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Homelessness Among OlderAdults with Severe MentalIllnessRupert van Wormer MSW aa Portland State University , 610 Tremont Street,Cedar Falls, IA, 50613, USAPublished online: 22 Sep 2008.

To cite this article: Rupert van Wormer MSW (2005) Homelessness Among Older Adultswith Severe Mental Illness, Journal of Human Behavior in the Social Environment,10:4, 39-49, DOI: 10.1300/J137v10n04_03

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Homelessness Among Older Adultswith Severe Mental Illness:

A Biologically BasedDevelopmental Perspective

Rupert van Wormer

ABSTRACT. This article tackles a problem that is often overlooked inthe literature–the plight of homeless elders with severe mental disabili-ties. Drawing on his personal experience working with sheltered home-less persons who were mentally ill, the author argues for a focus not onself-sufficiency but on closely supervised care for this vulnerable popu-lation. [Article copies available for a fee from The Haworth Document DeliveryService: 1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.com>Website: <http://www.HaworthPress.com> © 2004 by The Haworth Press, Inc.All rights reserved.]

KEYWORDS. Homelessness, older adults, older adults with severemental illness, self-sufficiency

Members of the homeless mentally ill population who are also el-derly are likely among the most vulnerable of the overall homeless pop-ulation. Many of these individuals have had negative experiences withsocial services in the past, including involuntary psychiatric commit-ments, and therefore, are reluctant to accept services now (both psychi-

Rupert van Wormer, MSW, is affiliated with Portland State University, 610 TremontStreet, Cedar Falls, IA 50613 (E-mail: Rupertvw@msn.com).

Journal of Human Behavior in the Social Environment, Vol. 10(4) 2004http://www.haworthpress.com/web/JHBSE

© 2004 by The Haworth Press, Inc. All rights reserved.Digital Object Identifier: 10.1300/J137v10n04_03 39

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atric and physical health). This article will explore issues that relate tohomelessness among adults with severe mental illness and aging from amainly micro perspective. Age-based developmental theory with anemphasis on biological illness informs this discussion. The main focus,however, is on what the homeless experience is like for homeless indi-viduals with severe mental illness as they become older adults.

The first section of this paper introduces the topic with a discussionof the social problem and specific focus of the paper. The next sectionprovides a discussion of the social problem as it relates to adult stages ofdevelopment from a biological theoretical perspective. In conclusion, Ipresent a personal history of my work with elderly, sheltered, homelesspeople at an innovative community agency in Seattle.

EXTENT OF THE PROBLEM

Over the past few decades, homeless older adults with severe mentalillness have become an increasingly visible part of many urban commu-nities. It is difficult to know the exact number of these individuals or themagnitude of this social problem as homeless people, in general, are adifficult population to count due to their lack of a fixed address and re-luctance of some to speak to researchers. Stergiopoulos and Herrmann(2003) report that the characteristics and needs of homeless seniorshave thus far been overlooked and that there is very little in the literatureconcerning this subset of the homeless population. It can be assumedthat even less literature exists that specifically addresses homelessnessamong older adults with severe mental illness.

A further complication related to research on this topic is that re-searchers who study homelessness among older adults are not in con-sensus as to what ages should be considered older adults within thispopulation (National Coalition for the Homeless, 1999). The ages con-sidered to be older adults range from 50 and older to 65 and older. Thisdisagreement is likely related to the assumption of some researcherswho study this population that homeless persons do not live as long asnon-homeless persons. While the Centers for Disease Control and Pre-vention (2004) may have recently announced that life expectancy in theUnited States was the highest ever in 2002, reaching a new high of 77.4years, up from 77.2 in 2001, it is likely that individuals with severe men-tal illness, who have suffered years of chronic homelessness throughouttheir adult lives, are not on average living to this age. The life expec-tancy rate of this subset of the homeless population (not currently re-

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ported by the U.S. government) is likely as much as 20 years lower thanit is for the non-homeless U.S. population (National Coalition for theHomeless, 1999; Stergiopoulos & Herrmann, 2003). If it is significantlylower, then it would be appropriate to adjust the age ranges for lateadulthood to reflect this.

According to a variety of studies on the homeless, the percentage ofthe overall homeless population that is 50 and older is estimated to bebetween 14.5% and 28%, and for those 60 and older, it ranges from 3%to 8% (Stergiopoulos & Herrmann, 2003). Although we do not have aprecise number, it is likely that it is on the rise as recent indicators haveshown a dramatic increase in the overall homeless population in the pastfew years, a trend similar to past economic downturns, but exacerbatedby rising housing and health care costs (McClam, 2002). In New YorkCity, for example, it was recently reported that the number of peoplestaying at city shelters increased from 21,000 in 1998, to “the highestlevel on record,” 37,000 in 2002 (Seattle Times, November 30, 2002).The U.S. Conference of Mayors reports that in 2001 requests for emer-gency shelter assistance grew an average of 19 percent in the 18 citiesthat reported an increase, the steepest rise in a decade (U.S. Conferenceof Mayors, 2002). According to their 2003 report, rates of homelessnesscontinued to rise in 2002 with requests for emergency shelter increasingby 13 percent from the year before (U.S. Conference of Mayors, 2003).The National Alliance to End Homelessness estimates that 700,000-800,000 people are homeless in the United States at any given time, andthat “over the course of a year, between 2.5 and 3.5 million people willexperience homelessness in this country” (National Alliance to EndHomelessness, 2000).

The National Coalition for the Homeless (1999) reports that, approx-imately 20-25% of the single adult homeless population suffers fromsome form of severe and persistent mental illness. Research by the Ur-ban Institute estimates that, on any given day, as many as 110,000 singleadults with severe mental illness are homeless in the United States (NewYork Times, May 2, 2001). How many of these individuals are olderadults? The answer to this question is unknown, though it is likely to bein the thousands if not tens of thousands.

The overall homeless population is made up of people from a diver-sity of backgrounds; however, it is likely that people with mental illnessfrom disadvantaged backgrounds are at greater risk of becoming home-less (Cohen, M., 2001). Of the general homeless population, racial andethnic minorities are over-represented, with an estimated 49 percent ofthis population being African American, 35 percent white, 13 percent

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Hispanic, two percent Native American, and one percent Asian (U.S.Conference of Mayors, 2003). Racial and ethnic characteristics of thehomeless older adult mentally ill subgroup are likely to be similar. Inany case, what is clear is that the elderly homeless are extremely hetero-geneous, comprising different subpopulations with different character-istics and different needs (Stergiopoulos & Herrmann, 2003).

DEVELOPMENTAL PERSPECTIVES RELATING TO BIOLOGY

In this section of the paper I will provide a discussion of the socialproblem of homelessness among older adults with severe mental illnessas it relates to adult stages of development. The developmental tasks ofold age, as Zastrow and Kirst-Ashman (2004) suggest, are largely psy-chological. These have to do with maintaining family ties, continuingsocial responsibilities, dealing with loss and grief, and finding satisfac-tory living arrangements. The final stage of life, according to ErikErikson (1950), is a wrestling between the forces of integrity and de-spair. The process of psychological adjustment is made more difficultby the fact that the role of the elderly is so devalued in our society. Thenif one’s physical health deteriorates, achieving integrity can become ex-tremely difficult without a strong support system. Biological theorieshave special relevance for the older homeless population because sur-vival on the streets depends greatly on one’s physical strength and agil-ity. Exposure to the elements without relief is extremely taxing to thebody. Exposure to violence on the streets is a constant threat to one’sphysical well-being as well. Then when mental illness, including or-ganic depression, strikes, the biopsychological impacts are formidable.

Mental health professionals are increasingly turning to biologicaltheories to explain the root cause of the symptoms associated with se-vere mental illness (Saleebey, 2001). Other theories, such as those thatwould explain schizophrenia as having been caused by “bad parenting,trauma, abuse, or personal weakness,” are slowly falling out of favor asresearch has failed to provide evidence of a correlation between these(Williamson, 2000).

Biological theories typically view severe mental illness (e.g., schizo-phrenia, bipolar disorder) as occurring in individuals as a result ofchemical imbalances in the brain. Such psychiatric illnesses lead to al-terations in thinking, mood, and behavior. These illnesses are observedin cultures throughout the world and are probably at least as old as hu-man beings (Cohen, 2001).

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Biologically based theories generally view psychotropic medicationsas being the most appropriate treatment for severe mental illness asthese drugs are designed to counteract chemical imbalances. Antipsy-chotic drugs, for example, “block signals at some, but not all receptorsfor the chemical messengers dopamine, norepinephrine, and serotonin”(Cohen, 2001). In doing so, psychotic symptoms are minimized but notcured.

Biological theories also view genetics as playing a key role in deter-mining who will develop certain types of mental illness. Regarding this,Cohen states: “While the specific genes that predispose us to psychiatricdisorders have not yet been identified, the presence of these genes isthoroughly and convincingly documented from family, twin, and adop-tion studies” (Cohen, 2001, p. 698).

Furthermore, recent neurological research is providing evidence thatthe brains of persons with severe mental illness are physically differentfrom the brains of individuals who do not have severe mental illness.Recent advancements in technology are accelerating this process. Ac-cording to Cohen, “subtle but repeatedly observed differences in thebrain between those with and without psychiatric disorders are nowdocumented by post mortem studies and observation of the brain duringlife using technologies such as magnetic resonance imaging (MRI),positron emission tomography (PET), and single photon emission com-puterized tomography (SPECT)” (2001, p. 698).

Biological theories also view people with biological abnormalities,including traumatic brain damage, as having more difficulty with sur-vival in their environments than people who do not have biological ab-normalities. For example, people with damage to their prefrontal cortexare less able to create goals for themselves or follow through with thetasks required to achieve goals (Davidson, 2002).

For people with severe mental illness, homeless or otherwise, agingcan be an especially challenging process. Addressing this issue, Kelley(2003) writes:

The biological and psychological declines that typically accom-pany aging–stamina and endurance, memory, and alterations inmetabolism, to name a few–can be compensated for in some indi-viduals to the extent that their daily functioning is not compro-mised. But for elders with comorbid mental health and physicalimpairments, typical declines become more pronounced, threaten-ing their abilities and capacities for self-care. (p. 19)

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LIFE EXPERIENCES

How do older (age 55 and above) homeless persons differ from theiryounger counterparts? Drawing on shelter intake data from 3,132homeless clients who registered for case management services, Hechtand Coyle (2001) found many significant differences. Older shelterseekers are more likely to be veterans, unmarried, not with children, andto receive social security or disability payments. Many, however, hadno income at all. Older clients, moreover, had experienced homeless-ness for very long periods, often having become homeless due to healthproblems. Younger women, in contrast, often cited domestic violenceas the cause of their homelessness. Older men often cited alcohol as aproblem while older women commonly reported histories of mentalhealth problems.

The life circumstances, events, and relationships that have shaped thelives of older homeless adults with severe mental illness, likely differgreatly from the experiences of the average or typical older adult whodoes not have a severe mental illness and has not experienced long peri-ods of homelessness. Symptoms of serious mental illness often first ap-pear when individuals are in their teens and early twenties. Therefore, itis likely that many of these individuals have had typical (or fairly typi-cal) life experiences prior to the onset of their psychiatric symptoms.Concerning this, Cohen states: “Psychotic disorders are among the mostdisabling of illnesses, disturbing thinking, perception, mood, and theirinterconnections, and diminishing normal human interactions. They of-ten strike the young and can prevent a normal life or reduce successfulpeople to homelessness” (2001). For many individuals who develop se-vere mental illness as young adults, all is changed from this point on:Earlier life goals evaporate; relationships are lost as a result of isolativebehavior; and interests, ideas, and attitudes become tainted by delu-sions.

While not all of these individuals become homeless, a significantproportion, 20% to 25% of single homeless adults (mentioned in Part I),are estimated to have severe mental illness (National Coalition for theHomeless, 1999). Prior to the deinstitutionalization movement of thesecond half of the 20th century it is likely this proportion was much less.During this period, many people began to view state mental hospitals ascruel and dehumanizing (Trattner, 1999). This, along with the inventionof new medications, led to new laws being passed in 1970s that made itmore difficult to involuntarily commit people (Barusch, 2002). As thelaw stands currently, for an individual to be treated or be placed in a

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mental hospital against his or her will, a court must determine that thisindividual is either a harm to his or her self, a harm to others, or begravely disabled (Jencks, 1994; Cohen, 2001). Accordingly, jails havebecome the new dumping grounds for mentally ill persons whose life onthe streets exposes them to the risk of various forms of lawbreaking(van Wormer, 2004).

It is likely that many homeless persons with severe mental illnesswho are currently in or near late adulthood may have experienced thedeinstitutionalization movement first hand as state mental hospital pa-tients who where later released to the community in the 1970s or 1980s.Many of these individuals were prescribed psychiatric drugs earlier inlife as either a patient in an inpatient psychiatric hospital or at a commu-nity psychiatric center. As a result, some have developed tardivedyskinesia, a disorder often associated with long-term use of olderantipsychotic medications such as Haloperidol, that in many cases is ir-reversible (Surgeon General, 2004).

Today’s newer medications are reported to have fewer side effectsthan the older medications; however, medication compliance in the out-patient setting continues to be an ongoing problem (Suppes & Wells,2003). Some individuals with severe mental illness cycle in and out ofpsychiatric hospitals fairly regularly because they fail to take their med-ications when they are not monitored closely by mental health profes-sionals (p. 212). For example, it may be possible for an older homelessadult diagnosed with schizophrenia to become stable while takingantipsychotic medications that are closely monitored within a hospitalsetting. Then, once psychologically stable after a few weeks at the hos-pital, this person no longer meets the legal criteria for hospitalization(suicidal or homicidal ideation) and is discharged to the community(usually referred to a local homeless shelter). A short time later, thissame individual may have to be re-hospitalized if he stops taking hismedication and the psychiatric symptoms and behaviors return. Forsome individuals with severe mental illness this is an ongoing cycle thatmakes maintaining housing nearly impossible. This type of cyclingback and forward from street to hospital to street is a process that many,but not all, homeless persons with severe mental illness experience.

Neither this cycling process, nor homelessness, continues indefi-nitely. As physical health and strength decline with age, homeless per-sons become increasingly vulnerable. Eventually, homelessness forthese individuals will end as their physical health declines. For some, itwill end when they become aware that homelessness is no longer an op-tion and finally accept services. For others, homelessness will end when

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they are involuntarily detained for grave disability and placed in nursinghomes. For individuals over age 65, who qualify for Medicare andMedicaid coverage, nursing home care is often the best available op-tion. It is estimated, in fact, that two-thirds of nursing home residentshave some mental disorder or illness (U.S. Department of Health andHuman Services, 2001). However, nursing homes are ill-prepared todeal with this strain on their services. And many of the elderly whocould qualify for nursing home care are reluctant to go there. And, for afew, homelessness ends in death on the streets.

PERSONAL REFLECTIONS ON WORKWITH OLDER HOMELESS ADULTS

While writing this paper I reflected on my own experiences workingwith older homeless adults with severe mental illness as a long-termmental health case manager at an agency in Seattle, Washington, thatspecializes in serving homeless adults with severe mental illness. Atthis agency, the Downtown Emergency Service Center (DESC), I hadthe unique opportunity to get to know several individuals from this sub-set of the homeless population. One individual I remember particularlywell died at age 68 after living on the streets and in shelters for at least30 years. I was told that in the 1970s she was known as “the bag lady ofPioneer Square” (the old part of Seattle’s downtown). Now there aredozens of “bag ladies” in Pioneer Square. Her refusal to go with me tothe hospital when she became ill made me wonder if during an earlierperiod in her life she had been involuntarily committed, perhaps to astate psychiatric hospital. Eventually, she became too sick to movewhile sitting next to a bus tunnel. A nurse and I called for an ambulance,which took her to Harborview Medical Center. She died about twomonths later. No family members could be located.

After she died, it was my responsibility to conduct the memorial ser-vice. This was the custom at DESC. We would announce the time andplace in a newsletter circulated among the homeless population, and inthe Quaker-style, individuals would recall their memories of the person.Staff members enlarged and displayed a photograph found among herpossessions so that the woman’s presence could be felt by the partici-pants at the service. The gathering was amazingly well attended as thishomeless woman, in the days when she lived on the streets, had touchedmany lives.

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IMPLICATIONS FOR SOCIAL WORK

Advocacy for greater funding for affordable housing and health-pro-moting residential assisted-care centers for mentally ill members of so-ciety of all ages is essential. Progressive services in housing mentally illpersons and supervising their mental health care, such as at DESC, arefew and far between. There is a paucity, in fact, of advocacy groups thatwork for the support of geriatric mental health, many more are focusedon young people (Jensen & Semke, 2003).

Instead of sending elderly people to jail for strange and bizarre be-havior, mentally-ill homeless persons are often placed in clean andfor-profit adult homes in crumbling buildings. Social workers would dowell to advocate for such safe housing programs as that offered at Flem-ing House in New York City’s Chelsea area. With room for 47 people,Fleming House is one of a dozen residences that together house over1,500 frail, low-income elderly men and women–many of whom havesevere psychiatric disabilities (Anderson, 2001). The cheerful sur-roundings of Fleming House are in sharp contrast to the inadequate pri-vatized services offered elsewhere.

CONCLUSION

The problem of the elderly homeless with mental illness will not besolved until the housing needs of all the people are met and until healthcare and mental health care services are universally available. Theremust be an understanding, moreover, that the housing needs of mentallyimpaired older persons are unique. Self-sufficiency cannot be the modelfor a population of elders with serious disabilities. Instead, there mustbe ample resources provided for continuing supportive services. Exten-sive mental health services are necessary to help vulnerable elderly per-sons not only to gain shelter but also to keep it. Harm reduction policiesare highly recommended so that residents with drinking problems andthe like are protected from themselves and not removed from muchneeded services. (DESC follows such a model.)

Because I was unable to locate any literature that specifically ad-dresses homelessness among older adults with severe mental illness, Ihad to resort to piecing together, in a sort of montage fashion, literatureon older adults with severe mental illness, older homeless adults, andhomeless adults with severe mental illness. I was able to draw on thispieced-together literature and on my personal experience working with

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homeless, mentally ill elders to present a picture of the needs of thismarginalized population.

From a developmental perspective I have become aware that there isa very unique cohort of older adults with severe mental illness whosemembers are being steadily depleted. This is the cohort of individualswith severe mental illness who experienced life in the state mental hos-pitals in their youth and homelessness during midlife and later adult-hood. This cohort’s members were (for those who have died) and are(for those still living) a brave and resilient group of individuals who sur-vived, mostly on their own, for many years with very little social oremotional support from the rest of our society. This literature gapclearly indicates that future research on this topic is needed.

As seen in this paper, even with the limited research available, youngand older homeless persons differ significantly in terms of their needsand life experiences. We have also seen how persons without adequatehousing age prematurely, and qualify for only limited financial aidbased on their mental disability but not for Medicare or general socialsecurity if they are not yet 65 years of age. To enhance our advocacy forthe needs of these individuals caught between the cracks of social ser-vices, greater research is needed on this often neglected and highlymarginalized population.

REFERENCES

Anderson, G.M. (2001, September 24). Of many things. America, 185 (8), 2.Barusch, A.S. (2002). Foundations of social policy: Social justice, public programs, and

the social work profession. Itasca, IL: F.E. Peacock Publishers.Becker, E. (2002, December 18). Mayors say requests for food and shelter are up. New

York Times.Bernstein, N. (2001, May 2). Housing mentally ill people is cost-effective, study finds.

The New York Times.Centers for Disease Control and Prevention (February, 2004). U.S. Life Expectancy at

all-time high, but infant mortality increases. Retrieved March 7, 2004 from http://www.cdc.gov/nchs/releases/04news/infantmort.htm

Cohen, B. (2001). Mind and medicine: Drug treatments for psychiatric illnesses. SocialResearch, 68 (3), 697-716.

Cohen, M. (2001). Homeless people. In A. Gitterman, (Ed.), Handbook of social workpractice with vulnerable and resilient populations (2nd ed.). (pp. 628-650). New York:Columbia University Press.

Davidson, R.J. (2002). Depression: Perspectives from affective neuroscience. AnnualReview of Psychology, 53, 545-574.

Erikson, E. (1950). Childhood and society. New York: Norton.

48 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT

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rsity

] at

17:

16 0

9 O

ctob

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014

Hecht, L., & Coyle, B. (2001). Elderly homeless: A comparison of older and youngeradult emergency shelter seekers in Bakersfield, California. American BehavioralScientist, 45 (1), 66-79.

Jencks, C. (1994). The homeless. London: Harvard University Press.Jensen, J., & Semke, J. (2003). Geriatric. Washington Institute for Mental Illness Re-

search. Retrieved from www.spokane.wsu.edu/research&serviceKelley, S. (2003). Prevalent mental health disorders in the aging population: Issues of

comorbidity and functional disability. Journal of Rehabilitation, 69 (2), 19-28.McClam, E. (2002, November 30). Urban plight: NYC’s homeless have reached record

levels. Voice for Change. Retrieved April 19, 2004, from www.voice4change.orgNational Alliance to End Homelessness. (2000). A plan, not a dream: How to end

homelessness in ten years. Retrieved November 11, 2003, from http://www.endhomelessness.org/pub/tenyear/demograp.htm

National Coalition for the Homeless. (1999, April). Mental illness and homelessness.Retrieved March 6, 2004 from http://www.nationalhomeless.org/mental.html

National Coalition for the Homeless. (1999, June). Homelessness among elderly per-sons. Retrieved February 3, 2004, from http://www.nationalhomeless.org/elderly.html

Saleebey, D. (2001). Human behavior and social environments: A biopsychosocial ap-proach. New York: Columbia University Press.

Stergiopoulos, V., & Herrmann, N. (2003). Old and homeless: A review and survey ofolder adults who use shelters in an urban setting. Canadian Journal of Psychiatry, 58(6), 374-380.

Suppes, M., & Wells, C. (2003). The social work experience: An introduction to socialwork and social welfare, (4th ed.). Boston: McGraw Hill.

Surgeon General (2004). Mental health: A report of the Surgeon General. RetrievedMarch 7, 2004, from http://www.surgeongeneral.gov/library/mentalhealth/home.html

Trattner, W. I. (1999). Poor law to welfare state: A history of social welfare in America(6th ed). New York: Free Press.

U.S. Conference of Mayors (2002, December 18). Hunger, homelessness on the rise inmajor U.S. cities. Retrieved November 17, 2003, from http://www.usmayors.org/uscm/news/press_releases/documents/hunger_121802.asp

U.S. Conference of Mayors (2003, December 18). Hunger, homelessness still on therise in major U.S. cities. Retrieved March 6, 2004, from http://www.usmayors.org/uscm/news/press_releases/documents/hunger_121803.asp

Van Wormer, K. (2004). Confronting oppression, restoring justice: From policy analysisto social action. Alexandria, VA: CSWE.

Williamson, J. (2000, November). Treating schizophrenia: New strategies. Drug top-ics, 64-73.

Zastrow, C., & Kirst-Ashman, K. (2004). Understanding human behavior and the socialenvironment. Belmont, CA: Brooks/Cole.

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