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Mental health problems are often a consequence—not a cause—of homelessness

Photo courtesy of flickr user Fabrice Florin: http://bit.ly/2gDBEcy
Tents in West Oakland

This story originally aired in December 7, 2016 and most recently aired in the November 2, 2022 episode of Crosscurrents.

UCSF is conducting one of the first ongoing studies on the experience of homelessness among adults over 50. It’s called the Health Outcomes of People Experiencing Homelessness in Older Middle Age, or HOPE - HOME.

The study watches how 350 older adults move into and out of homelessness, how they do or don’t manage to find housing again, and how living on the street affects the body and mind. The aim is to use the data to help guide prevention, health care, social service and housing interventions. 

If you’ve experienced homelessness or been close to someone who has, maybe you won’t be surprised by what the researchers are learning.  For example, some people choose to go off their medications when they’re on the street because they can’t chance the side effect of being sluggish when they need to be alert. Or, the fact that many people on the street are in close contact with family and friends, but can’t move in with them because the households in their network are already over-crowded, or housing subsidies prohibit it. 

The HOPE - HOME research consists of open-ended interviews, and clinical evaluations of mental and physical health. UCSF gives participants gift cards in exchange for checking in regularly. They also do a fair amount of tracking people down outside on the street.

Research director Dr. Margot Kushel says because it’s a long-term study, participants' voices actually help shape the lines of inquiry. 

“We’ve wound up adding things and thinking of things very differently from the stories that our participants tell us,” says Kushel. “The solutions that they have make a lot of sense.”

Since the study began, about half the participants have found housing. Half of those have done it without formal assistance—often by moving out of Oakland.

Some participants are newly homeless–displaced by the rising rents in Oakland. Others have been in and out of homelessness since childhood. Like Kim Colman, who left the projects in New York as a teenager to hang out in train tunnels. 

“It was ridiculous. It was insane.” says Colman. “I just didn’t wanna go home.”

Some participants are cycling in and out of homelessness, and some fall fast and deep into it. Like Maria Haverstock, who left her abusive husband—and her home—about 15 years ago. She’s been at the San Pablo, a single room occupancy hotel, for the last three years. 

“I think the single strongest thing I remember about homelessness is how quickly you can go from renting a place, having a car, and something catastrophic happens to you and there is no safety net,” says Haverstock.

When she began living on the streets, Haverstock says she lost some sense of her place in the world.

“One of the worst things about being homeless is the way people look at you,” she says. “Because I have a college education, I grew up in San Francisco, I practiced as an architect for over 30 years.”

Shame and despair are common among the participants in the study. So are stress, fear and anxiety. Maria recalls feeling endangered—she was threatened with a gun once.

Many of the study participants try to sleep during the day, or in shifts, in order to minimize their exposure to danger. Dr. Kushel says sleep deprivation can exacerbate all kinds of mental health problems.

“Homelessness is pretty much like bizarro world. It's like to take everything that a professional health person might recommend and turning it on its head,” says Kushel. “You take people who are in a situation where they're under incredible stress, they're isolated, they get little sleep, they're away from their friends and family, where they're stigmatized, where they feel shame, where they don't have access to food or care. Everything about homelessness is almost set up to worsen people's health.”

That’s why, contrary to a lot of popular assumptions, mental health problems are often a consequence–not a cause— of homelessness. 

Dr. Kushel says she gets frustrated with the way she sees people conflating mental illness with homelessness.

“Clearly people with mental health problems are at a higher risk because there's a stigma, it's harder to get jobs, all of those things are true,” says Kushel. “But I think we need to keep it in context that people that are wealthy but have mental health problems don't become homeless. So, it's a risk factor, but it’s not the only story.”

Depression, anxiety, post traumatic stress, behavioral disorders, and cognitive impairment are all more common among the homeless population than the general population. But Kushel says each of these symptoms are found in less than half the HOPE - HOME participants. That suggests that people do find ways to cope. Maria Haverstock says part of her coping strategy was forgetting.

“You have to block stuff out and just be an accepting kind of person and that becomes second nature to a lot of people,” she says. “They forget what it's like to have a house.”

Maria says when she was on the street she didn’t want to think about what she’d lost, so she focused on the camaraderie she’d found. Relationships that she formed while she was homeless have lasted, including the partner she’s still with today.

“I appreciated different things that even being homeless can’t take away from you.”

Kim Colman also notes the way he and other people on the street took care of each other.

“Say a person has business to take care of with social services or SSI or school, and they're intimidated by the situation they're in. They may come and ask me about it. I've even gone to the places with people,” says Colman. “I enjoy doing that.”

Colman is now going to school to become a counselor. He says he wants to give back to people that are in the same place he was.

“Some people are just poverty stricken. It has nothing to do with drugs or mental illness, it’s just they don’t make enough money. It’s just poverty. It’s just what is.”

After 50 years in and out of homelessness, Colman says he's seen people on the street slide into mental illness. But he says “I’m the same person, I'm me. I know what I’ve done and I know what I can do.”

Dr. Kushel says people tend to emphasize their own choices when telling their stories. 

“What is really clear to us having now followed these incredible 350 people for a couple years, is how much the individuals tend to blame themselves—even though, we who hear their narrative think ‘God the world was really stacked against them in a bad way.’ But I think we also really have found tales of people's resilience and own expertise.”

Nationally, about 20 percent of people who fall into homelessness go on to be unsheltered for over a year. And, unfortunately, Kushel says that number is creeping up—more and more people are becoming locked in chronic homelessness.

This story was reported as part of the SF Homeless Project, a media effort to cover the causes of and solutions to homelessness.

Crosscurrents UCSF