on the dimension
of suicidality. The third reflected moderate levels of
personality dysfunction and the fourth did not
deviate from adult nonclinical norms. Brief
personality assessment can be a cost-effective
approach to matching services with clinical needs of
homeless adults by attending to interpersonal
dimensions that will likely affect service provision
The prevalence of diagnosed psychiatric disorders
was 71 %; the leading disorder was substance
abuse/dependence (43 %), followed by anxiety
disorders (35 %) and schizophrenia (12 %). Multiple
diagnoses were made in 35 % of the women.
DISCUSSION: Striking features were the often early
onset of homelessness and the reticence in seeking
help. The flight from violence was a crucial
precipitant of the loss of the home and should also
be discussed in the context of the development of
the psychiatric disorders.
About one-third (35.5%) of the runaways met
lifetime criteria for PTSD and 16.1% met 12-month
criteria for the disorder. More than 90% of the
adolescents who met criteria for PTSD met criteria
for at least one of the other four diagnoses.
Multivariate analyses indicated that correlates of
PTSD were age of adolescent, being female, having
experienced serious physical abuse and/or sexual
abuse from an adult caretaker, and having been
assaulted or injured by weapon when on the street.
The multiplicative interaction between sexual abuse
38
(Whitbeck,
Johnson et al.
2004)
428
US
Adolescents (1619years)
Streets and shelter
UM-CIDI and
DISC-R structured
interviews
Prevalence and
comorbidity
(Winkleby,
Rockhill et al.
1992)
1437
US
adult
Survey
Prevalence
(Yoder,
Longley et al.
2008)
428
US
adolescents
Factor Analysis
Suicidality and
psychopathology
by caretaker and sexual assault when the
adolescents were on their own was statistically
significant, indicating that rape victims were highly
likely to meet criteria for PTSD regardless of early
sexual abuse. At very high levels of early sexual
abuse, the probability of meeting criteria for PTSD
converges with that for sexual assault victims
Homeless and runaway adolescents in small and
mid-sized Midwestern cities report significant levels
of mental disorder and comorbidity that are
comparable and often exceed that reported in
studies of larger magnet cities.
The largest differences between the homeless and a
comparison group of 3122 nonhomeless adults were
for psychiatric hospitalization (odds ratios [ORs] of
4.6 for men and 5.9 for women) and alcohol abuse
(ORs of 2.3 for men and 4.0 for women). However,
when pre-homeless prevalences of addictive and
psychiatric disorders were compared with
prevalences among the non-homeless, absolute
differences were no greater than 12%.
support for a three-factor model in which suicidality
(measured with lifetime suicidal ideation and suicide
attempts), internalizing disorders (assessed with
lifetime diagnoses of major depressive episode and
post-traumatic stress disorder), and externalizing
disorders (indicated by lifetime diagnoses of conduct
disorder, alcohol abuse, and drug abuse) were
positively intercorrelated. The findings illustrate the
utility of a dimensional approach that integrates
suicidality and psychopathology into one model.
39
Research looking at interventions
Literature reviews
(Bhui, Shanahan et al.
2006)
UK
(Dickey 2000)
US
A literature review of homeless service users' perceptions of services for homeless mentally ill people was
supplemented by a qualitative in-depth survey of 10 homeless people. This article reports on their views about the
services they receive. Mismatch between expectations and provision, disputes with healthcare providers, dissatisfaction
with the degree to which they have choice in their care, and suspicions about the intentions of health professionals
demonstrate the extent to which powerlessness and social exclusion are replicated in healthcare economies.
Despite recent prosperity in the U.S., homelessness is still a widespread social problem. It is estimated that 25% of
homeless persons have a serious mental illness. This article will review the literature evaluating prevention services and
specialized outreach, treatment, and housing programs designed to reduce homelessness for individuals who are
mentally ill. Although these interventions have been helpful in addressing the complex needs of the homeless mentally
ill, it is difficult to measure how they have improved outcomes. It is even more challenging to determine whether the
programs are cost-effective.
Research Articles
Reference
(Ball, CobbRichardson et
al. 2005)
(Christensen,
Hodgkins et al.
2005)
n
Country
US
Population
adolescents
78
US
Comorbid
serious mental
illness and
substance abuse
Method/measures
intervention
Dual focus schema
therapy vs substance
abuse counselling
STAR, description of
trauma intervention
and prevalence
Outcome
Overall better use of DFST,but severe
personality disorders used SAC better
(n=78) were analyzed for a history of trauma
events. Of those individuals evaluated, 79.5%
(62/78) acknowledged a history of either
physical and/or sexual abuse at some time in
their lifetimes. Of this population, 100% of the
homeless women (27/27) with co-occurring
disorders had experienced a life-altering
traumatic event while 68.6% (35/51) of the
homeless men also reported trauma histories.
We describe the trauma-based interventions
made in the STAR Program that have the
potential for replication in other initiatives
40
Commander
(Desai, HarpazRotem et al.
2008)
(Gonzalez and
Rosenheck
2002)
359
UK
US
5432
US
Women,
veterans
Seeking safety, CBT
manual
Serious mental
illness and
substance abuse
ACCESS centre for
mental health
services (Access to
Community ~Care
and Effective
Services)
Dual diagnosis vs
other
(Karim, Tischler
et al. 2006)
35
UK
Families
following
mental health
(Hospital Anxiety and
Depression Scale,
following admission
to two homeless
hostels
committed to serving homeless individuals
with co-occurring disorders.
No abstract
CBT manual group reported significantly
better outcomes over one year in
employment, social support, general
symptoms of psychiatric distress, and
symptoms of posttraumatic stress disorder,
particularly in the avoidance and arousal
clusters. However, the Seeking Safety cohort
was significantly more likely to have used
drugs in the past 30 days.
At baseline, clients with dual diagnoses were
worse off than those without dual diagnoses
on most clinical and social adjustment
measures. Clients with dual diagnoses also
had poorer outcomes at follow-up on 15 (62
percent) of 24 outcome measures. However,
among clients with dual diagnoses, those who
reported extensive participation in substance
abuse treatment showed clinical improvement
comparable to or better than that of clients
without dual diagnoses. On measures of
alcohol problems, clients with dual diagnoses
who had a high rate of participation in selfhelp groups had outcomes superior to those
of other clients with dual diagnoses. Clients
with dual diagnoses who received high levels
of professional services also had superior
outcomes in terms of social support and
involvement in the criminal justice system.
Children and their mothers continued to
experience high rates of mental health
problems whilst resident in the hostels and
41
admission to two
homeless hostels
(Lester, Milby et
al. 2007)
118
US
Dual diagnosis,
cocaine
dependant
(Maguire 2006)
4
UK
referral criteria :
1) had alcohol
and/or
substance
misuse
problems,
Eyberg Child
Behaviour Inventory
Scale, Health of the
Nation Outcome
Scales for Children
and Adolescents),
parenting problems
(Parenting Daily
Hassles Scale), and
service satisfaction
(semi-structured
interview)
.A number of
measures including
mental health and
social functioning
constructs were used
to evaluate the
CBT and
homelessness
after rehousing. However, a proportion of
parents expressed a subjective improvement,
which was often associated with their housing
and social circumstances. A diverse range of
further needs was described. CONCLUSIONS:
There is a need to address the complex
problems experienced by these families, with
housing only forming one aspect of this
provision. Interagency strategy,
commissioning and services are required to
meet the needs of this vulnerable group of
parents and children
Among those with trauma exposure and PTSD
symptoms, the group receiving more
behaviorally intensive, contingency
management treatment had significantly
greater reductions in PTSD symptomatology
than did the group receiving less-intensive
treatment. Regression analyses revealed that
greater positive distraction coping and lower
negative avoidance coping at baseline, in
addition to changes in avoidance coping over
the 6-month study period, were significantly
related to greater symptom and severity
reductions. The study provides some initial
evidence of important treatment outcomes
other than abstinence in addiction-related
interventions.
All residents reduced incidents of theft,
violence and alcohol consumption. Risk to self
and others was also reduced for all residents.
Perceived self-efficacy increased slightly for all
residents, and staff perceived that they could
be more effective, less hopeless, and
42
2)were roofless
3) difficulty
accessing hostel
places
(Morrissey,
Calloway et al.
2002)
project, in addition to
some qualitative data.
therefore possibly less stressed as a result of
training.
US
ACCESS
START, referral to a
specialist team
(Power and
Attenborough
2003)
100
UK
(Rosenheck,
Kasprow et al.
2003)
182
US
veterans
Supported housing
integrating clinical
and housing services
Contrary to expectations, the nine
experimental sites did not demonstrate
significantly greater overall systems
integration than the nine comparison sites.
However, the experimental sites demonstrated
better project-centered integration than the
comparison sites. Moreover, more extensive
implementation of strategies for system
change was associated with higher levels of
overall systems integration as well as projectcentered integration at both the experimental
sites and the comparison sites.
Clients referred to the team on more than one
occasion were marginally more likely to
remain in contact with services. 10% of the
sample had returned to the homeless circuit;
49% were resettled to more permanent
accommodation. 43% were not in contact
with services while 55% were still in contact 4
years later. This study supports the
suggestion that with specialist intervention
and support people with mental health
problems who are homeless can live a more
settled existence
During a 3-year follow-up, HUD-VASH
veterans had 16% more days housed than the
case management-only group and 25% more
days housed than the standard care group
(P<.001 for both). The case managementonly group had only 7% more days housed
43
(Slesnick, Kang
et al. 2008)
133
US
youth
Stepwise regression
(Slesnick and
Prestopnik
2005)
124
US
adolescents
Self-report
Ecologically-based
family therapy vs
service as usual
through a shelter
than the standard care group (P =.29). The
HUD-VASH group also experienced 35% and
36% fewer days homeless than each of the
control groups (P<.005 for both). There were
no significant differences on any measures of
psychiatric or substance abuse status or
community adjustment, although HUD-VASH
clients had larger social networks. From the
societal perspective, HUD-VASH was 6200 US
dollars (15%) more costly than standard care.
Incremental cost-effectiveness ratios suggest
that HUD-VASH cost 45 US dollars more than
standard care for each additional day housed
(95% confidence interval, -19 US dollars to
108 US dollars). CONCLUSIONS: Supported
housing for homeless people with mental
illness results in superior housing outcomes
than intensive case management alone or
standard care and modestly increases societal
costs.
Stepwise regression results indicated that a
history of sexual abuse and suicide attempts
were the two strongest predictors of the
treatment attendance rate, higher attendance
among those with these histories. Youths who
attended greater than 6 treatment sessions
showed a significant reduction in alcohol use
at post-treatment, but attendance rates did
not impact other substance use.
Youth assigned to EBFT reported greater
reductions in overall substance abuse
compared to youth assigned to SAU while
other problem areas improved in both
conditions. Findings suggest that EBFT is an
44
efficacious intervention for this relatively
severe population of youth.
(Stergiopoulos,
Dewa et al.
2008)
73
Canada
(Taylor,
Stuttaford et al.
2007)
150
UK
Shelter-based
collaborative MH
team
Young people1625 years.
Health of the Nation
Outcome Scales
(HoNOS), a risk
assessment, and a
service checklist at
referral and final
service contact.
short-term clinical
outcome of young
homeless people in
contact with a
designated mental
health service,
Among the referred clients, the prevalence of
severe and persistent mental illness and
substance use disorders was 76.5% and
48.5%, respectively. At 6 months, 24 clients
(35.3%) had improved clinically, and 33
(48.5%) were housed. Logistic regression
identified 2 factors associated with clinical
improvement: the number of visits with a
psychiatrist and treatment adherence. The
same 2 factors were associated with higher
odds of housing, and presence of substance
use disorder was associated with lower odds
of housing at 6-month follow-up.
Young homeless people have high rates of
psychiatric disorders and related complex
needs. However, they often find it difficult to
access mainstream mental health services.
The aim of this study was to establish the and
whether this is predicted by variables in young
people's profiles. Young people reported a
range of previous adversities and service
contacts, and high HoNOS and risk scores.
There was significant improvement on most
HoNOS items for those who attended more
than one session, but only one risk behaviour
(self-harm) significantly decreased. Previous
experience of mental health problems and
agreed completion of treatment predicted
better clinical outcome. Despite their multiple
and complex mental health needs, at least a
proportion of young homeless people, can
45
engage and benefit from their contact with a
designated mental health service.
Methodological considerations
References
(Cwikel 1994)
Country
Israel
Population
Measure/Method
Outcome
The epidemiological triangle of host, agent, and environmental
risk factors is presented as a method of organizing available
research on homelessness and conceptualizing methods of
treatment and prevention.
Diagnostic Interview
Schedule (DIS)
administered by a clinical
social worker + a full
clinical psychiatric social
work assessment + a
thorough and systematic
clinical psychiatric
evaluation by a
psychiatrist or
psychologist
Homeless Supplement to
the Diagnostic Interview
Schedule
Compared to clinician assessment, structured interviews
underdiagnosed antisocial personality disorder (ASPD) and
overdiagnosed major depression. Alcohol use disorder and
schizophrenia showed only small discrepancies by assessment
method. Drug use disorder revealed no bias according to
method of ascertainment, but showed very discrepant kappa
levels comparing DIS to clinician assessment in the two
different comparison contexts.
(Koegel, Burnham et al.
1992)
(North, Pollio et al.
1997)
US
(North, Eyrich et al.
2004)
US
Test-rest analysis
Subtance Abuse-no direct link with homelessness
–
(Vangeest and
Johnson 2002)
US
To investigate whether substance abuse is a direct factor in the explanation of homelessness or one that operates indirectly
through disaffiliation and human capital processes to place individuals at greater risk of the condition. Analysis of several
46
nested models of homelessness links substance abuse only indirectly to loss of domicile, primarily through its impact on
social and institutional affiliations. Contrary to expectations, substance abuse did not impact homelessness indirectly by
diminishing the accumulation of human capital. CONCLUSIONS: The role of disaffiliation as a proximate cause of
homelessness was confirmed. This locates the phenomenon within the context of society itself, as a direct result of a
breakdown in the social bonds necessary for human community. Substance abuse plays a critical role in this breakdown,
negatively influencing social as well as institutional relationships
Policy
(Becker and
Kunstmann 2001)
Germany
(Gupta 1995)
US
(Staller 2004)
US
(Velleman, Baker
et al. 2007)
UK
Provides: (1) brief information on the social and economic background of homelessness in Germany; (2) a summary of
existing research on homelessness and mental health; and (3) a discussion of health-care approaches and further
development of health services for mentally ill homeless people. The authors note that there is no evidence that
deinstitutionalization was a major factor leading to the increase in homelessness in Germany, but the extent to which
established psychiatric outpatient services are providing sufficient support for their clientele is debated. It is argued that the
problems of homeless people can be overcome only be a functional network of different, responsible, and accountable
services.
Reviews factors associated with homelessness. The loss of employment and income are significant variables involved in
homelessness. During the early decades, most of the homeless were single men with little education and skills who were
unemployed. However, recent reports indicate an increasing number of families in the homeless population. Estimates of the
number of homeless people range between 300,000 and 3,000,000. Inconsistencies are observed in the public policies, most
policymakers dealing with homelessness as a local concern. Homelessness is found to be associated with mental health and
unemployment. It can be interpreted as a generalizational problem, an extreme end of poverty syndrome, fueled by poor
planning and the lack of incentives to find a job
System dynamics models help explain why intuitive, well-intentioned solutions to social problems go awry when introduced
into complicated social systems. In this article, the author develops a dynamic model, applying it to runaway and homeless
youth behavior and shelter usage. Together, the model and supporting evidence imply that simple linear thinking may guide
policy expansion to the detriment of homeless youth. Shelters provide incentives for other service systems to neglect difficult
cases, which raises serious questions about the efficacy of the shelter system. This model provides common ground upon
which practitioners, administrators, policymakers, and research communities can consider the impact and effectiveness of
policy and service. Furthermore, the model challenges these communities to bring dynamic system considerations to their
work
Notes that there is convincing evidence that homeless people have higher rates of both mental health and substance misuse
problems than the general population, in addition to lowered access to services and other helping resources. It is proposed
that a model of care which includes designated, well-trained, and well-supervised workers who can work effectively across
47
the various domains of mental health, substance misuse, and housing will be the main future direction. The author argues
that it is important to adopt a holistic (and pragmatic) view as to what the targets of treatment should be, and that
therapists need very high levels of skill in engagement. In addition, the assessment of co-existing mental health and
alcohol/other drug use problems in people who are also homeless should follow a similar process as for other clients.
However, there are important individual barriers and organizational issues that need to be addressed. The author concludes
by suggesting that there are four areas from which treatment ideas can be drawn: substance misuse, mental health
generally, assertive outreach in particular, and housing.
48
References
Aichhorn, W., S. Santeler, et al. (2008). "[Prevalence of psychiatric disorders among homeless adolescents]." Neuropsychiatrie:
Klinik, Diagnostik, Therapie Und Rehabilitation: Organ Der Gesellschaft Österreichischer Nervenärzte Und Psychiater 22(3):
180-188.
Andres-Lemay, V. J., E. Jamieson, et al. (2005). "Child abuse, psychiatric disorder, and running away in a community sample of
women." Canadian Journal Of Psychiatry. Revue Canadienne De Psychiatrie 50(11): 684-689.
Ball, S. A., P. Cobb-Richardson, et al. (2005). "Substance abuse and personality disorders in homeless drop-in center clients:
symptom severity and psychotherapy retention in a randomized clinical trial." Comprehensive Psychiatry 46(5): 371-379.
Barak, Y. and A. Cohen (2003). "Characterizing the elderly homeless: a 10-year study in Israel." Archives Of Gerontology And
Geriatrics 37(2): 147-155.
Bassuk, E. L., J. C. Buckner, et al. (1998). "Prevalence of mental health and substance use disorders among homeless and lowincome housed mothers." The American Journal Of Psychiatry 155(11): 1561-1564.
Bassuk, E. L., R. Dawson, et al. (2001). "Post-traumatic stress disorder in extremely poor women: implications for health care
clinicians." Journal Of The American Medical Women's Association (1972) 56(2): 79-85.
Bassuk, E. L., S. Melnick, et al. (1998). "Responding to the needs of low-income and homeless women who are survivors of family
violence." Journal Of The American Medical Women's Association (1972) 53(2): 57-64.
Bassuk, E. L., L. Rubin, et al. (1984). "Is homelessness a mental health problem?" The American Journal Of Psychiatry 141(12):
1546-1550.
Bearsley-Smith, C., L. Bond, et al. (2008). "The psychosocial profile of adolescent risk of homelessness." European Child &
Adolescent Psychiatry 17(4): 226-234.
Bebbington, P. E., D. Bhugra, et al. (2004). "Psychosis, victimisation and childhood disadvantage: Evidence from the second British
National Survey of Psychiatric Morbidity." British Journal of Psychiatry 185(3): 220-226.
Bebout, R. R., M. Harris, et al. (2001). Trauma-informed approaches to housing. Using trauma theory to design service systems.
San Francisco, CA US, Jossey-Bass: 47-55.
Becker, H. and W. Kunstmann (2001). "The homeless mentally ill in Germany." International Journal of Mental Health 30(3): 57-73.
Belcher, J. R., J. A. Greene, et al. (2001). "Considering pathways into homelessness: mothers, addictions, and trauma." Journal of
Addictions Nursing 13(3/4): 199-208.
49
Bhui, K., L. Shanahan, et al. (2006). "Homelessness and mental illness: a literature review and a qualitative study of perceptions of
the adequacy of care." The International Journal Of Social Psychiatry 52(2): 152-165.
Blankertz, L. E., R. A. Cnaan, et al. (1993). "Childhood risk factors in dually diagnosed homeless adults." Social Work 38(5): 587596.
Booth, R. E. and Y. Zhang (1996). "Severe aggression and related conduct problems among runaway and homeless adolescents."
Psychiatric Services 47(1): 75-80.
Breakey, W. R., P. J. Fischer, et al. (1989). "Health and mental health problems of homeless men and women in Baltimore." JAMA:
The Journal Of The American Medical Association 262(10): 1352-1357.
Browne, A. (1993). "Family violence and homelessness: The relevance of trauma histories in the lives of homeless women."
American Journal of Orthopsychiatry 63(3): 370-384.
Browne, A. and S. S. Bassuk (1997). "Intimate violence in the lives of homeless and poor housed women: Prevalence and patterns
in an ethnically diverse sample." American Journal of Orthopsychiatry 67(2): 261-278.
Buckner, J. C., E. L. Bassuk, et al. (1993). "Mental health issues affecting homeless women: implications for intervention." The
American Journal Of Orthopsychiatry 63(3): 385-399.
Buhrich, N., T. Hodder, et al. (2000). "Lifetime prevalence of trauma among homeless people in Sydney." The Australian And New
Zealand Journal Of Psychiatry 34(6): 963-966.
Carroll, J. J. and L. A. Trull (1999). "Homeless African American women's interpretations of child abuse as an antecedent of
chemical dependence." Early Child Development and Care 155: 1-16.
Caton, C. L. M., P. E. Shrout, et al. (1995). "Risk factors for homelessness among women with schizophrenia." American Journal of
Public Health 85(8 part 1): 1153-1156.
Cauce, A. M., M. Paradise, et al. (2000). "The characteristics and mental health of homeless adolescents: Age and gender
differences." Journal of Emotional and Behavioral Disorders 8(4): 230-239.
Chen, X., L. Thrane, et al. (2007). "Onset of conduct disorder, use of delinquent subsistence strategies, and street victimization
among homeless and runaway adolescents in the Midwest." Journal Of Interpersonal Violence 22(9): 1156-1183.
Chen, X., K. A. Tyler, et al. (2004). "Early Sexual Abuse, Street Adversity, and Drug Use Among Female Homeless and Runaway
Adolescents in the Midwest." Journal of Drug Issues 34(1): 1-21.
Christensen, R. C., C. C. Hodgkins, et al. (2005). "Homeless, mentally ill and addicted: the need for abuse and trauma services."
Journal of Health Care for the Poor & Underserved 16(4): 615-621.
50
Commander, M., A. Davis, et al. (2002). "A comparison of homeless and domiciled young people." Journal of Mental Health 11(5):
557-564.
Commander, M. J. and S. M. Odell (2001). "A comparison of the needs of homeless and never homeless patients with psychotic
disorders." Journal of Mental Health 10(4): 449-456.
Connolly, A. J., P. Cobb-Richardson, et al. (2008). "Personality disorders in homeless drop-in center clients." Journal of Personality
Disorders 22(6): 573-588.
Cougnard, A., S. Grolleau, et al. (2006). "Psychotic disorders among homeless subjects attending a psychiatric emergency service."
Social Psychiatry And Psychiatric Epidemiology 41(11): 904-910.
Craig, T. K. and S. Hodson (1998). "Homeless youth in London: I. Childhood antecedents and psychiatric disorder." Psychological
Medicine 28(6): 1379-1388.
Crane, M. (1998). "The associations between mental illness and homelessness among older people: an exploratory study." Aging &
Mental Health 2(3): 171-180.
Cwikel, J. (1994). "Social epidemiology: An integrative research and practice strategy applied to homelessness." Journal of Social
Service Research 19(1): 23-47.
Davies-Netzley, S., M. S. Hurlburt, et al. (1996). "Childhood abuse as a precursor to homelessness for homeless women with
severe mental illness." Violence And Victims 11(2): 129-142.
DeMallie, D. A., C. S. North, et al. (1997). "Psychiatric disorders among the homeless: a comparison of older and younger groups."
The Gerontologist 37(1): 61-66.
Desai, R. A., I. Harpaz-Rotem, et al. (2008). "Impact of the seeking safety program on clinical outcomes among homeless female
veterans with psychiatric disorders." Psychiatric Services (Washington, D.C.) 59(9): 996-1003.
Dickey, B. (2000). "Review of programs for persons who are homeless and mentally ill." Harvard Review Of Psychiatry 8(5): 242250.
Driessen, M. and H. Dilling (1997). "[Psychiatric disorders in homeless persons--Anglo-American studies of epidemiology and
management]." Psychiatrische Praxis 24(4): 162-166.
Eagle, P. F., C. L. M. Caton, et al. (1990). Homelessness and mental illness. Homeless in America. New York, NY US, Oxford
University Press: 59-75.
Fazel, S., V. Khosla, et al. (2008). "The prevalence of mental disorders among the homeless in western countries: systematic
review and meta-regression analysis." Plos Medicine 5(12): e225-e225.
51
Feitel, B., N. Margetson, et al. (1992). "Psychosocial background and behavioral and emotional disorders of homeless and runaway
youth." Hospital & Community Psychiatry 43(2): 155-159.
Fichter, M. M., M. Koniarczyk, et al. (1996). "Mental illness in a representative sample of homeless men in Munich, Germany."
European Archives of Psychiatry and Clinical Neuroscience 246(4): 185-196.
Fichter, M. M. and N. Quadflieg (2005). "Three year course and outcome of mental illness in homeless men: a prospective
longitudinal study based on a representative sample." European Archives Of Psychiatry And Clinical Neuroscience 255(2):
111-120.
Fischer, P. J. and W. R. Breakey (1991). "The epidemiology of alcohol, drug, and mental disorders among homeless persons."
American Psychologist 46(11): 1115-1128.
Fischer, P. J., S. Shapiro, et al. (1986). "Mental health and social characteristics of the homeless: a survey of mission users."
American Journal Of Public Health 76(5): 519-524.
Folsom, D. and D. V. Jeste (2002). "Schizophrenia in homeless persons: a systematic review of the literature." Acta Psychiatrica
Scandinavica 105(6): 404-413.
Gonzalez, G. and R. A. Rosenheck (2002). "Outcomes and service use among homeless persons with serious mental illness and
substance abuse." Psychiatric Services (Washington, D.C.) 53(4): 437-446.
Goodman, L. A. (1991). "The prevalence of abuse among homeless and housed poor mothers: a comparison study." The American
Journal Of Orthopsychiatry 61(4): 489-500.
Goodman, L. A., M. A. Dutton, et al. (1995). "Episodically homeless women with serious mental illness: prevalence of physical and
sexual assault." The American Journal Of Orthopsychiatry 65(4): 468-478.
Goodman, L. A., S. D. Rosenberg, et al. (1997). "Physical and sexual assault history in women with serious mental illness:
prevalence, correlates, treatment, and future research directions." Schizophrenia Bulletin 23(4): 685-696.
Goodman, L. A., L. Saxe, et al. (1991). "Homelessness as psychological trauma: Broadening perspectives." American Psychologist
46(11): 1219-1225.
Greifenhagen, A. and M. Fichter (1997). "Mental illness in homeless women: An epidemiological study in Munich, Germany."
European Archives of Psychiatry and Clinical Neuroscience 247(3): 162-172.
Gupta, G. R. (1995). "Homelessness and mental disorder: Policy considerations." Journal of Social Distress & the Homeless 4(1):
33-42.
52
Gwadz, M. V., D. Nish, et al. (2007). "Gender differences in traumatic events and rates of post-traumatic stress disorder among
homeless youth." Journal Of Adolescence 30(1): 117-129.
Haugland, G., C. Siegel, et al. (1997). "Mental illness among homeless individuals in a suburban county." Psychiatric Services
(Washington, D.C.) 48(4): 504-509.
Heffron, W. A., B. J. Skipper, et al. (1995). "Risk factors for homelessness: a study of families of origin." Family Medicine 27(9):
586-591.
Herman, D. B., E. S. Susser, et al. (1997). "Adverse childhood experiences: are they risk factors for adult homelessness?" American
Journal Of Public Health 87(2): 249-255.
Hyde, J. (2005). "From home to street: Understanding young people's transitions into homelessness." Journal of Adolescence
28(2): 171-183.
Jainchill, N., J. Hawke, et al. (2000). "Gender, psychopathology, and patterns of homelessness among clients in shelter-based
TCs." The American Journal Of Drug And Alcohol Abuse 26(4): 553-567.
Janus, M. D., F. X. Archambault, et al. (1995). "Physical abuse in Canadian runaway adolescents." Child Abuse & Neglect 19(4):
433-447.
Johnson, R. J., L. Rew, et al. (2006). "Gender differences in victimized homeless adolescents." Adolescence 41(161): 39-53.
Johnson, R. J., L. Rew, et al. (2006). "The relationship between childhood sexual abuse and sexual health practices of homeless
adolescents." Adolescence 41(162): 221-234.
Kamieniecki, G. W. (2001). "Prevalence of psychological distress and psychiatric disorders among homeless youth in Australia: A
comparative review." Australian and New Zealand Journal of Psychiatry 35(3): 352-358.
Karim, K., V. Tischler, et al. (2006). "Homeless children and parents: short-term mental health outcome." International Journal of
Social Psychiatry 52(5): 447-458.
Kaufman, J. G. and C. S. Widom (1999). "Childhood victimization, running away, and delinquency." Journal of Research in Crime
and Delinquency 36(4): 347-370.
Khurana, S., N. Sharma, et al. (2004). "Mental health status of runaway adolescents." Indian Journal Of Pediatrics 71(5): 405-409.
Kim, M. M. and E. M. Arnold (2004). "Stressful life events and trauma among substance-abusing homeless men." Journal of Social
Work Practice in the Addictions 4(2): 3-19.
Kim, M. M. and J. D. Ford (2006). "Trauma and post-traumatic stress among homeless men: a review of current research." Journal
of Aggression, Maltreatment & Trauma 13(2): 1-22.
53
Koegel, P., M. A. Burnam, et al. (1988). "The prevalence of specific psychiatric disorders among homeless individuals in the inner
city of Los Angeles." Archives of General Psychiatry 45(12): 1085-1092.
Koegel, P., M. A. Burnham, et al. (1992). Problems in the assessment of mental illness among the homeless: An empirical approach.
Homelessness: A national perspective. New York, NY US, Plenum Press: 77-99.
Kovess, V. and C. Mangin Lazarus (1999). "The prevalence of psychiatric disorders and use of care by homeless people in Paris."
Social Psychiatry And Psychiatric Epidemiology 34(11): 580-587.
Lester, K. M., J. B. Milby, et al. (2007). "Impact of behavioral contingency management intervention on coping behaviors and PTSD
symptom reduction in cocaine-addicted homeless." Journal Of Traumatic Stress 20(4): 565-575.
Maguire, N. (2006). "Cognitive behavioural therapy and homelessness: A case series pilot study." Behavioural and Cognitive
Psychotherapy 34(1): 107-111.
Martijn, C. and L. Sharpe (2006). "Pathways to youth homelessness." Social Science & Medicine 62(1): 1-12.
McGilloway, S. a. and M. Donnelly (2001). "Prevalence and nature of mental health problems among single, homeless people in
Belfast, Northern Ireland." International Journal of Mental Health 30(3): 40-49.
McManus, H. H. and S. J. Thompson (2008). "Trauma among unaccompanied homeless youth: the integration of street culture into
a model of intervention." Journal of Aggression, Maltreatment & Trauma 16(1): 92-109.
McQuiston, H. L., P. M. Gillig, et al. (2006). Mental Illness and Homelessness: An Introduction. Clinical guide to the treatment of
the mentally ill homeless person. Arlington, VA US, American Psychiatric Publishing, Inc.: 1-8.
Minkoff, K., R. E. Drake, et al. (1992). Homelessness and dual diagnosis. Treating the homeless mentally ill: A report of the Task
Force on the Homeless Mentally Ill. Arlington, VA US, American Psychiatric Publishing, Inc.: 221-247.
Morrell-Bellai, T., P. N. Goering, et al. (2000). "Becoming and remaining homeless: a qualitative investigation." Issues in Mental
Health Nursing 21(6): 581-604.
Morrissey, J. P., M. O. Calloway, et al. (2002). "Integration of service systems for homeless persons with serious mental illness
through the ACCESS program. Access to Community Care and Effective Services and Supports." Psychiatric Services
(Washington, D.C.) 53(8): 949-957.
Mounier, C. and E. Andujo (2003). "Defensive functioning of homeless youth in relation to experiences of child maltreatment and
cumulative victimization." Child Abuse & Neglect 27(10): 1187-1204.
Mundy, P., M. Robertson, et al. (1990). "The prevalence of psychotic symptoms in homeless adolescents." Journal Of The American
Academy Of Child And Adolescent Psychiatry 29(5): 724-731.
54
North, C. S., K. M. Eyrich, et al. (2004). "The Homeless Supplement to the Diagnostic Interview Schedule: test-retest analyses."
International Journal of Methods in Psychiatric Research 13(3): 184-191.
North, C. S., D. E. Pollio, et al. (1997). "A comparison of clinical and structured interview diagnoses in a homeless mental health
clinic." Community Mental Health Journal 33(6): 531-543.
North, C. S. and E. M. Smith (1992). "Posttraumatic stress disorder among homeless men and women." Hospital & Community
Psychiatry: A Journal of the American Psychiatric Association 43(10): 1010-1016.
North, C. S., E. M. Smith, et al. (1993). "Is antisocial personality a valid diagnosis among the homeless?" The American Journal Of
Psychiatry 150(4): 578-583.
North, C. S., E. M. Smith, et al. (1994). "Violence and the homeless: an epidemiologic study of victimization and aggression."
Journal Of Traumatic Stress 7(1): 95-110.
North, C. S., S. J. Thompson, et al. (1997). "A diagnostic comparison of homeless and nonhomeless patients in an urban mental
health clinic." Social Psychiatry And Psychiatric Epidemiology 32(4): 236-240.
Nyamathi, A., L. Bayley, et al. (1999). "Perceived factors influencing the initiation of drug and alcohol use among homeless women
and reported consequences of use." Women & Health 29(2): 99-114.
Nyamathi, A., S. L. Wenzel, et al. (2001). "Comparison of psychosocial and behavioral profiles of victimized and nonvictimized
homeless women and their intimate partners." Research In Nursing & Health 24(4): 324-335.
Nyamathi, A. M., D. Longshore, et al. (2001). "Childhood predictors of daily substance use among homeless women of different
ethnicities." American Behavioral Scientist 45(1): 35-50.
O'Reilly, M., H. C. Taylor, et al. (2009). ""Nuts, schiz, psycho": An exploration of young homeless people's perceptions and
dilemmas of defining mental health." Social Science & Medicine (1982) 68(9): 1737-1744.
Philippot, P., C. Lecocq, et al. (2007). "Psychological research on homelessness in Western Europe: A review from 1970 to 2001."
Journal of Social Issues 63(3): 483-504.
Pollio, D. E., C. S. North, et al. (1997). "Predictors of achieving stable housing in a mentally ill homeless population." Psychiatric
Services (Washington, D.C.) 48(4): 528-530.
Power, C. and J. Attenborough (2003). "Up from the streets: A follow-up study of people referred to a specialist team for the
homeless mentally ill." Journal of Mental Health 12(1): 41-49.
Powers, J. L., B. Jaklitsch, et al. (1989). "Behavioral characteristics of maltreatment among runaway and homeless youth." Early
Child Development and Care 42: 127-139.
55
Rayburn, N. R., S. L. Wenzel, et al. (2005). "Trauma, Depression, Coping, and Mental Health Service Seeking Among Impoverished
Women." Journal of Consulting and Clinical Psychology 73(4): 667-677.
Rees, S. (2009) “Mental Ill Health in the Adult Single Homeless Population: a review of the literature". Crisis/PHRU
Reinking, D. P., J. R. Wolf, et al. (2001). "[High prevalence of mental disorders and addiction problems among the homeless in
Utrecht]." Nederlands Tijdschrift Voor Geneeskunde 145(24): 1161-1166.
Rew, L. (2002). "Relationships of sexual abuse, connectedness, and loneliness to perceived well-being in homeless youth." Journal
for Specialists in Pediatric Nursing 7(2): 51-63.
Rew, L., M. Taylor-Seehafer, et al. (2001). "Sexual abuse, alcohol and other drug use, and suicidal behaviors in homeless
adolescents." Issues in Comprehensive Pediatric Nursing 24(4): 225-240.
Robert, M., L. Fournier, et al. (2004). "La victimisation et les problèmes de comportement. Deux composantes de profils types de
fugueurs adolescents." Child Abuse & Neglect 28(2): 193-208.
Rosenheck, R. and A. Fontana (1994). "A model of homelessness among male veterans of the Vietnam War generation." American
Journal of Psychiatry 151(3): 421-427.
Rosenheck, R., W. Kasprow, et al. (2003). "Cost-effectiveness of supported housing for homeless persons with mental illness."
Archives Of General Psychiatry 60(9): 940-951.
Rosenthal, D., S. Mallett, et al. (2006). "Why do homeless young people leave home?" Australian & New Zealand Journal of Public
Health 30(3): 281-285.
Ryan, K. D., R. P. Kilmer, et al. (2000). "Psychological consequences of child maltreatment in homeless adolescents: untangling the
unique effects of maltreatment and family environment." Child Abuse & Neglect 24(3): 333-352.
Scott, J. (1993). "Homelessness and mental illness." The British Journal Of Psychiatry: The Journal Of Mental Science 162: 314324.
Shelton, K. H., P. J. Taylor, et al. (2009). "Risk factors for homelessness: evidence from a population-based study." Psychiatric
Services (Washington, D.C.) 60(4): 465-472.
Sleegers, J., J. Spijker, et al. (1998). "Mental health problems among homeless adolescents." Acta Psychiatrica Scandinavica 97(4):
253-259.
Slesnick, N., M. J. Kang, et al. (2008). "Treatment attendance among homeless youth: the impact of childhood abuse and prior
suicide attempts." Substance Abuse 29(2): 43-52.
56
Slesnick, N. and J. Prestopnik (2005). "Dual and multiple diagnosis among substance using runaway youth." The American Journal
Of Drug And Alcohol Abuse 31(1): 179-201.
Slesnick, N. and J. L. Prestopnik (2005). "Ecologically based family therapy outcome with substance abusing runaway adolescents."
Journal Of Adolescence 28(2): 277-298.
Smith, E. M., C. S. North, et al. (1993). "Alcohol, drugs, and psychiatric comorbidity among homeless women: an epidemiologic
study." The Journal Of Clinical Psychiatry 54(3): 82-87.
Spence, S. A., K. H. Lee, et al. (2006). "Childhood abuse and adult violence in homeless people." Psychiatry And Clinical
Neurosciences 60(2): 259-259.
Staller, K. M. (2004). "Runaway Youth System Dynamics: A Theoretical Framework for Analyzing Runaway and Homeless Youth
Policy." Families in Society 85(3): 379-390.
Stein, J. A., M. B. Leslie, et al. (2002). "Relative contributions of parent substance use and childhood maltreatment to chronic
homelessness, depression, and substance abuse problems among homeless women: mediating roles of self-esteem and
abuse in adulthood." Child Abuse & Neglect 26(10): 1011-1027.
Stergiopoulos, V., C. S. Dewa, et al. (2008). "Collaborative mental health care for the homeless: the role of psychiatry in positive
housing and mental health outcomes." Canadian Journal Of Psychiatry. Revue Canadienne De Psychiatrie 53(1): 61-67.
Stump, M. J. and J. E. Smith (2008). "The relationship between posttraumatic growth and substance use in homeless women with
histories of traumatic experience." The American Journal On Addictions / American Academy Of Psychiatrists In Alcoholism
And Addictions 17(6): 478-487.
Sumerlin, J. R. (1999). "Cognitive-affective preparation for homelessness: quantitative and qualitative analyses of childhood out-ofhome placement and child abuse in a sample of homeless men." Psychological Reports 85(2): 553-573.
Tam, T. W., C. Zlotnick, et al. (2003). "Longitudinal perspective: Adverse childhood events, substance use, and labor force
participation among homeless adults." American Journal of Drug and Alcohol Abuse 29(4): 829-846.
Taylor-Seehafer, M., D. Jacobvitz, et al. (2008). "Patterns of attachment organization, social connectedness, and substance use in
a sample of older homeless adolescents: preliminary findings." Family & Community Health 31(1S): S81-8.
Taylor, H., M. Stuttaford, et al. (2006). "Why a 'roof' is not enough: the characteristics of young homeless people referred to a
designated mental health service." Journal of Mental Health 15(4): 491-501.
Taylor, H., M. Stuttaford, et al. (2007). "Short-term outcome of young homeless people in contact with a designated mental health
service." European Journal of Psychiatry 21(4): 268-278.
57
Taylor, K. M. and L. Sharpe (2008). "Trauma and post-traumatic stress disorder among homeless adults in Sydney." The Australian
And New Zealand Journal Of Psychiatry 42(3): 206-213.
Thompson, S. J. (2005). "Factors Associated with Trauma Symptoms Among Runaway/Homeless Adolescents." Stress, Trauma and
Crisis: An International Journal 8(2): 143-156.
Thompson, S. J. and E. K. Carll (2007). Youth homelessness and trauma. Trauma psychology: Issues in violence, disaster, health,
and illness, Vol 2: Health and illness. Westport, CT US, Praeger Publishers/Greenwood Publishing Group: 203-229.
Thrane, L. E., D. R. Hoyt, et al. (2006). "Impact of family abuse on running away, deviance, and street victimization among
homeless rural and urban youth." Child Abuse & Neglect 30(10): 1117-1128.
Timms, P. W. and A. H. Fry (1989). "Homelessness and mental illness." Health Trends 21(3): 70-71.
Tischler, V., V. Edwards, et al. (2009). "Working therapeutically with mothers who experience the trauma of homelessness: an
opportunity for growth." Counselling & Psychotherapy Research 9(1): 42-46.
Tischler, V. A. and P. Vostanis (2007). "Homeless mothers: Is there a relationship between coping strategies, mental health and
goal achievement?" Journal of Community & Applied Social Psychology 17(2): 85-102.
Tiwari, P. A., N. Gulati, et al. (2002). "Why do some boys run away from home?" Indian Journal Of Pediatrics 69(5): 397-399.
Tolomiczenko, G. S., T. Sota, et al. (2000). "Personality assessment of homeless adults as a tool for service planning." Journal of
Personality Disorders 14(2): 152-161.
Tyler, K. A. (2006). "A qualitative study of early family histories and transitions of homeless youth." Journal of Interpersonal
Violence 21(10): 1385-1393.
Tyler, K. A. and A. M. Cauce (2002). "Perpetrators of early physical and sexual abuse among homeless and runaway adolescents."
Child Abuse & Neglect 26(12): 1261-1274.
Tyler, K. A., D. R. Hoyt, et al. (2000). "The effects of early sexual abuse on later sexual victimization among female homeless and
runaway adolescents." Journal Of Interpersonal Violence 15(3): 235-250.
Tyler, K. A., D. R. Hoyt, et al. (2001). "The impact of childhood sexual abuse on later sexual victimization among runaway youth."
Journal of Research on Adolescence 11(2): 151-176.
Vázquez, C. and M. Muñoz (2001). "Homelessness, mental health, and stressful life events: The Madrid experience."
International Journal of Mental Health 30(3): 6-25.
Vangeest, J. B. and T. P. Johnson (2002). "Substance abuse and homelessness: direct or indirect effects?" Annals of Epidemiology
12(7): 455-461.
58
Velleman, R., A. Baker, et al. (2007). Homelessness alongside co-existing mental health and drug and alcohol problems. Clinical
handbook of co-existing mental health and drug and alcohol problems. New York, NY US, Routledge/Taylor & Francis Group:
177-196.
Wallace, R., E. Struening, et al. (1993). Homelessness and psychopathology. Environment and psychopathology. New York, NY US,
Springer Publishing Co: 87-101.
Warren, J. K., F. Gary, et al. (1994). "Self-reported experiences of physical and sexual abuse among runaway youths." Perspectives
in Psychiatric Care 30(1): 23-28.
Whitbeck, L. B., D. R. Hoyt, et al. (1997). "Abusive family backgrounds and later victimization among runaway and homeless
adolescents." Journal of Research on Adolescence 7(4): 375-392.
Whitbeck, L. B., D. R. Hoyt, et al. (1997). "Families of homeless and runaway adolescents: a comparison of parent/caretaker and
adolescent perspectives on parenting, family violence, and adolescent conduct." Child Abuse & Neglect 21(6): 517-528.
Whitbeck, L. B., D. R. Hoyt, et al. (2007). "Victimization and posttraumatic stress disorder among runaway and homeless
adolescents." Violence And Victims 22(6): 721-734.
Whitbeck, L. B., K. D. Johnson, et al. (2004). "Mental disorder and comorbidity among runaway and homeless adolescents."
Journal of Adolescent Health 35(2): 132-140.
Whitbeck, L. B. and R. L. Simons (1993). "A comparison of adaptive strategies and patterns of victimization among homeless
adolescents and adults." Violence and Victims 8(2): 135-152.
Winkleby, M. A., B. Rockhill, et al. (1992). "The medical origins of homelessness." American Journal of Public Health 82(10): 13941398.
Yoder, K. A., S. L. Longley, et al. (2008). "A dimensional model of psychopathology among homeless adolescents: suicidality,
internalizing, and externalizing disorders." Journal Of Abnormal Child Psychology 36(1): 95-104.
Zozus, R. T., Jr. and M. Zax (1991). "Perceptions of childhood: exploring possible etiological factors in homelessness." Hospital &
Community Psychiatry 42(5): 535-537.
59