Learning Objectives
By the end of this section, you will be able to:
- Discuss risks for housing instability and mental health needs of unhoused and displaced persons
- Give examples of barriers to mental health care
- Develop collaborative nursing strategies to promote health
The intersection of mental health and homelessness or displacement has emerged as an important focal point within the realm of psychiatric-mental health nursing. Unhoused and displaced populations face a variety of unique mental health challenges, stemming from a complex web of factors, such as poverty, trauma, and social isolation. For individuals grappling with homelessness or displacement, access to mental health care is often fraught with barriers, ranging from stigmatization to the lack of resources and support networks. In response to these challenges, psychiatric-mental health nurses are often at the forefront of developing innovative strategies aimed at promoting mental well-being and holistic health within these marginalized communities. Nurses explore their distinct mental health needs, the hurdles to care, and the development of nursing strategies designed to bridge the gap, restore dignity, and facilitate recovery within these often-overlooked communities.
Risks for Housing Instability and Accompanying Mental Health Needs
Loss of home or housing stability can result from various risks and causes, often a combination of factors (Table 27.3). Being homeless generally means lacking a stable, safe, and adequate place to live, or living without a fixed residence. The term unsheltered generally refers to individuals experiencing homelessness who lack any form of shelter, such as those living on the streets, in cars, or in other places not meant for human habitation, without access to conventional housing or shelter facilities. Orenstein (2020) writes that people living in certain situations should be the ones to guide the language used to describe them. For example, some people (and some organizations and advocates) use the term "houseless" or "unhoused" to refer to their specific living situation; a person who lives in a tent may consider themselves "unhoused" but not "homeless," because they do have a home. Nurses should consider the stigma and assumptions that arrive with all terminology.
| Category | Risks | Description |
|---|---|---|
| Economic factors | Financial instability | Job loss, underemployment, low wages, or unexpected expenses can make it difficult for individuals and families to maintain stable housing. |
| Rising housing costs | Rapid increases in rent or mortgage payments that outpace income growth can force people out of their homes. | |
| Health-related factors | Medical expenses | High medical bills, especially in the absence of adequate health insurance, can lead to financial distress and housing instability. |
| Mental health issues | Mental health challenges can disrupt a person’s ability to maintain housing and stability. | |
| Physical disabilities | Disabilities that limit mobility or the ability to work can impact housing stability. | |
| Family and relationship factors | Domestic violence | Escaping an abusive relationship may require leaving one’s home to ensure safety. |
| Family disputes | Conflict within families, disagreements over property, or strained relationships can result in loss of housing. | |
| Social factors | Social isolation | Lack of a support network or social connections can contribute to housing instability, as individuals may have no one to turn to in times of crisis. |
| Discrimination | Discrimination based on race, ethnicity, gender, or other factors can limit housing opportunities and contribute to housing instability. | |
| Legal factors | Eviction | Legal actions leading to eviction, often due to unpaid rent or lease violations, can result in the loss of housing. |
| Foreclosure | Homeowners may lose their homes due to inability to meet mortgage payments, leading to foreclosure. | |
| Natural factors | Natural disasters | Hurricanes, floods, wildfires, or earthquakes can destroy homes and displace individuals and families. |
| Policy and economic trends | Gentrification | Neighborhood revitalization efforts can lead to increased housing costs, pushing out long-term residents. |
| Inadequate affordable housing | Shortages of affordable housing options in some areas can make it challenging for low-income individuals and families to secure stable housing. | |
| Substance use factors | Substance misuse | Substance use and misuse can lead to financial instability and homelessness. |
| Support services | Limited access | Limited access to social services, mental health treatment, or substance misuse recovery programs can contribute to housing instability for vulnerable populations. |
Mental Illness
Mental illness is a significant contributing factor to homelessness, and the relationship between mental health and homelessness is complex. According to the National Alliance on Mental Illness (NAMI, 2023), as of 2020, 21.1 percent of the unhoused population in the United States had a serious mental illness (SMI), which means an illness that causes diminished capacity or ability to participate in and function in daily life endeavors. Several key factors illustrate how mental illness can play a role in homelessness and how homelessness can cause or exacerbate mental illness:
- Preexisting mental health conditions: Many individuals experiencing homelessness have preexisting mental health conditions, such as schizophrenia, bipolar disorder, depression, or PTSD. These conditions can make it challenging to maintain stable employment, housing, and social relationships.
- Lack of access to mental health care: Homeless individuals often struggle to access mental health services due to financial constraints, lack of insurance, or limited availability of services. This can result in untreated or undertreated mental illness, exacerbating their challenges.
- Self-medication: Some individuals with mental health issues may turn to self-medication through substance abuse as a way to cope with their symptoms. This can further complicate their ability to secure stable housing and employment.
- Crisis events: Mental health crises, such as severe episodes of psychosis or severe depression, can lead to disruptions in employment and housing. Without adequate support and treatment, these crises can result in homelessness.
- Stigma and discrimination: Stigmatization and discrimination against people with mental health issues can lead to social isolation and exclusion, making it more difficult for them to maintain relationships, find housing, or secure employment.
- Cycling in and out of homelessness: Some individuals with mental illness may experience cycles of homelessness, where they briefly obtain housing but lose it due to difficulties related to their mental health. They encounter housing instability, generally a state of uncertainty or vulnerability in one’s housing situation, characterized by frequent moves, risk of eviction, difficulty paying rent or mortgage, or a lack of stable, secure housing. It can increase stress, and the cycle can perpetuate homelessness and mental health issues.
- Trauma and PTSD: Homelessness itself can be a traumatic experience, leading to the development or worsening of mental health conditions like PTSD. Trauma from experiences, such as domestic violence, childhood abuse, or military service can also contribute to mental illness and homelessness.
Substance Use Disorder
The relationship between substance use disorder (SUD) and homelessness is also complex, with several key factors highlighting how SUD can contribute to homelessness. For many individuals experiencing homelessness, substances like alcohol or drugs serve as coping mechanisms to manage the immense stress, trauma, and hardships associated with life on the streets. These substances can temporarily numb emotional pain or provide a brief respite from the harsh realities of homelessness. The misuse of substances often leads to addiction and physical dependency. As the addiction progresses, individuals may prioritize obtaining and using drugs or alcohol over maintaining stable housing, employment, or relationships. Maintaining a substance use disorder can be financially draining, as the costs of obtaining drugs or alcohol can deplete financial resources. Consequently, individuals may struggle to afford housing, rent, or utilities, leading to eviction or housing loss.
Additionally, substance use frequently brings legal issues, including arrests for drug-related offenses. Legal problems can result in incarceration, probation, or parole, making it challenging to secure stable housing or employment upon release.
Social isolation is also a consequence of substance use, as it can lead to the isolation of individuals from their support networks and families. This social isolation can result in strained or severed relationships, reducing the likelihood of receiving help from friends or family when faced with housing instability.
Moreover, substance use can exacerbate or co-occur with mental health disorders, further complicating efforts to secure stable housing and employment. These co-occurring disorders often require integrated treatment approaches for effective management.
Further, individuals experiencing homelessness and substance use disorders may encounter barriers to accessing addiction treatment services. These barriers can include lack of insurance, transportation, or access to detoxification and rehabilitation programs, which hinder their path to recovery and housing stability.
Mental Health Needs of Individuals with SUD Housing Instability
Understanding these complex interconnections between housing and mental illness and housing and substance misuse is crucial for health-care professionals. By comprehending a holistic picture, nurses are able to provide better, comprehensive care and support to individuals facing homelessness and SUD.
Motivational Therapies
Motivational therapies have proven to be effective tools in addressing substance use disorders among homeless individuals. One that is particularly effective is motivational interviewing (MI), a client-centered approach that aims to enhance an individual’s intrinsic motivation to change their behavior (Psychology Today, 2022). In the context of homelessness and substance use, MI can be a powerful technique for engaging individuals who may be ambivalent about seeking treatment. By empathetically exploring their concerns and values, MI helps homeless individuals recognize the impact of substance use on their lives, fostering a genuine desire for change. It acknowledges the complex challenges faced by this population and works collaboratively to set achievable goals for recovery. It is a valuable approach to providing tailored support for those struggling with substance use within the homeless community.
Recovery Housing
The concept of recovery housing, supportive and structured environments that offer a safe and stable place for individuals in recovery, creates a conducive setting for healing and sobriety. It represents a crucial component in addressing substance use disorder among individuals without housing. Recovery housing typically promotes abstinence, provides access to counseling and support services, and encourages residents to actively engage in their recovery journey. For unhoused individuals grappling with substance use disorders, such housing can be a lifeline, offering not only a physical place to stay but also a community of peers who understand their struggles. It helps break the cycle of homelessness and substance misuse, fostering an environment where individuals can rebuild their lives and work toward sustained recovery.
Link to Learning
The Substance Abuse and Mental Health Services Administration (SAMHSA) created their Best Practices for Recovery Housing in recognition of its crucial role in positive outcomes. It contains evidence-based practice guidelines for creating successful recovery housing.
Barriers to Stability and Results of Instability
Homelessness is compounded by a multitude of barriers for individuals striving to regain housing and financial security. As discussed, living with a mental illness can exacerbate these situations. Barriers include the absence of a credit or rental history, which can deter landlords from renting to those without proven financial reliability. Lack of insurance can hinder access to vital health care, perpetuating health-related issues, while limited transportation options impede access to employment, social services, and medical care. Unemployment remains a central hurdle, as income is crucial for maintaining housing, and the cyclical nature of homelessness often hampers job-seeking efforts. Addressing these multifaceted barriers and fostering stability requires a comprehensive approach, including affordable housing initiatives, employment support, health-care access, and financial literacy programs.
Psychosocial Barriers
Psychosocial barriers play a pivotal role in perpetuating homelessness, encompassing a range of factors that affect an individual’s ability to regain stability. Trust issues, often stemming from past traumas or exploitation, can hinder engagement with support services and housing programs. Stigma associated with homelessness can lead to social isolation and keep individuals from seeking assistance, particularly among young and older adults who may face unique challenges due to their age. Limited access to education or lack of skills can constrain employment opportunities, while the cycle of homelessness itself can disrupt education for youth. Overcoming these psychosocial barriers necessitates a holistic approach, including trauma-informed care, anti-stigma campaigns, targeted interventions for vulnerable age groups, and educational support to empower individuals on their journey toward housing stability (SAMHSA, 2015).
Societal Impact of Instability
The societal impact of barriers to housing stability is far-reaching and multifaceted. Persons living with mental illness and homelessness may be overrepresented among defendants entering the criminal justice system and have higher rates of arrest and victimization (Sipes, 2022). Some life-sustaining activities, such as sleeping, camping, or asking for money in public places can be subject to arrest (National Coalition for the Homeless, 2023). The lack of stable housing can also contribute to increased utilization of emergency medical care; unhoused individuals may rely on emergency rooms for primary health-care needs, straining health-care resources and increasing costs. To mitigate these societal impacts, it is crucial to invest in comprehensive homelessness prevention and support programs that address the root causes of homelessness, ultimately benefiting both individuals and society as a whole.
Special Populations: Veterans, Families, Rural Areas
Homelessness unevenly affects various special populations, each facing unique challenges of which nurses should be aware. Mental health concerns complicate these scenarios. One Veterans Affairs study in 2017 found that out of 300,000 veterans who had been referred for anxiety or PTSD, 5.6 percent experienced homelessness within one year (Tsai et al., 2017). The overall Veteran population shows homelessness of approximately 3.7 percent over a five-year period (U.S. Department of Veterans Affairs, 2021).
Families and children impacted by mental health concerns also constitute a particularly vulnerable group, with homelessness adding to detrimental effects on children’s development and well-being. In rural areas, homelessness can be especially hidden and persistent due to a lack of infrastructure and resources, resulting in limited access to shelters and support services. Limited, also, are community mental health centers and resources specifically for the care of a diverse rural population (Morales et al., 2020). Addressing homelessness in these special populations requires tailored interventions, such as veteran-specific housing programs, family-oriented shelters, and outreach efforts in rural communities.
Nursing Collaboration
Collaboration between nursing professionals, other disciplines, and government agencies is essential to improving access to mental health care for unhoused clients (Robert Wood Johnson Foundation, 2021). Nurses often serve as the first point of contact in health-care settings, making them crucial in identifying mental health needs among homeless individuals. To enhance accessibility, nurses can collaborate with social workers, psychologists, and outreach workers to conduct intake assessments in easily accessible locations, such as homeless shelters, drop-in centers, or mobile clinics. This collaborative effort ensures that individuals experiencing homelessness receive timely mental health assessments and referrals to appropriate services. Additionally, partnerships with government agencies at the local, state, and federal levels can help secure funding for mental health programs and increase the availability of resources, including affordable housing and substance misuse treatment, which are vital components of comprehensive care for unhoused individuals with mental health needs. By working together across disciplines and with government support, nurses can help bridge the gap in mental health-care accessibility for unhoused clients and improve their overall well-being.
Link to Learning
The Robert Wood Johnson Foundation framework can assist nurses who must coordinate with other disciplines and organizations when providing care to clients.
Advocacy for Support
Advocacy for support is a crucial component of psychiatric-mental health nursing. Psychiatric-mental health nurses often witness firsthand the challenges faced by individuals with mental illness who lack stable housing. Communities with supportive housing can not only provide a safe and stable environment, but can also offer essential services like counseling, medication management, and social support that are integral to mental health recovery. Psychiatric-mental health nurses can advocate for increased funding and policy changes to expand supportive programs and services, ensuring that vulnerable populations, such as those experiencing homelessness or severe mental illness, have access to these vital resources. Individuals living without secure housing also benefit from practical assistance where they are.
Link to Learning
Nurses can find resources from the American Nurses Association for legislative advocacy.
Homeless Health Nursing/Street Nursing
Homeless health nursing, often referred to as street nursing, is a specialized field that focuses on providing health-care services to individuals experiencing homelessness in nontraditional settings, such as shelters, encampments, or on the streets (Cavazos, 2022). These dedicated nurses play a vital role in addressing the complex health needs of this marginalized population, including mental health and substance use issues, infectious diseases, and chronic illnesses. Street nurses build trusting relationships with their clients, offering not only essential medical care but also support, referrals to social services, and advocacy for improved living conditions. Their work is essential in addressing health disparities and improving the overall well-being of those who are unhoused, often acting as a link between the health-care system and this vulnerable population.