research paper outline on homelessness

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• Published: 22 August 2017

Social conditions of becoming homelessness: qualitative analysis of life stories of homeless peoples

• Mzwandile A. Mabhala   ORCID: orcid.org/0000-0003-1350-7065 1 , 3 ,
• Asmait Yohannes 2 &
• Mariska Griffith 1  

International Journal for Equity in Health volume  16 , Article number:  150 ( 2017 ) Cite this article

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It is increasingly acknowledged that homelessness is a more complex social and public health phenomenon than the absence of a place to live. This view signifies a paradigm shift, from the definition of homelessness in terms of the absence of permanent accommodation, with its focus on pathways out of homelessness through the acquisition and maintenance of permanent housing, to understanding the social context of homelessness and social interventions to prevent it.

However, despite evidence of the association between homelessness and social factors, there is very little research that examines the wider social context within which homelessness occurs from the perspective of homeless people themselves. This study aims to examine the stories of homeless people to gain understanding of the social conditions under which homelessness occurs, in order to propose a theoretical explanation for it.

Twenty-six semi-structured interviews were conducted with homeless people in three centres for homeless people in Cheshire North West of England.

The analysis revealed that becoming homeless is a process characterised by a progressive waning of resilience capacity to cope with life challenges created by series of adverse incidents in one’s life. The data show that final stage in the process of becoming homeless is complete collapse of relationships with those close to them. Most prominent pattern of behaviours participants often describe as main causes of breakdown of their relationships are:

engaging in maladaptive behavioural lifestyle including taking drugs and/or excessive alcohol drinking

Being in trouble with people in authorities.

Homeless people describe the immediate behavioural causes of homelessness, however, the analysis revealed the social and economic conditions within which homelessness occurred. The participants’ descriptions of the social conditions in which were raised and their references to maladaptive behaviours which led to them becoming homeless, led us to conclude that they believe that their social condition affected their life chances: that these conditions were responsible for their low quality of social connections, poor educational attainment, insecure employment and other reduced life opportunities available to them.

It is increasingly acknowledged that homelessness is a more complex social and public health phenomenon than the absence of a place to live. This view signifies a paradigm shift, from the definition of homelessness in terms of the absence of permanent accommodation [ 1 , 2 , 3 , 4 , 5 ], with its focus on pathways out of homelessness through the acquisition and maintenance of permanent housing [ 6 ], to understanding the social context of homelessness and social interventions to prevent it [ 6 ].

Several studies explain the link between social factors and homelessness [ 6 , 7 , 8 , 9 , 10 ]. The most common social explanations centre on seven distinct domains of deprivation: income; employment; health and disability; education, skills and training; crime; barriers to housing and social support services; and living environment [ 11 ]. Of all forms, income deprivation has been reported as having the highest risk factors associated with homelessness [ 7 , 12 , 13 , 14 ]: studies indicate that people from the most deprived backgrounds are disproportionately represented amongst the homeless [ 7 , 13 ]. This population group experiences clusters of multiple adverse health, economic and social conditions such as alcohol and drug misuse, lack of affordable housing and crime [ 10 , 12 , 15 ]. Studies consistently show an association between risk of homelessness and clusters of poverty, low levels of education, unemployment or poor employment, and lack of social and community support [ 7 , 10 , 13 , 16 ].

Studies in different countries throughout the world have found that while the visible form of homelessness becomes evident when people reach adulthood, a large proportion of homeless people have had extreme social disadvantage and traumatic experiences in childhood including poverty, shortage of social housing stocks, disrupted schooling, lack of social and psychological support, physical, sexual, and emotional abuse, neglect, dysfunctional family environments, and unstable family structures, all of which increase the likelihood of homelessness [ 10 , 13 , 14 ].

Furthermore, a large body of evidence suggests that people exposed to diverse social disadvantages at an early age are less likely to adapt successfully compared to people without such exposure [ 9 , 10 , 13 , 17 ], being more susceptible to adopting maladaptive coping behaviours such as theft, trading sex for money, and selling or using drugs and alcohol [ 7 , 9 , 18 , 19 ]. Studies show that these adverse childhood experiences tend to cluster together, and that the number of adverse experiences may be more predictive of negative adult outcomes than particular categories of events [ 17 , 20 ]. The evidence suggests that some clusters are more predictive of homelessness than others [ 7 , 12 ]: a cluster of childhood problems including mental health and behavioural disorders, poor school performance, a history of foster care, and disrupted family structure was most associated with adult criminal activities, adult substance use, unemployment and subsequent homelessness [ 12 , 17 , 21 ]. However, despite evidence of the association between homelessness and social factors, there is very little research that examines the wider social context within which homelessness occurs from the perspective of homeless people themselves.

This paper adopted Anderson and Christian’s [ 18 ] definition, which sees homelessness as a ‘function of gaining access to adequate, affordable housing, and any necessary social support needed to ensure the success of the tenancy’. Based on our synthesis of the evidence, this paper proposes that homelessness is a progressive process that begins at childhood and manifests itself at adulthood, one characterised by loss of the personal resources essential for successful adaptation. We adopted the definition of personal resources used by DeForge et al. ([ 7 ], p. 223), which is ‘those entities that either are centrally valued in their own right (e.g. self-esteem, close attachment, health and inner peace) or act as a means to obtain centrally valued ends (e.g. money, social support and credit)’. We propose that the new paradigm focusing on social explanations of homelessness has the potential to inform social interventions to reduce it.

In this study, we examine the stories of homeless people to gain understanding of the conditions under which homelessness occurs, in order to propose a theoretical explanation for it.

The design of this study was philosophically influenced by constructivist grounded theory (CGT). The aspect of CGT that made it appropriate for this study is its fundamental ontological belief in multiple realities constructed through the experience and understanding of different participants’ perspectives, and generated from their different demographic, social, cultural and political backgrounds [ 22 ]. The researchers’ resulting theoretical explanation constitutes their interpretation of the meanings that participants ascribe to their own situations and actions in their contexts [ 22 ].

The stages of data collection and analysis drew heavily on other variants of grounded theory, including those of Glaser [ 23 ] and Corbin and Strauss [ 24 ].

Setting and sampling strategy

The settings for this study were three centres for homeless people in two cities (Chester and Crewe) in Cheshire, UK. Two sampling strategies were used in this study: purposive and theoretical. The study started with purposive sampling and in-depth one-to-one semi-structured interviews with eight homeless people to generate themes for further exploration.

One of the main considerations for the recruitment strategy was to ensure that the process complies with the ethical principles of voluntary participation and equal opportunity to participate. To achieve this, an email was sent to all the known homeless centres in the Cheshire and Merseyside region, inviting them to participate. Three centres agreed to participate, all of them in Cheshire – two in Chester and one in Crewe.

Chester is the most affluent city in Cheshire and Merseyside, and therefore might not be expected to be considered for a homelessness project. The reasons for including it were: first, it was a natural choice, since the organisations that funded the project and the one that led the research project were based in Chester; second, despite its affluence, there is visible evidence of homelessness in the streets of Chester; and third, it has several local authority and charity-funded facilities for homeless people.

The principal investigator spent 1 day a week for 2 months in three participating centres, during that time oral presentation of study was given to all users of the centre and invited all the participants to participate and written participants information sheet was provided to those who wished to participate. During that time the principal investigator learned that the majority of homeless people that we were working with in Chester were not local. They told us that they came to Chester because there was no provision for homeless people in their former towns.

To help potential participants make a self-assessment of their suitability to participate without unfairly depriving others of the opportunity, participants information sheet outline criteria that potential participants had to meet: consistent with Economic and Social Research Council’s Research Ethics Guidebook [ 25 ], at the time of consenting to and commencing the interview, the participant must appear to be under no influence of alcohol or drugs, have a capacity to consent as stipulated in England and Wales Mental Capacity Act 2005 [ 26 ], be able to speak English, and be free from physical pain or discomfort.

As categories emerged from the data analysis, theoretical sampling was used to refine undeveloped categories in accordance with Strauss and Corbin’s [ 27 ] recommendations. In total 26 semi-structured interviews were carried out. Theoretical sampling involved review of memos or raw data, looking for data that might have been overlooked [ 27 , 28 ], and returning to key participants asking them to give more information on categories that seemed central to the emerging theory [ 27 , 28 ].

The sample comprised of 22 male and 4 female, the youndgest participant was 18 the eldest was 74 years, the mean age was 38.6 years. Table 1 illustrates participant’s education history, childhood living arrangements, brief participants family and social history, emotional and physical health, the onset of and trigger for homelessness.

Ethical approval

Ethical approval was obtained from the Research Ethics Committee of the University of Chester. The centre managers granted access once ethical approval had been obtained, and after their review of the study design and other research material, and of the participant information sheet which included a letter of invitation highlighting that participation was voluntary.

Data analysis

In this study data collection and analysis occurred simultaneously. Analysis drew on Glaser’s [ 23 ] grounded theory processes of open coding, use of the constant comparative method, and the iterative process of data collection and data analysis to develop theoretical explanation of homelessness.

The process began by reading the text line-by-line identifying and open coding the significant incidents in the data that required further investigation. The findings from the initial stage of analysis are published in Mabhala [ 29 ]. The the second stage the data were organised into three themes that were considered significant in becoming homeless (see Fig. 1 ):

Engaging in maladaptive behaviour

Being in trouble with the authorities.

Being in abusive environments.

Social explanation of becoming homeless. Legend: Fig. 1 illustrates the process of becoming homeless

The key questions that we asked as we continued to interrogate the data were: What category does this incident indicate? What is actually happening in the data? What is the main concern being faced by the participants? Interrogation of the data revealed that participants were describing the process of becoming homeless.

The comparative analysis involved three processes described by Glaser ([ 23 ], p. 58–60): each incident in the data was compared with incidents from both the same participant and other participants, looking for similarities and differences. Significant incidents were coded or given labels that represented what they stood for, and similarly coded or labeled when they were judged to be about the same topic, theme or concept.

After a period of interrogation of the data, it was decided that the two categories - destabilising behaviour, and waning ofcapacity for resilience were sufficiently conceptual to be used as theoretical categories around which subcategories could be grouped (Fig. 1 ).

Once the major categories had been developed, the next step consisted of a combination of theoretical comparison and theoretical sampling. The emerging categories were theoretically compared with the existing literature. Once this was achieved, the next step was filling in and refining the poorly defined categories. The process continued until theoretical sufficiency was achieved.

Figure 1 illustrates the process of becoming homeless. The analysis revealed that becoming homeless is a process characterised by a progressive waning of resilience created by a series of adverse incidents in one’s life. Amongst the frequently cited incidents were being in an abusive environment and losing a significant person in one’s life. However, being in an abusive environment emerged from this and previously published studies as a major theme; therefore, we decided to analyse it in more detail.

The data further show that the final stage in the process of becoming homeless is a complete collapse of relationships with those with whom they live. The most prominent behaviours described by the participants as being a main cause of breakdown are:

Engaging in maladaptive behaviour: substance misuse, alcoholism, self-harm and disruptive behaviours

Being in trouble with the authorities: theft, burglary, arson, criminal offenses and convictions

The interrogation of data in relation to the conditions within which these behaviours occurred revealed that participants believed that their social contexts influenced their life chance, their engagement with social institution such as education and social services and in turn their ability to acquire and maintain home. Our experiences have also shown that homeless people readily express the view that behavioural lifestyle factors such as substance misuse and engaging in criminal activities are the causes of becoming homeless. However, when we spent time talking about their lives within the context of their status as homeless people, we began to uncover incidents in their lives that appeared to have weakened their capacity to constructively engage in relationships, engage with social institutions to make use of social goods [ 29 , 30 , 31 ] and maturely deal with societal demands.

Being in abusive environments

Several participants explicitly stated that their childhood experiences and damage that occurred to them as children had major influences on their ability to negotiate their way through the education system, gain and sustain employment, make appropriate choices of social networks, and form and maintain healthy relationships as adults.

It appears that childhood experiences remain resonant in the minds of homeless participants, who perceive that these have had bearing on their homelessness. Their influence is best articulated in the extracts below. When participants were asked to tell their stories of what led to them becoming homeless, some of their opening lines were:

What basically happened, is that I had a childhood of so much persistent, consistent abuse from my mother and what was my stepfather. Literally consistent, we went around with my mother one Sunday where a friend had asked us to stay for dinner and mother took the invitation up because it saved her from getting off her ass basically and do anything. I came away from that dinner genuinely believing that the children in that house weren’t loved and cared for, because they were not being hit, there was no shouting, no door slamming. [Marco]

It appears that Marco internalised the incidents of abuse, characterised by shouting, door slamming and beating as normal behaviour. He goes on to intimate how the internalised abusive behaviour affected his interaction with his employers.

‘…but consistently being put down, consistently being told I was thick, I started taking jobs and having employers effing and blinding at me. One employer actually used a “c” word ending in “t” at me quite frequently and I thought it was acceptable, which obviously now I know it’s not. So I am taking on one job after another that, how can I put it? That no one else would do basically. I was so desperate to work and earn my own money. [Marco]

Similarly, David makes a connection between his childhood experience and his homelessness. When he was asked to tell his life story leading to becoming homeless, his opening line was:

I think it [homelessness] started off when I was a child. I was neglected by my mum. I was physically and mentally abused by my mum. I got put into foster care, when I left foster care I was put in the hostel, from there I turn into alcoholic. Then I was homeless all the time because I got kicked out of the hostels, because you are not allowed to drink in the hostel. [David]

David and Marco’s experiences are similar to those of many participants. The youngest participant in this study, Clarke, had fresh memories of his abusive environment under his stepdad:

I wouldn't want to go back home if I had a choice to, because before I got kicked out me stepdad was like hitting me. I wouldn't want to go back to put up with that again. [I didn't tell anyone] because I was scared of telling someone and that someone telling me stepdad that I've told other people. ‘[Be] cause he might have just started doing again because I told people. It might have gotten him into trouble. [Clarke]

In some cases, participants expressed the beliefs that their abusive experience not only deprived them life opportunities but also opportunities to have families of their own. As Tom and Marie explain:

We were getting done for child neglect because one of our child has a disorder that means she bruise very easily. They all our four kids into care, social workers said because we had a bad childhood ourselves because I was abused by my father as well, they felt that we will fail our children because we were failed by our parents. We weren’t given any chance [Tom and Marie]

Norma, described the removal of her child to care and her maladaptive behaviour of excessive alcohol use in the same context as her experience of sexual abuse by her father.

I had two little boys with me and got took off from me and put into care. I got sexually abused by my father when I was six. So we were put into care. He abused me when I was five and raped me when I was six. Then we went into care all of us I have four brothers and four sisters. My dad did eighteen months for sexually abusing me and my sister. I thought it was normal as well I thought that is what dads do [Norma]

The analysis of participants in this study appears to suggest that social condition one is raised influence the choice of social connections and life partner. Some participants who have had experience of abuse as children had partner who had similar experience as children Tom and Marie, Lee, David and his partners all had partners who experienced child abuse as children.

Tom and Marie is a couple we interviewed together. They met in hostel for homeless people they have got four children. All four children have been removed from them and placed into care. They sleep rough along the canal. They explained:

We have been together for seven years we had a house and children social services removed children from us, we fell within bedroom tax. …we received an eviction order …on the 26th and the eviction date was the 27th while we were in family court fighting for our children. …because of my mental health …they were refusing to help us.

Our children have been adopted now. The adoption was done without our permission we didn’t agree to it because we wanted our children home because we felt we were unfairly treated and I [Marie] was left out in all this and they pin it all on you [Tom] didn’t they yeah, my [Tom] history that I was in care didn’t help.

Tom went on to talk about the condition under which he was raised:

I was abandoned by my mother when I was 12 I was then put into care; I was placed with my dad when I was 13 who physically abused me then sent back to care. [Tom].

David’s story provides another example of how social condition one is raised influence the choice of social connections and life partner. David has two children from two different women, both women grew up in care. Lisa one of David’s child mother is a second generation of children in care, her mother was raised in care too.

I drink to deal with problems. As I say I’ve got two kids with my girlfriend Kyleigh, but I got another lad with Lisa, he was taken off me by social services and put on for adoption ten years ago and that really what started it; to deal with that. Basically, because I was young, and I had been in care and the way I had been treated by my mum. Basically laid on me in the same score as my mum and because his mum [Lisa] was in care as well. So they treated us like that, which was just wrong. [David]

In this study, most participants identified alcohol or drugs and crime as the cause of relationships breakdown. However, the language they used indicates that these were secondary reasons rather than primary reasons for their homelessness. The typical question that MA and MG asked the interview participants was “tell us how did you become homeless”? Typically, participants cited different maladaptive behaviours to explain how they became homeless.

Alvin’s story is typical of:

Basically I started off as a bricklayer, … when the recession hit, there was an abundance of bricklayers so the prices went down in the bricklaying so basically with me having two young children and the only breadwinner in the family... so I had to kinda look for factory work and so I managed to get a job… somewhere else…. It was shift work like four 12 hour days, four 12 hour nights and six [days] off and stuff like that, you know, real hard shifts. My shift was starting Friday night and I’ll do Friday night, Saturday night to Monday night and then I was off Tuesday, Wednesday and Thursday, but I’d treat that like me weekend you know because I’ve worked all weekend. Then… so I’d have a drink then and stuff like that, you know. 7 o’ clock on a Monday morning not really the time to be drinking, but I used to treat it like me weekend. So we argued, me and my ex-missus [wife], a little bit and in the end we split up so moved back to me mum's, but kept on with me job, I was at me mum’s for possibly about five years and but gradually the drinking got worse and worse, really bad. I was diagnosed with depression and anxiety. … I used to drink to get rid of the anxiety and also to numb the pain of the breakup of me marriage really, you know it wasn’t good, you know. One thing led to another and I just couldn’t stop me alcohol. I mean I’ve done drugs you know, I was into the rave scene and I’ve never done hard drugs like heroin or... I smoke cannabis and I use cocaine, and I used to go for a pint with me mates and that. It all came to a head about November/December time, you know it was like I either stop drinking or I had to move out of me mum's. I lost me job in the January through being over the limit in work from the night before uum so one thing led to another and I just had to leave. [Alvin]

Similarly, Gary identified alcohol as the main cause of his relationship breakdown. However, when one listens to the full story alcohol appears to be a manifestation of other issues, including financial insecurities and insecure attachment etc.

It [the process of becoming homeless] mainly started with the breakdown of the relationship with me partner. I was with her for 15 years and we always had somewhere to live but we didn't have kids till about 13 years into the relationship. The last two years when the kids come along, I had an injury to me ankle which stopped me from working. I was at home all day everyday. …I was drinking because I was bored. I started drinking a lot ‘cause I couldn't move bout the house. It was a really bad injury I had to me ankle. Um, and one day me and me partner were having this argument and I turned round and saw my little boy just stood there stiff as a board just staring, looking at us. And from that day on I just said to me partner that I'll move out, ‘cause I didn't want me little boy to be seeing this all the time. [Gary]

In both cases Gary and Alvin indicate that changes in their employment status created conditions that promoted alcohol dependency, though both explained that they drank alcohol before the changes in their employment status occurred and the breakdown of relationships. Both intimated that that their job commitment limited the amount of time available to drink alcohol. As Gary explained, it is the frequency and amount of alcohol drinking that changed as a result of change in their employment status:

I used to have a bit of a drink, but it wasn’t a problem because I used to get up in the morning and go out to work and enjoy a couple of beers every evening after a day’s work. Um, but then when I wasn't working I was drinking, and it just snowballed out, you know snowball effect, having four cans every evening and then it went from there. I was drinking more ‘cause I was depressed. I was very active before and then I became like non-active, not being able to do anything and in a lot of pain as well. [Gary]

Furthermore, although the participants claim that drinking alcohol was not a problem until their employment circumstances changed, one gets a sense that alcohol was partly responsible for creating conditions that resulted in the loss of their jobs. In Gary’s case, for example, alcohol increased his vulnerability to the assault and injuries that cost him his job:

I got assaulted, kicked down a flight of stairs. I landed on me back on the bottom of the stairs, but me heel hit the stairs as it was still going up if you know what I mean. Smashed me heel, fractured me heel… So, by the time I got to the hospital and they x-rayed it they wasn't even able to operate ‘cause it was in that many pieces, they weren't even able to pin it if you know what I mean. [Gary]

Alvin, of the other hand, explained that:

I lost my job in the January through being over the limit in work from the night before, uum so one thing led to another and I just had to leave. [Alvin]

In all cases participants appear to construct marriage breakdown as an exacerbating factor for their alcohol dependence. Danny, for example, constructed marriage breakdown as a condition that created his alcohol dependence and alcohol dependence as a cause of breakdown of his relationship with his parents. He explains:

I left school when I was 16. Straight away I got married, had children. I have three children and marriage was fine. Umm, I was married for 17 years. As the marriage broke up I turned to alcohol and it really, really got out of control. I moved in with my parents... It was unfair for them to put up with me; you know um in which I became... I ended up on the streets, this was about when I was 30, 31, something like that and ever since it's just been a real struggle to get some permanent accommodation. [Danny]

Danny goes on to explain:

Yes [I drank alcohol before marriage broke down but] not very heavily, just like a sociable drink after work. I'd call into like the local pub and have a few pints and it was controlled. My drinking habit was controlled then. I did go back to my parents after my marriage break up, yes. I was drinking quite heavily then. I suppose it was a form of release, you know, in terms of the alcohol which I wish I'd never had now. When I did start drinking heavy at me parents’ house, I was getting in trouble with the police being drunk and disorderly. That was unfair on them. [Danny]

The data in this study indicate that homelessness occurs when the relationships collapse, irrespective of the nature of the relationship. There were several cases where lifestyle behaviour led to a relationship collapse between child and parents or legal guardians.

In the next excerpt, Emily outlines the incidents: smoking weed, doing crack and heroin, and drinking alcohol. She also uses the words ‘because’, ‘when’ and ‘obviously’, which provide clues about the precipitating condition for her behaviours “spending long time with people who take drugs”.

I've got ADHD like, so obviously my mum kicked me out when I was 17 and then like I went to **Beswick** and stuff like that. My mum in the end just let me do what I wanted to do, ‘cause she couldn't cope anymore. …I mean I tried to run away from home before that, but she'd always like come after me in like her nightie and pyjamas and all that. But in the end she just washed her hands of me . [Emily]

Emily presented a complex factors that made it difficult for her mother to live with her. These included her mother struggle with raising four kids as a single parent, Emily’s mental health (ADHD], alcohol and drug use. She goes on to explain that:

Ummm, well the reason I got kicked out of my hostel was ‘cause of me drinking, so I'd get notice to quit every month, then I’d have a meeting with the main boss and then they'd overturn it and this went on every month for about six months. Also, it was me behaviour as well, but obviously drink makes you do stuff you don't normally do and all that shit. I lived here for six months, got kicked out because I jumped out the window and broke me foot. I was on the streets for six months and then they gave me a second chance and I've been here a year now. So that's it basically. [Emily]

There were several stories of being evicted from accommodation due to excessive use of alcohol. One of those is David:

I got put into foster care. When I left foster care I was put in the hostel, from there I turn into alcoholic. Then I was homeless all the time because I got kicked out of the hostels, because you are not allowed to drink in the hostel. It’s been going on now for about… I was thirty-one on Wednesday, so it’s been going on for about thirteen years, homeless on and off. Otherwise if not having shoplifted for food and then go to jail, and when I don’t drink I have lot of seizures and I end up in the hospital. Every time I end up on the street. I trained as a chef, I have not qualified yet, because of alcohol addiction, it didn’t go very well. I did couple of jobs in restaurants and diners, I got caught taking a drink. [David]

Contrary to the other incidents where alcohol was a factor that led to homelessness, Barry’s description of his story appears to suggest that the reason he had to leave his parents’ home was his parents’ perception that his sexuality brought shame to the family:

When I came out they I’m gay, my mum and dad said you can’t live here anymore. I lived in a wonderful place called Nordic... but fortunately, mum and dad ran a pub called […] [and] one of the next door neighbours lived in a mansion. His name was [….] [and] when I came out, he came out as in he said “I'm a gay guy”, but he took me into Liverpool and housed me because I had nowhere to live. My mum and dad said you can't live here anymore. And unfortunately, we get to the present day. I got attacked. I got mugged... only walked away with a £5 note, it’s all they could get off me. They nearly kicked me to death so I was in hospital for three weeks. By the time I came out, I got evicted from my flat. I was made homeless. [Barry]

We used the phrase “engaging in maladaptive behaviour” to conceptualise the behaviours that led to the loss of accommodation because our analysis appear to suggest that these behaviours were strategies to cope with the conditions they found themselves in. For example, all participants in this category explained that they drank alcohol to cope with multiple health (mental health) and social challenges.

In the UK adulthood homelessness is more visible than childhood homelessness. However, most participants in this research reveal that the process of becoming homeless begins at their childhood, but becomes visible after the legal age of consent (16). Participants described long history of trouble with people in authority including parents, legal guardians and teachers. However, at the age of 16 they gain legal powers to leave children homes, foster homes, parental homes and schools, and move outside some of the childhood legal protections. Their act of defiance becomes subject to interdiction by the criminal justice system. This is reflected in number of convictions for criminal offenses some of the participants in this study had.

Participants Ruddle, David, Lee, Emily, Pat, Marco, Henry and many other participants in this study (see Table 1 ) clearly traced the beginning of their troubles with authority back at school. They all expressed the belief that had their schooling experience been more supportive, their lives would have been different. Lee explains that being in trouble with the authorities began while he was at school:

‘The school I came from a rough school, it was a main school, it consisted of A, B, C, D and The school I came from [was] a rough school, it was a main school, it consisted of A, B, C, D and E. I was in the lowest set, I was in E because of my English and maths. I was not interested, I was more interested in going outside with big lads smoking weed, bunking school. I used to bunk school inside school. I used to bunk where all cameras can catch me. They caught me and reported me back to my parents. My mum had a phone call from school asking where your son is. My mum grounded me. While my mum grounded me I had a drain pipe outside my house, I climbed down the drain pipe outside my bedroom window. I used to climb back inside. [Lee]

Lee’s stories constructed his poor education experiences as a prime mover towards the process of becoming homeless. It could be noted in Table 1 that most participants who described poor education experiences came from institutions such as foster care, children home and special school for maladjusted children. These participants made a clear connection between their experiences of poor education characterised by defiance of authorities and poor life outcomes as manifested through homelessness.

Patrick made a distinct link between his school experience and his homelessness, for example, when asked to tell his story leading up to becoming homeless, Patrick’s response was:

I did not go to school because I kept on bunking. When I was fifteen I left school because I was caught robbing. The police took me home and my mum told me you’re not going back to school again, you are now off for good. Because if you go back to school you keep on thieving, she said I keep away from them lads. I said fair enough. When I was seventeen I got run over by a car. [Patrick]

Henry traces the beginning of his troubles with authorities back at school:

[My schooling experience]… was good, I got good, well average grades, until I got myself into [a] few fights mainly for self-defence. In primary schools, I had a pretty... I had a good report card. In the start of high school, it was good and then when the fights started that gave me sort of like a... bad reputation. I remember my principal one time made me cry. Actually made me cry, but eh... I don't know how, but I remember sitting there in the office and I was crying. My sister also stuck up for me when she found out what had happened, she was on my side; but I can’t remember exactly what happened at that time. [Henry]

Emily’s story provides some clues about the series of incidents - including, delay in diagnosing her health condition, being labelled as a naughty child at school, being regularly suspended from school and consequently poor educational attainment.

Obviously, I wasn't diagnosed with ADHD till I was like 13, so like in school they used to say that's just a naughty child. … So it was like always getting suspended, excluded and all that sort of stuff. And in the end [I] went to college and the same happened there. [Emily]

The excerpt above provides intimations of what she considers to be the underlying cause of her behaviour towards the authorities. Emily suggests that had the authorities taken appropriate intervention to address her condition, her life outcomes would have been different.

Although the next participant did not construct school as being a prime mover of their trouble with authorities, their serious encounters with the criminal justice system occurred shortly after leaving school:

Well I did a bit of time at a very early age, I was only 16… I did some remand there, but then when I went to court ‘cause I'd done enough remand, I got let out and went to YMCA in Runcorn. Well, that was when I was a kid. When I was a bit older, ‘cause it was the years 2000 that I was in jail, I was just trying to get by really. I wasn’t with Karen at the time. I was living in Crewe and at the time I was taking a lot of amphetamines and was selling amphetamines as well, and I got caught and got a custodial sentence for it. But I've never been back to jail since. I came out in the year 2000 so it's like 16 years I've kept meself away from jail and I don't have any intentions of going back. [Gary]

The move from school and children social care system to criminal justice was a common pathways for many participants in this study. Some including Lee, Crewe, David, Patrick spent multiple prison sentences (see Table 1 ). Although Crewe did not make connection between his schooling experiences and his trouble with law, it could be noted that his serious encounter with criminal justice system started shortly after leaving foster care and schooling systems. As he explains:

I was put into prison at age of 17 for arson that was a cry for help to get away from the family, I came out after nine months. I have been in prison four times in my life, its not very nice, when I came out I made a promise to myself that I’m never going to go back to prison again. [Crewe]

Lee recalls his education experience. He explained:

I left school when I was fifteen… then I went off the rails. I got kidnapped for three and half months. When I came back I was just more interested in crime. When I left school I was supposed to go to college, but I went with travellers. I was just more interested in getting arrested every weekend, until my mum say right I have enough of you. I was only seventeen. I went through the hostels when I was seventeen. [Lee]

None describe the educational experience with a similar profundity to Marco:

On few occasions I came out on the corridors I would be getting battered on to my hands and knees and teachers walk pass me. There was quite often blood on the floor from my nose, would be punched on my face and be thrown on the floor. …. It was hard school, pernicious. I would go as far as saying I never felt welcome in that school, I felt like a fish out of the water, being persistently bullied did my head in. Eventually I started striking back, when I started striking back suddenly I was a bad one. My mother decided to put me in … school for maladjusted boys, everyone who been there including myself have spent time in prison. [Marco]

The trouble with authorities that was observes in participants stories in this category appear to be part of the wider adverse social challenges that the participants in this study were facing. Crewe’s description of arson as a cry for help appears to be an appropriate summation of all participants in this category.

The participants’ description of the social conditions in which were raised and their references to maladaptive behaviours which led to them becoming homeless, led us to conclude that they believe that their social condition affected their life chances: that these conditions were responsible for their low quality of social connections, poor educational attainment, insecure employment and other reduced life opportunities available to them.

The key feature that distinguish this study from comparable previous studies is that it openly acknowledges that data collection and analysis were influenced by the principles of social justice [ 28 , 30 , 31 ]. The resulting theoretical explanation therefore constitutes our interpretation of the meanings that participants ascribe to their own situations and actions in their contexts. In this study, defining homelessness within the wider socioeconomic context seemed to fit the data, and offered one interpretation of the process of becoming homeless.

While the participants’ experiences leading to becoming homeless may sound trite. What is pertinent in this study is understanding the conditions within which their behaviours occurred. The data were examined through the lens of social justice and socio-economic inequalities: we analysed the social context within which these behaviours occurred. We listened to accounts of their schooling experiences, how they were raised and their social network. The intention was not to propose a cause-and-effect association, but to suggest that interventions to mitigate homelessness should consider the social conditions within which it occurred.

Participants in this study identified substance misuse and alcohol dependency as a main cause of their homelessness. These findings are consistent with several epidemiological studies that reported a prevalence of substance misuse amongst the homeless people [ 32 , 33 , 34 , 35 , 36 ]. However, most these studies are epidemiological; and by nature epidemiological studies are the ‘gold standard’ in determining causes and effects, but do not always examine the context within which the cause and effect occur. One qualitative study that explored homelessness was a Canadian study by Watson, Crawley and Cane [ 37 ]. Participants in the Watson, et al. described ‘lack of quality social interactions and pain of addition. However, Watson et al. focus on the experiences of being homeless, rather than the life experiences leading to becoming homeless. To our knowledge the current study is one of very few that specifically examine the conditions within which homelessness occurs, looking beyond the behavioural factors. Based on the synthesis of data from previous studies, it makes sense that many interventions to mitigate homelessness focus more on tackling behavioural causes of homelessness rather than fundamental determinants of it [ 38 ]. From the public health intervention’ point of view, however, understanding the conditions within which homelessness occurs is essential, as it will encourage policymakers and providers of the services for homelessness people to devote equal attention to tackling the fundamental determinants of homelessness as is granted in dealing behavioural causes.

Participants in this study reported that they have been defiant toward people in positions of authority. For most of them this trouble began when they were at school, and came to the attention of the criminal justice system as soon as they left school at the age of 16. These findings are similar to these in the survey conducted by Williams, Poyser, and Hopkins [ 39 ] which was commissioned by the UK Ministry of Justice. This survey found that 15 % of prisoners in the sample reported being homeless before custody [ 39 ]; while three and a half percent of the general population reported having ever been homeless [ 39 ]. As the current study reveals there are three possible explanations for the increased population of homeless young people in the criminal justice system: first, at the age of 16 they gain legal powers to leave their foster homes, parents homes, and schools and move beyond some of the childhood legal protections; second, prior to the age of 16 their defiant behaviours were controlled and contained by schools and parents/legal guardians; and third, after the age of 16 their acts of defiant behaviour become subject to interdiction by the criminal justice system.

The conditions in which they were born and raised were described by some participants in this study as ‘chaotic’, abusive’, ‘neglect’, ‘pernicious’ ‘familial instability’, ‘foster care’, ‘care home’, etc. Taking these conditions, and the fact that all but one participants in this left school at or before the age of 16 signifies the importance of living conditions in educational achievement. It has been reported in previous studies that children growing up in such conditions struggle to adjust in school and present with behavioural problems, and thus, poor academic performance [ 40 ]. It has also been reported that despite these families often being known to social services, criminal justice systems and education providers, the interventions in place do little to prevent homelessness [ 40 ].

Analysis of the conditions within which participants’ homelessness occurred reveals the adverse social conditions within which they were born and raised. The conditions they described included being in an abusive environment, poor education, poor employment or unemployment, poor social connections and low social cohesion. These conditions are consistent with high index of poverty [ 37 , 41 , 42 ]. And several other studies found similar associations between poverty and homelessness [ 42 ]. For example, the study by Watson, Crowley et al. [ 37 ] found that there were extreme levels of poverty and social exclusion amongst homeless people. Contrary to previous studies that appear to construct homelessness as a major form of social exclusion, the analysis of participants’ stories in this current study revealed that the conditions they were raised under limited their capacity to engage in meaningful social interactions, thus creating social exclusion.

Homeless people describe the immediate behavioural causes of homelessness; however, this analysis revealed the social and economic conditions within which homelessness occurred. The participants’ descriptions of the social conditions in which were raised and their references to maladaptive behaviours which led to them becoming homeless, led us to conclude that they believe that their social condition affected their life chances: that these conditions were responsible for their low quality of social connections, poor educational attainment, insecure employment and other reduced life opportunities available to them.

Limitations

The conclusions drawn relate only to the social and economic context of the participants in this study, and therefore may not be generalised to the wider population; nor can they be immediately applied in a different context. It has to be acknowledged that the method of recruitment of the 26 participants generates a bias in favour of those willing to talk. The methodology used in this study (constructivist grounded theory) advocates mutual construction of knowledge, which means that the researchers’ understanding and interpretations may have had some influence on the research process as the researchers are an integral part of the data collection and analysis

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Acknowledgements

The authors wish to thank all participants in this study; without their contribution it would not have been possible to undertake the research. The authors acknowledge the contribution of Professor Paul Kingston and Professor Basma Ellahi at the proposal stage of this project. A very special thanks to Robert Whitehall, John and all the staff at the centres for homeless people for their help in creating a conducive environment for this study to take place; and to Roger Whiteley for editorial support. A very special gratitude goes to the reviewers of this paper, who will have expended considerable effort on our behalf. 

This research was funded by quality-related research (QR) funding allocation for the University of Chester.

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MM wrote the entire manuscript, designed the study, collected data, analysed and interpreted data, and presented the findings. AY contributed to transcribing data and manuscript editing. MG contributed to data collection, and transcribed the majority of data. All authors read and approved the final manuscript.

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Mabhala, M.A., Yohannes, A. & Griffith, M. Social conditions of becoming homelessness: qualitative analysis of life stories of homeless peoples. Int J Equity Health 16 , 150 (2017). https://doi.org/10.1186/s12939-017-0646-3

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A qualitative systematic review on the experiences of homelessness among older adults

• Phuntsho Om 1 , 2 ,
• Lisa Whitehead 1 , 3 ,
• Caroline Vafeas 1 &
• Amanda Towell-Barnard 1  

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Adults who experience homelessness for an extended period of time also experience accelerated ageing and other negative impacts on their general health and wellbeing. Homelessness amongst older adults is on the rise, yet there are few systematic reviews investigating their experiences. Thus, this review classifies and synthesises qualitative research findings of studies published between 1990 to 2020 that have examined the needs and challenges of homeless older adults to elucidate their journey of homelessness. Seven papers met the requirements for inclusion. Three main themes were identified in the review: - (1) Pathways to homelessness, (2) Impact of homelessness, and (3) Outcomes and resolutions. This review collates current evidence on what is known about the experience of homelessness among older adults. In this study, homeless older adults identified a wide range of challenges associated with the experience of homelessness.

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The population globally is ageing. Although, ageing is truly a triumph of development, this demographic change presents both advantages and challenges. The concept of successful ageing is to “add life to years” rather than adding days to life and is about maximizing wellbeing and happiness for the older adult [ 1 ]. The risk of developing physical and mental health issues among older adults along with associated costs are linked to a higher demand for health and social care [ 2 ].

Theories on ageing have been developed with the goal of understanding the ageing process and how best to support “healthy ageing at home” and “ageing-in-place” [ 3 ] however these do not consider older adults who do not live in a supportive environment or adults who are homeless. The home setting can be a place associated with poor subjective well-being and some older adults may feel compelled to leave the home setting as a result [ 4 ].

There is no consistent definition of homelessness, rather it has been confined to socio-historical, geographical, and cultural contexts from which the term is drawn [ 5 ]. Homelessness can be defined by a range of categories: absolute and or hidden with homelessness defined as sleeping in parked cars or parks, in emergency shelters, or in temporary shelters (couch surfing) with no or minimal health and safety requirement standards, and risk to personal safety [ 6 , 7 , 8 ]. This includes people residing in sub-standard housing such, as single-room occupancy hotels, or cheap boarding houses, as well as low-cost tiny, lodgings with minimal amenities [ 9 , 10 ].

There is an increasing rise in homelessness among older adults and older homeless adults have been identified as the “new homeless”, a “forgotten group” and a “hidden group” [ 9 , 11 , 12 ].

The reasons for homelessness amongst older adults are diverse. These can include: the impact of natural disasters; the availability of affordable housing, including rising rental costs, a decline in social welfare and support programs; financial insecurity; a lack of social amenities; and increasing rates of mental health issues, combined with various addictions, including gambling [ 2 , 9 , 11 , 12 , 13 , 14 , 15 , 16 ]. In addition to this, family relationship breakdowns, or the death of loved ones, can cut people’s social connections, resulting in older adults experiencing homelessness for the first time. This displacement of older more vulnerable adults can lead to deprivation including the basic need for a place they can relate to as home, subsequently leaving them homeless [ 3 , 7 , 15 , 17 ].

Molinari, Brown and Frahm et al. (2013) found homelessness was unanimously perceived as a humiliating experience by homeless older adults [ 13 ]. According to a survey conducted by the United States Department of Housing and Urban Development, over 15% of 634,000 homeless individuals were 50 years or older, where the number of homeless people aged over 65 has been projected to double by 2050 [ 13 ]. The same survey reported that in the United States alone, adults as young as 50 years of age were facing challenges of homelessness, effectively accelerating ageing processes. Further to this, homeless older adults face a greater threat of age-related disease burden, where they are more likely to experience: functional, auditory, visual, and neurological impairments, frailty, emotional distress, and urinary incontinence, at higher rates than in the general community [ 18 ].

Similarly, van Dongen et al. have reported within a longitudinal cohort study, that older homeless adults, unlike their younger counterparts, reported a higher incidence of cardiovascular disease and visual problems, as well as reporting limited social support from family and friends or acquaintances, and limited medical or hospital care use in the past [ 19 ].

However, there is limited published research identifying the distinct needs of homeless older adults. This is a critical gap in the literature, where a deeper understanding of the experiences of older adults who have been or are currently homeless is required.

The main aim of this qualitative systematic review is to synthesise the evidence on the experience of homelessness of older adults.

Using Joanna Briggs Institute (JBI) guidelines, a meta-synthesis of global qualitative evidence was undertaken. Studies with titles and abstracts that met the analysis goals were retrieved and chosen, based on inclusion and exclusion criteria. These studies were further appraised to evaluate methodological validity by analysing evidence relevant to viability, appropriateness, meaningfulness, and effectiveness [ 20 ]. Qualitative and mixed-method studies with ample qualitative data in their results sections to allow secondary data analysis met the inclusion criteria. The sample comprised of older adults aged between 45 and 80 years that had experienced homelessness for at least one period. The search was restricted to studies that were published in English and available in full-text form, where studies with participants below 45 years, older adults in housing facilities, and aged care residents were excluded.

Search methods

This analysis followed the Joanna Briggs Institute (JBI) method for systematic reviews [ 20 ]. A qualitative assessment and review instrument (JBI-QARI 10 item tool) [ 20 ] was used to facilitate the meta-synthesis. Results from the studies were extracted, categorised, and synthesised. Searches were conducted in PsycINFO, Web of Science, Google Scholar, Medline, PubMed, and CINAHL using appropriate search terms. Additionally, important citations were searched from reference lists of relevant articles. Searches were limited to published studies from 1990 to 2020 (see Fig.  1 ).

PRISMA flowchart

Quality appraisal

Two reviewers independently assessed 21 articles for methodological quality in their design, conduct and analysis using the JBI-QARI 10 item tool [ 20 ]. Any discrepancies were discussed within the team. Out of the 21 articles, seven were included in the synthesis. Each selected study was re-read several times, discussed within the review team and data were abstracted for interpretation.

Data abstraction

Findings relating to both current and past experiences of homelessness among older adults were extracted from the seven selected studies. A total of 56 findings were extracted. Each finding was reviewed and further compared and manually coded to identify themes. Table  1 lists the author and year, sample size, design, setting, and participant characteristics of the selected studies.

Analysis of the seven reviewed articles was carried out using the qualitative evidence synthesis method [ 20 ] developed by JBI (2014). Qualitative findings from each study were first read and reread, followed by an identification of common themes. Recurring themes across studies were then grouped together in a meta-synthesis of the findings. This process comprised critical appraisal, data extraction, analysis, and a meta synthesis involving organisation and categorisation through decoding and encoding of the extracted data to produce a final summation of the findings. The qualitative evidence summation and synthesis were deliberated, cross-checked, and then reviewed by all the authors.

Of the seven studies identified for review (see Table 1 above), four studies directly explored pathways to homelessness amongst older adults. Individual study sample sizes ranged from 14 in Reynolds, et al. (2016) [ 21 ] to 60 in Viwatpanich (2015) [ 24 ]. Three studies applied in-depth face to face interviews, with three studies using semi-structured interviews, and one study conducting focus groups to collect data. The studies were conducted in three countries: Canada, USA, and Thailand.

Data synthesis commenced using open descriptive coding to search and identify concepts and finding relationship between them. Next using an interpretive process, the meaning units were categorised within each domain using labels close to the original language of the participants. The categorization of the data for each case was then followed by a cross-case analysis that examined the similarities and differences. Following categorisation, themes were conceptualised for each category. An overarching theme was identified: ‘the journey of homelessness’. Within this context, three core themes were identified: 1) Pathways to homelessness; 2) impact of homelessness; and 3) outcomes and resolutions, where each of these 3 themes had relevant sub-themes. (see Fig.  2 ).

The Journey of Homelessness Model

The conceptual model depicted in Fig. 2 represents the overarching theme of the ‘journey to homelessness,” and key concepts and relationships between variables from the synthesis of the literature. Unlike other conceptual models that involve causal and directional relationships, this model is both directional and non-hierarchical. The model illustrates the pathways to homelessness, the associated impacts of homelessness and the outcomes of homelessness. The following section explores the three themes and sub-themes in more detail.

Theme 1. Pathways to homelessness

The causes of homelessness were shown to be multifaceted, where pathways to homelessness revolved around a combination of individual, social, and structural factors. The reviewed data suggested that becoming homeless involved two distinct pathways: one that was gradual and one that was rapid.

Sub-theme 1.1: gradual pathway to homelessness

Findings from six studies contributed to this subtheme. This sub-theme captured the factors contributing to gradual pathways into homelessness amongst older people. These factors were identified as accelerated ageing, poverty, rising housing costs, failing and uncommitted social security systems, a lack of social programs and services, social distress, rural-urban migration, substance abuse and addiction, as well as estrangement from family or lack of living relatives [ 13 , 14 , 21 , 22 , 23 , 24 , 25 , 26 ].

The following quotations from these studies illustrate both estrangement from family and the impact of a lack of support from social services:

Many conflicts we had at that time, we never talked … never talked in normal way … nothing clear between us, emotion never came clear...they did not want to talk to me, not even to look at my face … I could not stand it, I surrendered. Beating and scolding by descendants is not in our tradition, no respect, if they did not want me to stay with them, I moved out [ 24 ] .

I submitted applications for low-income housing, I’ve been on the waiting list, seven years is a long time, especially at my age [ 22 ] .

Personal vulnerability to difficult familial relationships, neglected needs and unstable housing were the most cited causes of homelessness amongst these older adults [ 3 , 9 , 14 , 25 ].

Two studies [ 15 , 21 ] described a pathway to homelessness as related to alcoholism and drug abuse, as highlighted in the following quotation:

I got into crack cocaine, I got into hooking, I got into anything you could think of I guess . . . So it was my addictions that brought me down, and unhealthy relationships [ 25 ] .

Feeling ‘homeless at home’ [ 27 ] due to loneliness was noted by some older adults as their reason for ‘living on the streets’. For example, homeless older adults that experienced social rejection and conflicts with housing management, neighbours, and roommates, noted this to ultimately lead them to homelessness. For example, one participant stated, “I have lived alone and never really felt at home, because to me home is a place that includes other people, your family” [ 23 ].

Sub-theme 1.2: rapid pathway to homelessness

Some older adults described the process of homelessness as ‘rapid’. A rapid pathway to homelessness was associated with abrupt life changes such as losing a loved one, divorce, and the impact of these losses on their lives. The two quotes below highlight rapid pathway process:

Losing them, let’s just say it evaporates over time. It’s the fact that I wake up like I am here that I can’t accept … homeless … in the street. I sold everything, every single thing! I never thought I’d end up like this. It’s like starting from zero [ 23 ].

I had a wife, then she died, I did not know where to go, what to do, I turned homeless [ 24 ] .

Older adults that faced a series of losses and a rapid deprivation of social support systems noted the experience of disrupted circumstances. Accordingly, they noted their fear of losing their independence and ‘sense of self’ resulted in their resistance to any help that was offered, in turn contributing to their homelessness.

Theme 2. Impact of homelessness

Findings from five studies contributed to this subtheme. Homelessness and ageing were presented to form a ‘double jeopardy’ where homelessness aggravated the challenges of old age [ 15 , 21 , 22 , 23 , 24 ].

This theme included the subthemes of: unmet needs, coping strategies, and the realities of housing availability.

Sub-theme 2.1: unmet needs

‘Unmet needs’ amongst older homeless adults were categorised as involving physical, emotional and social needs leading to despair and destitution. As this quote below highlights:

I’m supposed to get a pneumoscopy, but where am I, where do I stay? How can they get a hold of me? I don’t have money to get around [ 15 ] .

Sub-theme 2.1.1: lack of physical wellbeing

Findings from six studies [ 14 , 15 , 18 , 21 , 22 , 24 ] contributed to this subtheme. Physical decline and physical disability were described as exacerbated by the experience of being homeless. Participants described a relationship between age and frailty, fatigue, poor physical health, and impaired mobility while homeless, as these quotes demonstrate:

Ah! Walking all day, for me, it’s very hard on the body, ok. Sleeping outside on a park bench, that’s very, very hard on the body. The bones, the humidity. Just leaving in the morning and then not going to work. … You’re always faced with the outdoors, and always faced with walking, walking. It’s not easy walking from downtown [ 15 ] .

My health was very poor. I was very prone to pneumonia. I was taken out of the shelter in the ambulance and it was later determined that I had actually contracted tuberculosis [ 22 ] .

At that time, I got Psoriasis, I knew that it was disgusting … . It looked scary. I am much too old. It is so difficult to find a job … nobody needed me … so I decided to stay and sleep here [ 24 ] .

Homelessness in later life was shown to often be linked to a multitude of health problems. Most studies described older homeless people as living with physical health problems including chronic diseases such as hypertension, diabetes, bone and joint diseases, respiratory illness, and skin diseases [ 14 , 21 , 22 ]..

Sub-theme 2.1.2: lack of emotional wellbeing

Findings from five studies contributed to this subtheme. Accordingly, homelessness was described as contributing to poor emotional health related to social exclusion and isolation amongst older adults. Further, homelessness was associated with cognitive impairment, stigma, shame, stress and anxiety, as well as depression amongst homeless older adults [ 15 , 21 , 24 , 25 ]. Homelessness was described as a humiliating and degrading experience, as evident in these quotes:

At my age, I don’t see life ahead of me anymore. You see, I don’t know, I don’t see the end of the tunnel, … … It’s as if I wanted to erase myself [ 15 ] .

All I could think about was suicide. How did I end up here? When I think a lot to myself, what the hell am I doing? [ 23 ] .

Feelings such as shame, demoralisation, and loss of dignity were described and these impacted on emotional health.

Opportunities to improve emotional wellbeing were rarely described, however one example stood out as an exception and this was related to volunteering:

One thing I didn’t expect was when I helped people with whatever issues they were having on their bicycle, I really enjoyed that. It gave me a chance to teach someone [ 25 ] .

Examples such as these were rare, with social exclusion and the lack of opportunity to contribute and connect with others more commonly described.

Sub-theme 2.1.3: lack of social relationships

Findings from four studies contributed to this subtheme. Social relationships were described as central to creating a life that had meaning and familial interactions. Disconnection from loved ones was associated with feelings of unhappiness [ 13 , 15 , 27 ], while companionship was shown to improve wellbeing [ 25 ]. Social relationships were shown to decline, leading to the experience of social exclusion and isolation.

I am a walking dying woman. I walk until I can’t walk anymore, and then I sit. The busses pass me by. We are untouchables and I do not think anybody’s going to do anything about it [ 25 ] .

At my age, I don’t see life ahead of me anymore. Because everywhere I go: “Ah! He’s homeless.” It is as if I wanted to erase myself. I think that it’s more “society,” as such, that rejects homeless people [ 15 ] .

I think that living homeless, you exclude yourself, and a lot of other people exclude you. I was on the other side before becoming homeless. So, you know, the perception that people have, it plays a big part. … So that together makes it so that, if you don’t have family either, let’s say, you don’t have … close friends or a strong social network. Well, you experience all that, you live with loneliness and isolation [ 15 ] .

Sub-theme 2.2: impaired coping strategies

Findings from four studies contributed to this subtheme. Older homeless adults described a range of factors as impacting their ability to cope. These included moving to shelters, challenges to adapt to their unique requirements, limited housing options, limited income supports, social exclusion, isolation, and a lack of coordination and access to community health and support services [ 13 , 15 , 23 , 25 ].

As the quote below shows, there were expressions about the fear of homelessness and how long it will last:

Struggling to get your basic needs met, scrounging, just trying to get by as best I can, and feeling desperation, humiliation, despair, a shocking feeling, full of fear, and turmoil. What’s tomorrow gonna bring? Why am I in this situation? How do I get out of it? [ 13 ]

Coping with the harsh realities of homelessness in later life was described as being increasingly challenging for most older adults because older homeless individuals experience mental health disorders and acute or chronic physical illnesses.

Sub-theme 2.3: realities of housing availability

Findings from three studies [ 13 , 15 , 23 ] described the challenges experienced in accessing housing services and fulfilling requirements for safe, secure, and affordable housing. This theme captured impacts of poor coordination and communication between homeless veterans and housing intervention providers in regard to information for service availability, gaining access to homeless shelters and a lack of training and education by some housing providers especially with regard to homelessness.

He … got this rule book and threw it at me. Find a place! [ 13 ]

You know, I’m 60, I’m not 20 anymore. So that’s what makes you tired, you get stressed. So, after that, they give you pills as a solution. I told the doctor, sorry I didn’t come here for pills, I came for housing [ 23 ] .

I submitted applications for low-income housing, I’ve been on the waiting list, seven years is a long time, especially at my age [ 23 ] .

I want a space where I can be well. I wasn’t well when I was young. I’ve never been well anywhere. I need a simple place … where I can have peace, and quiet … but not be all alone [ 15 ] .

Older homeless adults described a need to create stability and escape homelessness through the provision of services, and in particular, housing. Older adults described how oscillating in and out of shelters prevented senses of safety, stability, or autonomy.

Theme 3. Outcomes and resolutions

In four studies [ 13 , 15 , 21 , 24 ] homeless older adults described how the outcomes and resolutions of homelessness involved overcoming both complex challenges and habituations. This theme encompassed the finding of directions and strengths to improve difficult situations and overcome challenges that occurred at the intersection of homelessness and ageing.

Three subthemes were identified within this theme: building resilience, strength, and hope; seeking spiritual meaning; and exiting the cycle of homelessness.

Sub-theme 3.1: exiting the cycle of homelessness

Some older adults moved out of the phase of homelessness and described facilitators and barriers to this transition whilst other described choosing to stay homeless until the end of their lives.

Sub-theme 3.1.1: factors facilitating the exit

Two studies [ 13 , 15 ] contributed to this sub-theme, where older adults described means of overcoming challenges and establishing priorities in order to exit homelessness in later life. The results suggested that the creation of autonomy, flexibility, and privacy helped people feel belonging and often this meant living in a place where they could continue to drink and/or occasionally use drugs, have access to a health system to manage health problems; and have access to food and shelter facilitated exits.

They listen to you and they help you with . . . your transition, your program. You sit down and you work the program out with them;” “If you have a question, you can walk in anytime and ask them what’s going on [ 13 ] .

In the next couple years, I hope to find myself an apartment for the few good years I have left, before the big pains of “aging” come [ 15 ] .

Fulfilling financial support, housing and health care services was identified facilitate older adults exiting homelessness.

Sub-theme 3.2: remaining homeless

Some older adults experienced homelessness at a younger age and described continuing to be homeless in older age, where they oscillated between living in shelters and on the streets.

I am used to being in this way, moved from place to place … me alone, without father and mother since childhood … it become normal and I feel happier, than to stay with others [ 24 ] .

It’s just a continual cycle. I just got sucked down into it, you know. It’s hard to describe because when I found myself there, I was just like, wow. How did I get here? [ 21 ]

Participants described the chronic nature of homelessness as involving a challenge of disentangling themselves from the cycle of homelessness. A lack of tailored intervention programs to respond to homelessness in later life also prevented older adults from exiting homelessness.

Sub-theme 3.2.1: perceived barriers to exiting homelessness

In two studies [ 21 , 24 ], older adults described experiences of vulnerabilities and challenges to exiting homelessness. Shelters were described as constraining and not being able to adapt to the unique needs of older adults. Where limited housing options were seen as available, income supports were described as limited, with a lack of coordinated and, accessible community health and social support services, impacting on participants’ ability to ‘feel in place’.

My health pretty much stayed the same as when I was homeless. The conditions I have aren't gonna improve [ 22 ] .

It’s harder to keep a place, especially when you keep falling back in the same circle and you’re in the same crowd. I am finding out today, you keep falling back in the same circle, the same circle is not gonna change [ 21 ] .

One participant described the difficulty of obtaining employment as a barrier to exiting homelessness:

You know being 50 years old, it’s going to be really difficult to be able to reintegrate into the workforce [ 21 ] .

Housing facilities and transition to housing shelters were shown to present challenges for homeless older adults. A lack of privacy, autonomy, rigid rules, and challenging interpersonal relationships within housing and shelter programs were identified as leading older adults to feel homeless at home.

Sub-theme 3.3: building resilience and strength

This sub-theme captured the life lessons, resilience, strength, and hope of older homeless adults, described as having formed through experiences and skills developed whilst living on the streets. This theme also suggests how individuals cope with difficult symptoms related to social support and, addiction, relying on positive things learned while living with other homeless people on the streets. Some older adults chose to stay homeless accepting homelessness as their fate.

In the next couple years, I hope to find myself an apartment for the few good years I have left, before the big pains of “aging” come. I really want a normal life, get up in the morning, go to work, think about vacation. Hang out with other people … I don’t have a girlfriend but would like to start a life with someone else [ 15 ] .

What does ageing mean to you, getting older on the streets? A: Experience. Q: Ok. A: Wisdom. Q: Getting older on the streets, that’s how you see it, it’s the wisdom that you have gained. A: Yeah, that’s where I learned to be wise. Because there are several people who told me I am wise [ 15 ] .

I think because of karma … I accept it as punishment from bad deeds in my former life, but only in this life okay! Next life I am looking forward for a normal life, like others [ 24 ] .

Most studies [ 3 , 8 , 13 , 17 ] cited that wisdom, experience, and optimism were necessary in order to help older adults exit homelessness. Optimism instilled future hope and self-worth back into the self-esteem of homeless older adults.

Sub-theme 3.3.1: seeking spiritual meaning

In two studies [ 24 , 25 ], older adults described finding meaning in life through adopting and accepting religious faith with a belief to achieve higher self-actualisation.

I want to be closer to Dhamma (Buddhist teaching), I want to be a monk till I die [ 24 ] .

Meditate, just being by myself. Living the night, just being alone and listening to my music, that makes [my pain] feel better. I like jazz but I just listen to my music, just go away to myself. That makes me feel - I like being alone. I love being alone [ 25 ] .

When I feel [anger over my situation] I go to the water and I pray hard. I just start praising God until I can feel the spirit come over me to comfort me. I pray until He comes and allows his spirit to wrap his arm around me; I feel a lot better. A psychiatrist can’t tell me what’s wrong with me. For someone to try to help would mean a lot. I do not have nobody but to trust God. He’s my only psychiatrist [ 25 ] .

Homeless older adults recognised and confirmed that psychosocial and existential symptoms caused as much distress as physical symptoms triggering negative changes in personality, energy, and motivation. Some homeless older adults viewed their age as a source of strength, wisdom, and experience in learning to manage their symptoms, describing themselves as survivors who had overcome significant hardships. Higher levels of wellbeing were likely to be achieved when older people sought spiritual meaning through religion, socialising, reading, meditating, volunteering, and introspection practices.

This review synthesised evidence generated from qualitative studies to provide a glimpse into the experiences of homeless older adults. The review has shown that while drivers related to entry into homelessness were diverse, two distinct trajectories underpinned the experience of becoming homeless amongst older adults. Older people that faced a sudden series of losses that completely overturned their circumstances fell into the ‘rapid pathway’ to homelessness. Participants on a ‘gradual pathway’ were shown to become homeless due to a range of factors, for example - addiction problems, physical and mental health issues, relationship break-ups, foster care, poverty, unemployment, and greater housing instability [ 13 , 24 ]. Further to this, homeless older adults were shown to include a significant percentage of separated, divorced, or single individuals [ 28 ]. Likewise becoming single in later life was shown to be associated with homelessness amongst older people. Other studies found that ageing, its associated factors and a lack of stable housing were prominent reasons for homelessness [ 15 , 22 , 23 ].

Housing was perceived to offer a sense of security and a stable environment conducive for safe ageing. Further, housing was identified as offering protection from harsh weather and other dangers. Similar accounts relaying how the health of homeless older adults declined during episodes of homelessness was also reported [ 9 ]. Stable housing played an influencing role in physical health and general wellbeing. Although homeless older adults expressed satisfaction with life, they linked secure housing with healthy dietary habits, proper sleep patterns, enhanced self-care and reduced feelings of stress and anxiety [ 22 ]. In addition, this review found that most homeless older adults were more able to prioritise their health care needs when other necessities such as food and shelter were met. However, research has also suggested that living in scattered-site apartments can reinforce the process of social exclusion, and thus they are not appropriate for older adults living alone, with regard to their additional health and social needs [ 3 , 10 , 28 ].

Ageing intensified the adversities of homelessness experiences and presented a twofold risk where homelessness aggravated the challenges of old age and vice versa [ 15 ]. Old age and its associated conditions intensified older adults’ perceptions of homelessness later in life, including feelings of shame, anxiety, and worry. Studies by Cohen [ 9 ], Kwan, Lau and Cheung [ 29 ], and Molinari et al. [ 13 ], have unanimously shown older adults to perceive homelessness as a dehumanising experience. Homelessness was described as: struggling “to get your basic needs met,” “scrounging, just trying to get by as best I can,” and feeling “desperation,” “humiliation,” “despair,” “a shocking feeling,” “full of dread, turmoil,” “what will tomorrow bring? why am I in this predicament and how can I get over it?” [ 13 ]. For most participants, homelessness was not a preferred option.

The limitations of this review include the predominance of data collected in North America which may reduce the generalisability of the findings. Another drawback is that it presents only a cursory review of issues related to gender, race, and ethnicity. Finally, the qualitative data analysis applied by the majority of studies here is subjective, where outcomes could be affected by authors’ personal biases.

Despite these limitations, the review has conceptualised two divergent pathways into homelessness in later life, as well as the impacts of homelessness, drawing attention to a greater understanding of homelessness experienced by older adults.

The review sought to provide insight into the needs of homeless older adults. Awareness of the complexities faced by homeless older adults need to be acknowledged if policy and research are to support the population and improve access to resources and support. The review has highlighted areas for future research to expand knowledge and understanding of the unique needs and challenges of homeless older adults.

Synthesis of seven studies resulted in the identification of an overarching theme relating to the ‘journey of homelessness’ and three major themes, each with subthemes, to describe older adults’ experiences of homelessness. A broad range of diverse settings, cultures, and countries with a particular focus on homelessness in later life were included. The review has revealed homogeneity of experiences amongst homeless older adults, with the need for access to appropriate and affordable housing and adequate support systems.

The findings have identified pathways to homelessness require different prevention and support measures. People in the study who described a gradual pathway needed social support to address distress, which might have helped them avoid losing their homes. Those individuals with rapid pathways unanimously concluded that homelessness could have been avoided if independence and self-sufficiency were less regarded as a norm by society.

Availability of data and materials

The authors declare that all data generated or analysed during this study are included in this published article.

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Acknowledgements

We would like to acknowledge Lisa Webb, Librarian, Edith Cowan University Library for her support in the literature search and Dr. Michael Stein, HDR Communication Advisor, Edith Cowan University for editing.

There are no separate funding source for this review as it is part of my full-time PhD study with the School of Nursing Midwifery, Edith Cowan University.

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PO, LW, CV, and ATB substantially contributed to the conception and design of the article. All authors critically appraised the searched literature, discussed each item in the appraisal instrument for each study included in the review and interpreting the relevant findings. The primary author PO drafted the article and LW, CV and ATB revised it critically for important intellectual content. The author(s) read and approved the final manuscript.

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The study was classified as exempt from ethical review approved by the Human Research Ethics Committee of Edith Cowan University. All material included in this review are in the public domain and not applicable as it is a review article. Accordance: We declare that this systematic review was conducted in accordance with Joanna Briggs Institute (JBI) method for systematic reviews using the qualitative assessment and review instrument (QARIs) to facilitate the meta-synthesis. This review was followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (2009).

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Om, P., Whitehead, L., Vafeas, C. et al. A qualitative systematic review on the experiences of homelessness among older adults. BMC Geriatr 22 , 363 (2022). https://doi.org/10.1186/s12877-022-02978-9

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Improving health and healthcare for people experiencing homelessness (PEH) has become a national research priority. It is critical for research related to homelessness to be guided by input from PEH themselves. We are a group of researchers and individuals who have personally experienced homelessness collaborating on a study focused on homelessness and housing. In this Fresh Focus , we describe our partnership, lessons learned from our work together, what we have gained from our collaboration, and considerations for future homelessness research-lived experience partnerships.

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Homelessness is a growing social and public health crisis in the United States (U.S.), as approximately 580,000 individuals experienced homelessness on a given night in 2020 (U.S. Department of Housing and Urban Development, 2021 ). Compared to their housed counterparts, people experiencing homelessness (PEH) have elevated risk for serious health problems such as infectious disease (National Health Care for the Homeless Council – NHCH, 2019 ; Zlotnick,& Zerger. 2009 ; Zlotnick et al., 2013 ), behavioral health disorders (Fazel et al., 2008 ; Greenberg & Rosenheck, 2010 ; Zlotnick & Zerger, 2009 ), and multimorbidities (Vickery et al., 2021 ). Furthermore, the material hardships of homelessness accelerate aging, leading to the onset of geriatric conditions and medical conditions more typical of individuals 10–20 years older (Adams et al., 2007 ; Brown et al., 2012 ; Gelberg et al., 1990 ).

These issues are compounded by the fact that homelessness brings about significant barriers to consistent quality healthcare (Baggett et al., 2010 ; Zlotnick et al., 2013 ). Most PEH lack access to routine basic medical and behavioral services, and stigma and discrimination decrease treatment quality on the rare occasions they receive care (Baggett et al., 2010 ; Gilmer & Buccieri 2020 ; Jones et al., 2017 ; Jones et al., 2018 ; Mejia-Lancheros et al., 2020 ). The combination of increased risk, low access to services, and poor care quality has dire consequences. On average, individuals experiencing homelessness die 12 years younger than the rest of the U.S. population (NHCH, 2019 ).

The crisis of homelessness and health has spurred action, with the U.S. National Institutes of Health ( 2022 ) reporting that it is currently spending over $195 million to support 191 research projects related to homelessness as of August 2022, and other funders investing significantly in research on healthcare and homelessness. For this research to be impactful, it needs to be rooted in a solid understanding of the practical challenges homelessness brings. Basic necessities that are often taken for granted in the industrialized world—physical safety, private restrooms, and access to hygienic supplies, medication, food, and water—are rare luxuries when experiencing homelessness. Public responses to homelessness exacerbate these challenges. Ordinances prohibiting sleeping, resting, eating, panhandling, or sitting in public places lead to a de-facto criminalization of homelessness, causing constant stress and dislocation for PEH (Robinson, 2019 ; Tars, 2021 ). Forced evictions and law enforcement sweeps of encampments and tent communities frequently result in the loss or destruction of the few possessions PEH own (Tars, 2021 ). The impacts that these harsh realities have on well-being and ability to access services need to be incorporated into research on health and healthcare for populations experiencing homelessness.

Research on homelessness also needs to account for contextual factors that may inhibit participation in studies. Increasingly research utilizes digital platforms to collect data, but many PEH lack reliable access to the equipment or data plans needed to engage consistently as research participants (Humphry, 2019 ). Individuals living in encampments, shelters, and other congregate settings also lack privacy or quiet spaces needed to complete surveys and interviews. These factors are exacerbated by the fact that many studies do not recruit PEH directly, instead partnering with other homeless-interfacing institutions (e.g. housing programs, social service programs) to find and engage participants (Gordon, Baker, & Steffens, 2022 ). Many of these institutions have failed individuals experiencing homelessness in the past (Hoolachan, 2016 ; Woodhall-Melnik et al., 2018 ; Woodhall-Melnik et al., 2022 ), and studies’ association with them may compromise their trustworthiness in the eyes of potential participants, causing downstream problems for study recruitment, retention, and data quality.

In sum, research on homelessness and health is complex and nuanced, and researchers need to consider the aforementioned issues in all phases of study design and implementation. One way to do this is to engage people who have lived experience with homelessness as research partners (Franco et al., 2021 ; Kiser & Hulton 2018 ; Fletcher et al., 2022 ). Across healthcare and health services research, partnership with people with lived experience can contribute to the development of questions and outcomes that are more meaningful to patients and caregivers, and it is associated with higher levels of study enrollment and participant retention (Forsythe et al., 2019 ). With growing awareness of the importance of stakeholder partnership in research studies, funding agencies such as the National Institutes of Health and the Patient-Centered Outcomes Research Institute (PCORI) are increasingly providing research support to studies that rigorously incorporate stakeholder partnerships (Baker, 2022 ; Selby et al., 2012 ). In this paper, we—a group of homelessness researchers and individuals who have personally experienced homelessness—describe early phases of a study on homelessness and housing has brought us together. We share perspectives on what we have learned from our collaboration, what we have gained from our partnership, and lay out considerations for future efforts to integrate lived experience into research on homelessness.

Lived Experience and the Person-Centered Housing Options, Outcomes, Services, & Environment (PCHOOSE) Study

We formed our partnership to guide the Person-Centered Housing Options, Outcomes, Services, & Environment (PCHOOSE) study, a mixed-methods project examining the comparative effectiveness of different permanent supportive housing (PSH) configurations in improving housing, health, well-being, mental health, substance use, and healthcare utilization during the COVID-19 pandemic. The two models being studied are place-based PSH, which houses individuals in congregate settings where most residents are transitioning out of homelessness and supportive services are delivered onsite, and scattered-site PSH, which houses participants in apartments rented from private landlords and provides mobile case management services.

Our core investigative team consists of ten researchers from multiple disciplines, none of whom have personally experienced homelessness. To bring perspectives of individuals who have experienced homelessness and received housing services such as PSH to the project, the researchers organized a Lived Experience Group (LEG), consisting of eleven individuals with homelessness histories who have gone through the process of attaining and maintaining housing. LEG members were identified and recruited through pre-existing relationships that study investigators had with them from other projects and collaborations. Approximately half of LEG members (6/11) identify as male, and the majority of them (8/11) identify as Black or African American. The mean age of LEG members is 49 years old (SD = 15), and on average, they experienced 13.6 years of homelessness (SD = 11.9). LEG members are compensated for their time and expertise at the same rate as other project advisors and stakeholders (e.g. homelessness service advocates, policymakers, subject matter experts) who have been hired as study consultants.

We convene in meetings that bring together our core investigative team and our LEG roughly five times per year. LEG meetings occur on Zoom and generally last between 90 and 120 min. There have been twelve LEG meetings since July 2021. A member of the investigative team facilitates LEG meetings with support from other members of the research team. We organize LEG meetings around several principles of Community-Based Participatory Research (CBPR), including openness to influence from LEG members who do not have formal research training and recognition that LEG members’ strengths, resources, and experiences are invaluable assets for the research team (Israel et al., 2017 ; Wells et al., 2006 ). As described below, researchers made many decisions concerning study design and implementation based on recommendations from LEG members given their intimate, real-world knowledge of homelessness, the housing process, and mistrust PEH may have of researchers and the research process Acknowledging the structural disparities and inequalities between professional researchers and LEG members, the facilitator explicitly focuses on emphasizing and empowering the knowledge and expertise of LEG members, and making them equal partners in group discussions. Issues of race, ethnicity, and class often emerge during meetings, and both researchers and LEG members all discuss their own experiences, prejudices, and assumptions during meetings (Israel et al., 2017 ). To encourage honesty and trust, the group facilitator checks in with LEG members between meetings through surveys and one-to-one correspondence, eliciting feedback on how they feel about group meetings and ways that they could be improved.

The results presented below are a summary of how we have experienced this collaboration. The lead author—who is also the LEG group facilitator—wrote an outline of this summary based on detailed notes other team members took during LEG meetings, his own recollections of LEG discussions, and input he received from LEG members themselves. He then verified the trustworthiness of the notes and his interpretation of them through member-checking, having other investigators and LEG members review findings, and discuss them during a LEG meeting (Candela, 2019 ; Thomas, 2017 ). Next, LEG members shared their perspectives on the study and their experience with the lead author over email. The lead author analyzed respondent emails using content analysis (Hseih & Shannon, 2005), produced an outline summary of key themes and results that used direct quotes from LEG participants’ emails, and verified them through member-checking. All members of the core investigative team and the LEG are co-authors on this paper, and we all agree that the summary below is an accurate reflection of our experience and perspectives.

What We Have Learned So Far

We have learned that partnering with individuals who have personally experienced homelessness can enhance many phases of the research process, particularly ones that are challenging for scholars. For example, developing and implementing effective recruitment and retention strategies has historically been difficult in research on homelessness (Becker et al., 2014 ; North et al., 2012 ; Strehlau et al., 2017 ) When the researchers in our group asked LEG members how to address recruitment challenges, LEG members suggested that the study could be made more appealing if individuals who have personally experienced homelessness introduce the research and explain why it is important to potential participants. To do this, we created informational videos where LEG members introduced themselves, discussed their personal histories of homelessness, presented an overview of the study, explained why they believe the study is important, and emphasized that joining the study was a way for participants to make their voices heard. These videos were posted on the study’s webpage to help publicize the project. To help boost retention, LEG members provided the investigative team with input on how to use study funds to compensate participants after they took monthly surveys, and project researchers used these insights to design an incentive schedule that helped the study reach target follow-up rates.

LEG members have also contributed key insights that have helped the investigative team consider new perspectives when interpreting data and adjust its qualitative data collection and analysis plans accordingly. For example, when early quantitative data showed lower-than-expected rates of substance use among the study sample, LEG members suggested that study participants—all of whom had recently received PSH placements—could be underreporting substance use because they feared that if they disclosed alcohol or drug use the information could be used as “evidence” that could jeopardize their newly-secured housing. Based on this input, the study is emphasizing the confidentiality of all study data when asking participants about substance use, and considering the possibility that fear of disclosing substance use could be influencing the trends observed in quantitative and qualitative data When investigators shared early data about health service utilization, LEG members helped contextualize findings by highlighting that many respondents may have reported about mental health and substance use services—not primary care—in response to this question. The LEG members in our group explained that this is because for many PEH, the first thing that comes to mind when asked about “healthcare” is behavioral healthcare, since they see mental health and substance use service providers for groups, counseling, and medication regularly, but they only see physical healthcare providers when they are sick or injured. Based on these insights, the investigative team has supplemented qualitative semi-structured interview scripts and the accompanying analytic plan to be mindful that participants may define “healthcare” differently from the research team.

In one case, our LEG member insights contributed to the addition of new methodological approaches to the project. When the investigative team presented initial quantitative findings concerning social activity, it shared the information by highlighting differences and similarities among participants in different types of housing programs (place-based, scattered-site) since that was the focus of the original study. After hearing this analysis, LEG members highlighted that for many individuals in PSH, the perceived safety of the neighborhood and attractiveness of amenities available to them (e.g. shopping, parks)—not just the type of housing itself—could account for observed differences in social activity. Based largely on this insight, study investigators adjusted the qualitative data collection and analysis plans, supplementing traditional semi-structured interviews with recently-housed participants with photo-elicitation interviews (PEIs - Clark-Ibanez, 2004 ; Padgett, Smith, Derejko, Henwood, & Tiderington, 2013 ). In our PEIs, participants are asked take photos that they believe capture the essence of their daily lives on study-issued cell phones (which they already had been issued to take surveys) and share them with qualitative interviewers, who then use them as prompts to start conversations about participants’ neighborhood and day-to-day activities In addition to using PEI to facilitate interviews, the investigative team will also use the images themselves as a form of data (Richard & Lahman, 2015 ) that it will analyze, interpret, and integrate with other quantitative and qualitative data.

While helping the study add new dimensions to the study, LEG input has also kept the research team from pursuing activities that could have potentially undermined project success. When thinking about how to better capture information about how PSH spend their time, the investigative team considered adding a supplement to the study where a subset of participants would be given an option to have their study-issued phones’ geolocation data tracking activated and share location information with the project. When presented with this idea, LEG members strongly opposed it for several reasons. First, they expressed concern that for individuals who were survivors of abuse, the idea of geographic tracking could trigger a post-traumatic stress response or cause serious emotional distress. Second, LEG members highlighted that many PEH and recently housed individuals are highly concerned about surveillance and tracking, so the collection of such data could be seen as an inappropriate and suspicious invasion of privacy. When researchers on the team explained that they would inform participants that this information would be secure and used only by the study team, LEG members maintained that even so, proposing the idea could have negative impacts on the study. Many LEG members cautioned that PEH often feel “misled” by researchers after they complete studies because they are told that their participation will lead to improved services, but they rarely see substantive change. By adding a potentially troubling “ask” to the research project after initially enrolling participants only to collect information about health and quality of life information, LEG members felt that the study could come across as doing a “bait and switch” with participants, thus irrevocably compromising their trust in the study and potentially jeopardizing retention. Based on this input, the research team opted not to go back to participants to obtain additional consent to add the geo-tracking component to data collection after the study had already started.

What We Have Gained from Our Partnership

The researchers among us, while we had been highly cognizant of the challenges PEH face before, have gained a deeper understanding of what our LEG members term “the realism of homelessness, from real people” and the perspectives of “front-line soldiers who’ve lived and survived in that world (of homelessness)” though our collaboration. Getting to know the stories of misery, hardship, resilience, and recovery from LEG members with whom we have developed strong working relationships has added emotional depth and nuance to our understandings of individuals’ journeys through homelessness. Moreover, partnering with people with lived experience—and not just collecting data from them—has forced us to consider the perspectives of our participants first and foremost as we have designed and implemented the study. Consequently, we have taken information that is, as one LEG member writes, “very often overlooked or not seen as valid” seriously, and proactively tailored the study to be as cognizant of and responsive to the realities of homelessness as possible.

For the LEG members among us, collaborating with researchers has been an avenue for healing and empowerment. While LEG meetings are not specifically designed to be therapeutic, having a forum where we get to discuss some of our darkest and most vulnerable experiences from the past in a safe space bring us senses of emotional wellness and belonging. Using our past pain to help improve knowledge about homelessness and alleviate the suffering of our unsheltered and recently-housed neighbors makes us feel good, and that we are making a difference. For some of us, this research is one of the first opportunities we have had to contribute to something positive by making our voices heard. We also recognize that through this collaboration, we speak not only for ourselves, but for all of the people who are still suffering on the streets. We are empowered by the fact that when we contribute to this group and to research, and we are speaking for all of those who are suffering, but who have not yet found their voices or had a chance to be heard.

Considerations for Future Collaboration

Though our collaboration has been highly beneficial, we also recognize ways that future researcher-lived experience collaborative studies on homelessness and housing could be improved. First, the main question of our study—what is the comparative effectiveness of place-based and scattered-site housing—was generated by researchers based largely on a literature review. All of the LEG contributions discussed above occurred within the confines of a study that was already conceptualized by researchers who have not personally experienced homelessness, and chosen for funding by a scientific review committee that was likely mostly composed of individuals who had not experienced homelessness. If individuals with lived experience had played a more substantive role in conceptualizing our study, we may have designed it to better capture issues that LEG members believe are crucially important (such as the neighborhoods of PSH placements, and not just their configurations) from its outset. However, there are significant barriers—lack of resources to support the time of LEG members for conceptualizing studies that are not yet funded, not having the training and experience needed to design robust research projects, and unfamiliarity with the peer-review process among them—that make it difficult to meaningfully involve PEH in the development of research ideas. There are ways that future projects can address this issue. CBPR provides a roadmap that researchers can use to partner with community members—including those who have experienced homelessness—to develop research questions that address the community’s priorities, and not just those of researchers and scientific review boards (Fletcher et al., 2022 ; Forsythe et al., 2019 ; Franco et al., 2021 ; Israel et al., 2017 ; Kiser & Hulton 2018 ; Selby et al., 2012 ; Wells et al., 2006 ; Woodhall-Melnik et al., 2018 ; Woodhall-Melnik et al., 2022 ). The LEG group facilitator recently received funding to implement the Stakeholder Engagement in question Development and prioritization (SEED) method—an approach that combines CBPR principles with scientific reviews of available evidence to develop rigorous, community-driven ideas for research (Rafie et al., 2019 ; Zimmerman 2017 ; Zimmerman & Cook, 2017 ; Zimmerman et al., 2020 )—in collaboration with the LEG. Our hope is that this new project will continue bringing the benefits of CBPR to research on homelessness in the community, similar to how the U.S. Department of Veterans Affairs (VA) health system has been implementing CBPR with veterans who have experienced homelessness (Fletcher et al., 2022 ).

A second consideration for future collaboration is that our lived experience partners likely differ from much of the population experiencing homelessness in significant ways. In large part, this is because our LEG was formed by researchers who recruited members through pre-existing networks they had. Consequently, most LEG members have previously been involved in activities—such as volunteering for research projects, speaking at conferences, or working as peer advocates in PSH programs—that are not typically pursued by most people who experience homelessness. Many individuals exiting homelessness continue to experience a lack of meaningful activity and social integration, (Harris et al., 2019 ; Hawkins & Abrams, 2007 ; Pilla & Park-Taylor, 2022 ), and it is likely that that our LEG members are more active and engaged in their community than most people who are experiencing homelessness or transitioning to housing. Furthermore, in our study, lived experience contributions were confined to the perspectives of people who had previously experienced homelessness. No LEG members are currently unhoused, so their lived experience contributions of the LEG are based on retrospection—memory of the experience of homelessness in the past. The homelessness experience of LEG members is somewhat distal, with some individuals having been housed for over five years, so their understanding of homelessness could differ substantively from homelessness as it is today due to changes in the economy, society, and housing policy. If the LEG included people who are currently experiencing homelessness and/or received housing placements more recently, it could have potentially offered a different perspective to the project.

However, it is not clear if advising a research group would be a priority, or feasible, for people currently experiencing homelessness or who have been recently housed. The instability of being unhoused and logistical issues that often intersect with homelessness (e.g. lack of communication devices, transportation challenges, participation in residential behavioral health programs) make it difficult for PEH to engage with research teams and sustain these relationships (Fletcher et al., 2022 ). The same material and contextual factors that can affect their health and research participation also inhibit participation in academic-community collaborations. Furthermore, for most PEH, exiting homelessness and meeting basic needs for survival are pressing priorities, leaving them with little time or mental energy to dedicate to research (Fletcher et al., 2022 ). Even when partnering with people who had experienced homelessness but are currently housed this is an issue since individuals exiting homelessness tend to be under-employed and still struggle financially (Poremski et al., 2016 ). Several ongoing initiatives, including efforts being spearheaded by the National Health Care for the Homeless Council (National Health Care for the Homeless Council, 2022 ) and the VA (Fletcher et al., 2022 ), include individuals who are currently unhoused as research stakeholders. However, some of these efforts have encountered significant obstacles sustaining partnerships (Fletcher et al., 2022 ). Further research is needed to identify effective strategies and best practices not only for bringing people currently experiencing homelessness into research partnerships, but also to sustain these relationships.

It is notable that beyond improving the study, the LEG members among us have found partnership with researchers to be healing and empowering on a personal level. Homelessness can lead to experiences of trauma, marginalization, dehumanization, and exclusion (Hamilton et al., 2011 ; Magwood et al., 2019 ; Tsai et al., 2020 ), and activities that support empowerment, resilience, and a sense of personal mastery help facilitate the process of healing and recovery during the transition out of homelessness (Magwood et al., 2019 ; Manning & Greenwood 2019 ). The personal fulfillment and sense of meaning LEG members are deriving from this research partnership highlights how having individuals with lived experience join research teams can advance not only research, but also the process of healing and growth for PEH themselves. Finding purpose (conducting meaningful daily activities) and community (having relationships and social networks that provide support, friendship, love, and hope) are key dimensions of recovery (SAMHSA, 2023 ), and based on our experience, it seems that research partnerships can foster both. Future documentation of PEH’s experience in research partnerships, and its contributions to their senses of purpose and fulfillment, can help develop understanding of the role that partnering in research on homelessness can have for individuals who have experienced homelessness as they proceed on their own recovery journeys. At the same time, the limitations of research collaborations also need to be considered and better understood.

The Person-Centered Housing Options, Outcomes, Services, & Environment (PCHOOSE) study has benefited tremendously from the input of individuals who have lived experience with homelessness, underscoring the importance of bringing their voices to research. Our experience has shown how partnering with PEH can help investigators conduct research that is better informed by and aligned with the real-world experience of homelessness. At the same time, partnering with researchers seems to provide individuals with lived experience with opportunities for healing and empowerment, furthering their recovery from homelessness. Though these partnerships require a significant investment of time and resources, they can be critical to ensuring that research generates knowledge that improves clinical practice and policy, and contributes to the broader goal of improving the lives of individuals impacted by our nation’s homelessness crisis.

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Acknowledgements

The work reported in this article was funded through Patient-Centered Outcomes Research Institute Contract COVID-2020C2-10933. The views and opinions in this article are solely the responsibility of the authors, and do not necessarily represent the views of are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors or Methodology Committee.

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Padwa, H., Henwood, B.F., Ijadi-Maghsoodi, R. et al. Bringing Lived Experience to Research on Health and Homelessness: Perspectives of Researchers and Lived Experience Partners. Community Ment Health J 59 , 1235–1242 (2023). https://doi.org/10.1007/s10597-023-01138-6

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Published : 19 May 2023

Issue Date : October 2023

DOI : https://doi.org/10.1007/s10597-023-01138-6

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In addition to grant programs relevant to homelessness, the Department of Health and Human Services also works to advance research in this field. The Department funds the development of a range of research projects to aid providers and policymakers in better understanding and addressing the issues facing people experiencing homelessness.

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Homelessness Among People Living in Encampments (Conducted in partnership with HUD) As of 2019, homeless encampments were appearing in numbers not seen in almost a century. To learn more about encampments and cities’ approaches in responding to them, Abt Associates conducted the study Exploring Homelessness Among People Living in Encampments and Associated Costs for the U.S. Department of Health and Human Services and the U.S. Department of Housing and Urban Development (HUD). After completing a literature review, the study team selected nine cities currently responding to encampments to participate in telephone interviews in early 2019. Findings from this study – the report on costs, individual site summary reports, and the literature review – are intended to help federal, state, and local policymakers and practitioners understand the nature of encampments, strategies for responding to encampments, and the costs associated with those approaches.

Health Conditions Among Individuals With a History of Homelessness This paper uses a proprietary data set with electronic health records of more than 54,000 individuals with ICD-10 code of homelessness between 2015 and 2019. The paper found that for many chronic conditions, people with a history of homelessness have a greater prevalence than a comparison cohort of individuals matched on age and gender. In addition, the cohort with a history of homelessness had twice the rate of ever having head injuries and high rates of viral hepatitis, alcohol abuse, and opioid abuse.

Comorbid Health Conditions and Treatment Utilization among Individuals with Opioid Use Disorder Experiencing Homelessness People experiencing homelessness have been particularly hard hit by the opioid crisis. This epidemic has also impacted individuals experiencing homelessness in ways that are distinct from how it has impacted individuals with stable housing. However, not much is known about comorbid health conditions and health services utilization among adults with opioid use disorder (OUD) who are experiencing homelessness. A retrospective observational cohort study was conducted utilizing a large national all-payer electronic health record database, finding that underlying mental health conditions and polysubstance use contribute toward making individuals experiencing homelessness more susceptible to adverse health outcomes associated with OUD. Health policy initiatives directed toward treatment engagement might benefit from an emphasis on addressing housing instability that many individuals with OUD might be experiencing.

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Individuals Experiencing Homelessness Are Likely to Have Medical Conditions Associated with Severe Illness from COVID-19 This paper is a descriptive analysis of the prevalence rates of some chronic health conditions that are associated with a higher risk of severe illness from COVID-19 among people with a history of homelessness. It uses a proprietary dataset with electronic health records of 61,180 individuals with an ICD-10 code of homelessness between 2015 and 2019. The paper finds that many of the health conditions examined (those believed to be linked to higher risks of severe illness from COVID-19), people with a history of homelessness have greater prevalence than the general population. People with a history of homelessness have comorbidities that impact their health in multi-faceted ways.

Housing Models that May Promote Recovery for Individuals and Families Facing Opioid Use Disorder This project describes the housing models available for individuals with opioid use disorder (OUD) who experience housing instability or homelessness. The association between OUD and homelessness has been examined and established. To better understand housing models that may support those with OUD, the study team conducted an environmental scan and held discussions with experts and providers in four communities.

Behavioral Health Improvements Over Time among Adults in Families Experiencing Homelessness The Behavioral Health Improvements Over Time among Adults in Families Experiencing Homelessness brief explores parents’ behavioral health at the time the family was in emergency shelter and at 20 and 37 months after experiencing homelessness. This brief examines psychological distress, alcohol dependence, drug abuse, and symptoms of post-traumatic stress disorder; examines what family characteristics and experiences prior to shelter were associated with behavioral health problems and changes over time; and examines the relationship between housing instability and behavioral health 37 months after a shelter stay.

Employment of Families Experiencing Homelessness The Employment of Families Experiencing Homelessness brief explores parents’ earnings at the time the family was in emergency shelter, prior to becoming homeless and at 20 and 37 months after experiencing homelessness. This brief examines employment rates, compares the employment rates of families experiencing homelessness to the employment rate of parents in deeply poor families in the same communities, discusses barriers parents identified for not working, and explores the relationship between employment, income, and continued housing instability.

Child Separation among Families Experiencing Homelessness The Child Separation among Families Experiencing Homelessness brief explores child separations among families experiencing homelessness. It builds upon the fourth brief in this series, “Child and Partner Transitions among Families Experiencing Homelessness,” which looked at family separations and reunifications in the 20 months after being in emergency shelter and the association between family separation and recent housing instability following an initial shelter stay. This brief provides a more detailed examination of these families and their children before and after the initial shelter stay, revealing more extensive and persistent levels of child separation. It gives detailed characteristics of separated children and examines whether future child separation after a shelter stay is related to either housing instability of previous separations.

Child and Partner Transitions among Families Experiencing Homelessness This research brief takes advantage of data collected for the Family Options Study, sponsored by the U.S. Department of Housing and Urban Development. This brief examines the extent to which parents were separated from their children or adult partners, including spouses,1 during a stay in emergency shelter and whether they experienced additional separations or reunifications in the 20 months following the shelter stay. It also considers whether family separations while in shelter are associated with additional housing instability following the shelter stay, as well as whether continued housing instability is associated with subsequent family separations.

Well-being of Young Children after Experiencing Homelessness This research brief takes advantage of data collected for the Family Options Study, sponsored by the U.S. Department of Housing and Urban Development. High-quality early education and care arrangements have been linked to gains in school readiness for children in low-income families, but less is known about its influence on children who have experienced homelessness. This study examines the extent to which children are enrolled in Head Start and other early education and center-based care programs 20 months after a shelter stay, as well as whether continued housing instability after a shelter stay is related to enrollment rates and stability of care arrangements. The study then examine whether there is evidence of relationships between Head Start and other early education and center-based care enrollment and children’s school readiness and behavioral challenges.

Pretesting a Human Trafficking Screening Tool in the Child Welfare and Runaway and Homeless Youth Systems Despite the fact that youth involved in the child welfare (CW) and runaway and homeless youth (RHY) systems are particularly vulnerable to being trafficked, there is no consensus screening tool to identify trafficking experiences among such youth. In order to better serve youth trafficking victims, this study developed a Human Trafficking Screening Tool (HTST) and pretested it with 617 RHY- and CW-involved youth. This research established that the screening tool is accessible to youth and easy to administer, and that both the full-length tool and a shorter version were effective in identifying youth who are trafficking victims in RHY and CW systems, though additional research with more youth is needed.

Patterns of Benefit Receipt among Families who Experience Homelessness This brief uses data collected for the U.S. Department of Housing and Urban Development’s Family Options Study to analyze patterns of receipt of TANF cash assistance, SNAP food assistance, and publicly funded health insurance benefits among these families, with a focus on the characteristics of those receiving and not receiving benefits. The brief: Examines whether family characteristics, including age, marital status, and demographic characteristics relate to benefit receipt; Explores the relationship between benefit receipt and housing instability following an initial shelter stay; and examines whether help accessing benefits is related to families’ TANF receipt

Final Report – Street Outreach Program Data Collection Study This first-of-its-kind study focused on 873 youth ages 14 to 21 in 11 cities. Respondents included street youth receiving services from ACF’s Street Outreach Program grantees and street youth who were not currently using services from SOP grantees. Study findings include that: nearly half of respondents became homeless for the first time because they were asked to leave home by a parent or caregiver; more than half have tried to stay at a shelter but found it full; the average youth had spent nearly two years living on the street; and nearly 30 percent identified as lesbian, gay, or bisexual, and nearly 7 percent identified as transgender.

Are Homeless Families Connected to the Social Safety Net? This analysis of HUD's Family Options Study data shows that families in a shelter and 20 months later are generally connected to public benefits at similar rates to other families in deep poverty. This non-experimental analysis finds that homeless families receive TANF, publicly funded health insurance (including Medicaid, CHIP, and state-funded insurance), and SNAP at equal or greater rates than other families in their communities who are also living in deep poverty.

State Strategies for Coordinating Medicaid Services and Housing for Adults with Behavioral Health Conditions This Issue Brief describes the strategies used by four states--Louisiana, Massachusetts, Tennessee, and Illinois--to improve the link between Medicaid and housing services for adult Medicaid beneficiaries with behavioral health conditions. This brief does not assess the success of these strategies, but instead focuses on the mechanisms the states are using to improve care coordination for individuals with both behavioral health and housing needs. Federal and state policymakers and other stakeholders can use this information in developing their own initiatives.

Improving the Coordination of Services for Adults with Mental Health and Substance Use Disorders: Profiles for Four State Medicaid Initiatives In 2013, ASPE contracted with Mathematica Policy Research to conduct case studies of the financing arrangements and delivery models that states are using to improve the coordination of care for Medicaid beneficiaries with mental health and substance use disorders in four states: Illinois, Louisiana, Massachusetts, and Tennessee. This report profiles and describes the key elements of the strategy used in each state, including the financing mechanisms, state-level and local-level partnerships, use of data and information systems, and efforts to improve coordination with housing. Moreover, the case studies sought to describe the "on-the-ground" operation of the care coordination models from the perspectives of providers, consumers, and other stakeholders. Although these case studies do not evaluate the effectiveness or outcomes of the strategies used in these states, policymakers, managed care organizations, providers, and other stakeholders may wish to consider the components of these strategies in their own efforts to improve care coordination.

State Strategies for Improving Provider Collaboration and Care Coordination for Medicaid Beneficiaries with Behavioral Health Conditions This Issue Brief highlights the efforts of four states--Illinois, Louisiana, Massachusetts, and Tennessee--to facilitate provider-level coordination for Medicaid beneficiaries with behavioral health disorders. It describes the financing strategies and specific mechanisms that states are using to improve care coordination. It summarizes some of the key ingredients of these efforts as reported by providers, consumers, agency representatives, and managed care companies in the four states. This information may be useful to federal and state policymakers and other stakeholders as they develop their own initiatives.

"Homeless Caseload is Associated with Behavioral Health and Case Management Staffing in Health Centers"    [Journal Article authored by analysts at ASPE and SAMHSA)] This paper examines organizational characteristics and staffing patterns in FQHCs with large homeless caseloads. Regardless of whether each health center received targeted Health Care for the Homeless funding, health centers with high homeless caseloads were more likely to have high behavioral health and enabling services staffing—indicating that health centers tailor their staffing mix to the needs of their patients. The study also found that rural health centers had lower levels of behavioral health and enabling services staffing, highlighting the need to monitor disparities, link health centers with technical assistance on partnering with community-based behavioral health providers, and emphasize co-locating behavioral health services through grant oversight mechanisms.

Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Emerging Practices From the Field (Assistant Secretary for Planning and Evaluation) This report describes existing practices in the field of communities currently serving homeless and formerly homeless individuals as Medicaid beneficiaries.

Building Partnerships to Address Family Homelessness Around the country, Head Start and Early Head Start programs are building partnerships in their communities in order to make their services more accessible for children experiencing homelessness. This resource paper highlights the work being done by local Head Start and Early Head Start programs to connect with public housing associations, emergency shelter providers, local education agencies, and other community service providers. It also provides recommendations and resources to facilitate collaborations in other communities.

Promising Practices for Children Experiencing Homelessness: A Look at Two States This resource paper highlights work to create interventions that are specifically targeted at increasing access to high-quality early care and learning programs for children experiencing homelessness. It provides an overview of the effects of homelessness on young children, reviews federal initiatives that have expanded access to early care and learning for this population, looks at how two states - Massachusetts and Oregon - have implemented innovative policies to improve early childhood outcomes for this group, and presents recommendations for how other states can develop their own interventions.

Identifying and Serving LGBTQ Youth: Case Studies of Runaway and Homeless Youth Program Grantees To better understand provider experiences serving lesbian, gay, bisexual, transgender and Questioning (LGBTQ) runaway and homeless youth, this study reports on case studies of four local agencies receiving grants from the Administration for Children and Family’s Runaway and Homeless Youth (RHY) Program. The purpose of the study was to learn about programs’ strategies for identifying and serving LGBTQ RHY, the challenges programs face in understanding and addressing the needs of this population, and potential areas for future research.

Promoting Protective Factors for In-Risk Families and Youth: A Brief for Researchers    (Administration for Children and Families) This report explores the factors that make children and young people more able to cope with the trauma they face. It focuses on five populations that are often victimized the most: infants, children, and adolescents who are victims of child abuse and neglect; runaway and homeless youth; youth in or transitioning out of foster care; children and youth exposed to domestic violence; and pregnant and parenting teens.

Housing for Youth Aging Out of Foster Care (U.S. Department of Housing and Urban Development, with HHS’ Assistant Secretary for Planning and Evaluation) This research project focused on the housing needs of the over 25,000 youth who “age out” of the foster care system each year. It explores and documents the range of housing options available to these youth, includes an in-depth review of communities using the Family Unification Program (FUP) vouchers, identifies opportunities to mitigate the risk of homelessness for youth as they transition from the foster care system, and suggests areas for future research.

Housing Assistance and Supportive Services in Memphis: Best Practices for Serving High Needs Populations This standalone document from the Housing Assistance and Supportive Services in Memphis project synthesizes the literature and recent research on how to provide services to people in HUD-assisted housing.

Linking Human Services and Housing Assistance for Homeless Families and Families at Risk of Homelessness    (Assistant Secretary for Planning and Evaluation) This final report presents findings from the Linking Human Services and Housing Supports to Address Family Homelessness project. Through in-depth, on-site case studies, this study observed 14 communities that coordinate federally funded housing supports and comprehensive services to more effectively serve homeless families and families at risk of becoming homeless. Seven of the models include participation from local public housing agencies (PHAs). The report includes information about the structure of the programs examined, common promising practices identified across the models, and detailed case studies of the 14 models.

Establishing Eligibility for SSI for Chronically Homeless People    (Assistant Secretary for Planning and Evaluation) This issue paper describes innovative approaches to establishing SSI eligibility.

Health, Housing, and Service Supports for Three Groups of People Experiencing Chronic Homelessness  (Assistant Secretary for Planning and Evaluation) This issue paper describes three subgroups of the people experiencing chronic homelessness, and the services and housing configurations currently supporting them.

Public Housing Agencies and Permanent Supportive Housing for Chronically Homeless People    (Assistant Secretary for Planning and Evaluation) This issue paper looks at innovative ways that public housing agencies are supporting housing for formerly homeless people in the communities the researchers visited.

Medicaid Financing for Services in Supportive Housing for Chronically Homeless People: Current Practices and Opportunities    (Assistant Secretary for Planning and Evaluation) This issue paper describes the ways that Medicaid is being used now and might be used in the future under provisions of the Affordable Care Act of 2010 to serve chronically homeless people.

Housing Assistance for Youth Who Have Aged Out of Foster Care: The Role of the Chafee Foster Care Independence Program Each year the Chafee Foster Care Independence Program provides $140 million for independent living services to assist youth as they age out of foster care and enter adulthood. Under this formula grant program, states are provided allocations and allowed to use up to 30 percent of program funds for room and board for youth ages 18 to 21 who have left care. This report describes how states are using these funds to provide housing assistance to these vulnerable youth and explores how the assistance provided through this program fits in with other sources of housing assistance available in the states examined.

Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Literature Synthesis and Environmental Scan This report reflects existing published and unpublished literature on permanent supportive housing (PSH) for people who are chronically homeless. It has a particular focus on the role that Medicaid currently plays in covering the costs of the supportive services that help people keep their housing and improve their health and quality of life. In addition to written material, this document incorporates the knowledge of housing and service configurations and ways that providers have been able to cover the cost of supportive services, garnered over our many years in the field.

Human Services and Housing Supports to Address Family Homelessness: Promising Practices in the Field  (Assistant Secretary for Planning and Evaluation) This ASPE Research Brief explores local programs for linking human services and housing supports to prevent and end family homelessness. The Research Brief is based on interviews with stakeholders in 14 communities nationwide, highlighting key practices that facilitated the implementation and ongoing sustainability of the programs. The Research Brief was prepared by Abt Associates under contract with the Office of the Assistant Secretary for Planning and Evaluation.

Homeless Children Roundtable, Conference   (Assistant Secretary for Planning and Evaluation) The purpose of the Roundtable (May 2010) was to understand the impact of homelessness on children, identify the resources currently available to address the needs of homeless children, and discuss opportunities for coordination. While other meetings have focused on the adults in homeless families, the Roundtable focused specifically on the children in families that are experiencing homelessness. A diverse group of policy experts, researchers, practitioners, and federal agency staff were invited.

Homeless Children: Discussion Synthesis   (Assistant Secretary for Planning and Evaluation) This document synthesizes the discussion from the Roundtable on Homeless Children. The background paper from this meeting is also available and provides an update on the research, policy, laws, and funding for programs and services for children who are homeless in the United States.

Homeless Children: Update on Research, Policy, Programs, and Opportunities  (Assistant Secretary for Planning and Evaluation) Despite the knowledge that homeless children face poor outcomes, research has largely focused on the parent(s) in a homeless family, perhaps because these children are still part of a family unit. The children themselves, however, have different and separate needs from their parent(s). Given the impact of the current recession, it is critical to understand the impact of homelessness on our youngest population, and to ensure that resources are mobilized to guarantee that these children's needs are met quickly and thoroughly. This paper provides an update on the research, policy, laws, and funding for programs and services for children who are homeless in the United States. Education, health, and mental health for homeless children are examined.

Findings from a Study of the SSI/SSDI Outreach, Access, and Recovery (SOAR)  Initiative   (Assistant Secretary for Planning and Evaluation) The Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) programs provide critical income support for those who meet eligibility requirements. The SSI/SSDI Outreach, Access, and Recovery (SOAR) initiative aims to improve access to SSI/SSDI benefits for individuals who are homeless through a multi-pronged strategy designed to mitigate the challenges this population faces when navigating the SSI/SSDI application process. To determine how and the extent to which SOAR is achieving its goals, ASPE conducted an evaluation of SOAR. The goals of the evaluation were to (1) provide a comprehensive description of SOAR processes, (2) examine the outputs and some of the short- and long-term outcomes that may be associated with these processes, (3) assess the factors that appear to be associated with successful implementation of the initiative, and (4) describe ways in which the initiative might be improved at either the state or federal level. This report summarizes the findings from the evaluation.

Homelessness Data in HHS Mainstream Programs  (Assistant Secretary for Planning and Evaluation) This study explores the extent to which states collect data on housing status and homelessness from applicants for the two largest HHS mainstream programs that may serve individuals or families experiencing homelessness:  Medicaid and Temporary Assistance for Needy Families (TANF). Interviews were conducted with TANF and Medicaid directors in all 50 states and the District of Columbia to learn about state practices related to the collection of housing status and homelessness data from program applicants. The study also includes a review of data-collection practices in nine other HHS mainstream programs. The Assistant Secretary for Planning and Evaluation (ASPE) and the Health Resources and Services Administration (HRSA) jointly funded this project. The study yielded three publications:

• Homelessness Data in Health and Human Services Mainstream Programs , Final Report, Winter 2009.
• Housing Status Assessment Guide for State TANF and Medicaid Programs , Winter 2009.
• Potential Analyses with Homelessness Data: Ideas for Policymakers and Researchers , Winter 2009.

Study of HHS Programs Serving Human Trafficking Victims This project developed information on how HHS programs are currently addressing the needs of victims of human trafficking, including domestic victims (i.e., citizens and legal permanent residents), with a priority focus on domestic youth. The project provides in-depth and timely information to help HHS design and implement effective programs and services that help trafficking victims overcome the trauma and injuries they have suffered, to regain their dignity, and become self-sufficient. Components to the study include a comprehensive review of relevant literature, studies or data (published or unpublished) related to providing services to victims of human trafficking (including domestic victims); nine site visits to geographic areas (e.g., counties) containing at least one HHS- or federally-funded program currently assisting victims of human trafficking; at least three brief reports highlighting interesting, innovative, and/or effective experiences, knowledge, or information resulting from one or more of the site visits; and a final report providing a synthesis of all information obtained under the study.

The Mental Health of Vulnerable Youth and their Transition to Adulthood: Examining the Role of the Child Welfare, Juvenile Justice, and Runaway/Homeless Systems This project focused on the mental health of vulnerable youth who have been in contact with service systems, including child welfare, juvenile justice, and run-away and homeless programs. Data for this project come from the  National Longitudinal Study of Adolescent Health  (Add Health). The Add Health is a nationally representative study that was designed to examine the causes of health-related behaviors of adolescents and their outcomes in young adulthood. The analytic sample for this current study was limited to participants who completed an interview at Waves 1 and 3 and who have a valid population weight for these Waves.

Final Report for the Independent Evaluation of the Substance Abuse Prevention and Treatment Block Grant Program (Substance Abuse and Mental Health Services Administration) The independent evaluation of the Substance Abuse Prevention and Treatment Block Grant (SABG) was conducted to assess the extent to which the SABG Program is effective, functioning as intended, and achieving desired outcomes. Key Finding 1 indicates the SABG program demonstrated a positive outcome in the stable housing domain of the client-level National Outcome Measures (NOMs) between admission to and discharge from a treatment episode.

• Executive Summary (PDF | 209 KB)
• Highlights of Key Findings (PDF | 1.4 MB)
• Detailed Key Findings (PDF | 2.5 MB)
• Final Report (PDF | 1.1 MB)

Characteristics and Dynamics of Homeless Families with Children  (Assistant Secretary for Planning and Evaluation) This report investigates the availability of data with which to construct a typology of homeless families with the goal of identifying key knowledge gaps regarding homeless families and to consider whether these gaps may most efficiently be filled through secondary analysis of existing data, adding questions or a module to planned surveys that include low-income populations, or whether additional primary data collection would be needed. Ultimately, it is intended that an improved understanding of the characteristics of homeless families with children will guide the development of appropriate service responses to such families and provide an empirical foundation for the design of homelessness prevention and intervention approaches. The project consisted of three phases: assessing the availability of already existing data that could be mined through secondary data analysis; proposing a set of questions to modify existing and ongoing surveys that would allow for the key research questions related to homeless families to be answered, and conceptualizing various primary data collections that would specifically collect the kind of data required to develop a typology of homeless families.

Evaluation of the Collaborative Initiative to Help End Chronic Homelessness  (Assistant Secretary for Planning and Evaluation) A cornerstone effort of the Administration goal to end chronic homelessness was the development of the  Collaborative Initiative to Help End Chronic Homelessness  (CICH), an innovative demonstration project coordinated by the U.S. Interagency Council on Homelessness, jointly funded by the Departments of Housing and Urban Development, Health and Human Services (HHS: SAMHSA and HRSA), and Veterans Affairs.

Summary of CICH Interim Reports The summary reviews the background of the study, the methods, client outcomes, and system outcomes.

Preliminary Client Outcomes Report , February 2007  This report presents data on screening, enrollment, client characteristics across sites, service use over time, and outcomes during the first 12 months of CICH participation. Data are also presented on a comparison group that received some lesser combination of housing and services than the CICH clients.

An Evaluation of an Initiative to Improve Coordination and Service Delivery of Homeless Service Networks , February 2007  This report examines the service system of the CICH during the first 24 months of the program including the types of housing and service models that were available for the target population and the nature of the interaction between agencies in the CICH.

Is System Integration Associated with Client Outcomes? , June 2007 This report merges network data reflecting collaboration, trust and use of evidence-based practices at the time clients enrolled in the CICH with 12-month client outcome data to examine the association of interagency relationships at the start of the program and client outcome during the first year of program participation.

Computer Retrieval of Information on Scientific Projects   (National Institutes of Health) The National Institutes of Health (NIH) supports a wide range of studies involving homeless populations because of associations between homelessness and many adverse health conditions. Research projects funded via an NIH grant are traditionally published in scientific journals. To access a full list of research relevant to homelessness currently being supported by NIH and other Public Health Agencies, follow the link to search Computer Retrieval of Information on Scientific Projects (CRISP). CRISP is a searchable database of federally funded biomedical research projects conducted at universities, hospitals, and other research institutions. The database, maintained by the Office of Extramural Research at the National Institutes of Health, includes projects funded by the National Institutes of Health, Substance Abuse and Mental Health Services Administration, Health Resources and Services Administration, Food and Drug Administration, Centers for Disease Control and Prevention, Agency for Health Care Research and Quality, and Office of Assistant Secretary of Health.

Toward Understanding Homelessness: The 2007 National Symposium on Homelessness Research   (Department of Health and Human Services and Department of Housing and Urban Development) The National Symposium on Homelessness Research, co-funded by the Department of Health and Human Services (both Assistant Secretary for Planning and Evaluation and Substance Abuse Mental Health Services Administration) and the Department of Housing and Urban Development in FY 2005, sponsored the development of twelve research papers in an effort to capture the current state of the research related to homelessness. The Symposium event itself, which was held over two days in March of 2007, brought together 200 researchers, policy makers, government officials, service providers, and consumers from across the country to discuss the research papers and directions for future research related to homelessness. This Symposium was a follow-on event to the first National Symposium on Homelessness Research, which took place in 1998 and was also sponsored by Department of Health and Human Services and the Department of Housing and Urban Development. This volume presents the twelve papers developed and presented at the 2007 Symposium.

Promising Strategies to End Youth Homelessness  (Administration for Children and Families)

Provides an overview of youth homelessness, as well as a set of preventive strategies that show promise in the effort to end homelessness. This report was created by the Administration for Children and Families, in consultation with the U.S. Interagency Council on Homelessness.

Strategic Action Plan on Homelessness   (Department of Health and Human Services)

Report details Departmental strategies to prevent homelessness; ensures the provision of services to eligible individuals and families; empower states and community partners to improve their response to homelessness, and track Departmental progress in reaching these goals.

Condensed Version  of the Medicaid Primer on How to Use Medicaid to Assist Persons Who are Homeless to Access Medical, Behavioral Health and Support Services (Centers for Medicare and Medicaid Services) Primer to help to connect people who are homeless with critical Medicaid benefits

An Evaluation of the Respite Pilot Initiative  (Health Resources and Services Administration) In May 2000, Health Resources Services Administration (HRSA) funded ten Health Care for the Homeless grantees, for up to five years, to enhance their medical respite services for homeless persons. HRSA also supported a prospective evaluation to document the differing models of respite care delivery being used and assess the effect of those respite services on the health of homeless persons. 

Evaluability Assessment of Discharge Planning and the Prevention of Homelessness: Final Report   (Assistant Secretary for Planning and Evaluation) The purpose of this study was to conduct an evaluability assessment of discharge planning in institutional and custodial settings, with a specific focus on whether discharge planning is a strategy that can prevent homelessness. 

Using Medicaid to Support Working Age Adults with Serious Mental Illness in the Community: A Handbook  (Assistant Secretary for Planning and Evaluation) The purpose of this primer is to describe the Medicaid program in the delivery of services to adults with serious mental illnesses; specifically, the primer explains how existing Medicaid options and waivers are used by states to finance a broad range of community services and supports for adults with serious mental illnesses, and to demonstrate what aspects of state-of-the-art community services and supports for this population are funded by Medicaid.

The Implementation of Maternity Group Home Programs: Serving Pregnant and Parenting Teens in a Residential Setting Given the considerable interest in maternity group homes and the roles they can play in assisting pregnant and parenting teens’ transition to independence, it is important to fill some of the gaps in the existing research. For this reason, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) at the U.S. Department of Health and Human Services is interested in learning more about maternity group home programs and in assessing the feasibility of conducting a rigorous evaluation to measure the effectiveness of such programs. To this end, ASPE contracted with Mathematica Policy Research, Inc. to conduct a study of how these programs operate and to explore options for studying them further. This report aims to document the implementation of maternity group home programs.

Improving Medicaid Access for People Experiencing Chronic Homelessness: State Examples (Centers for Medicare & Medicaid Services) This technical assistance report is designed to highlight several state initiatives that increase Medicaid access for people who are chronically homeless.

Maternity Group Homes Classification and Literature Review This document provides an overview of past research and develops a preliminary classification framework for maternity group homes. The report classifies maternity group homes according to population served, degree of structure and supervision provided, and level of support services offered. The report also reviews research related to maternity group homes by categorizing existing studies into four groups: those that describe the characteristics of maternity group homes, but do not report data on outcomes; those that collect some data, but without any context for comparison; those that compare outcomes of different groups or at different points in time; and those that look at implementation of maternity group homes. Included in the review of research are resident characteristics, experiences during residence, outcomes after leaving maternity group homes, limitations of existing studies, and recommendations for future research.

Achieving the Promise: Transforming Mental Health Care in America  (President's New Freedom Commission on Mental Health) In 2002, the President announced the creation of the New Freedom Commission on Mental Health and charged the Commission to study the mental health service delivery system, and to make recommendations that would enable adults with serious mental illnesses and children with serious emotional disturbance to live, work, learn, and participate fully in their communities.  Achieving the Promise  is the final report of the New Freedom Commission.

Adapting Your Practice: Treatment and Recommendations for Homeless Patients with HIV/AIDS Pocket Guidebook (Health Resources and Services Administration) This condensed pocket guidebook on adapting clinical guidelines for homeless clients with HIV/AIDS was a project of the HIV/AIDS Bureau Homelessness and Housing Workgroup in revising the original manual,  Adapting Your Practice: Treatment and Recommendations for Homeless Patients with HIV/AIDS (2003) , developed by the Health Care for the Homeless Clinicians’ Network. 

Adapting Your Practice: Treatment and Recommendations for Homeless Patients with HIV/AIDS  (Health Resources and Services Administration) A clinical guidebook written by clinicians with extensive experience caring for individuals who are homeless and who routinely adapt their medical practice to foster better outcomes for these patients. 

Core Performance Indicators for Homeless-Serving Programs Administered by the U.S. Department of Health and Human Services  (Assistant Secretary for Planning and Evaluation) This report explores the feasibility of developing a core set of performance measures across four Health and Human Services (HHS) programs that focus on service delivery to homeless persons. The report also explores the extent to which mainstream service-delivery programs supported by HHS, i.e., those not specifically targeted to homelessness, could generate performance measures on the extent to which homeless persons are served and to what effect. 

Ending Chronic Homelessness: Strategies for Action   (Department of Health and Human Services) This document was developed in 2003 by the Health and Human Services Secretary’s Work Group on Ending Chronic Homelessness to outline a series of goal and strategies that would align the Department’s effort towards the goal of ending chronic homelessness.

The 1996 National Survey of Homeless Assistance Providers and Clients: A Comparison of Faith-Based and Secular Non-Profit Programs  (Assistant Secretary for Planning and Evaluation) This study examines data from National Survey of Homeless Assistance Providers and Clients to determine more thoroughly the role that faith-based programs play in the larger context of homeless assistance. The study has an explicit focus on comparing homeless assistance programs administered by faith-based versus secular non-profit service agencies. It provides a basic but comprehensive picture of the numbers and characteristics of the two types of homeless assistance programs.

Practical Lessons:  The 1998 National Symposium on Homelessness and Research   (Department of Health and Human Services and the Department of Housing and Urban Development) This symposium was jointly sponsored with HUD and provides 13 papers that summarize more than a decade of research on homelessness.

MINI REVIEW article

Homeless people: a review of personality disorders.

• 1 Centro de Investigação em Ciência Psicológica (CICPSI), Faculdade de Psicologia, Universidade de Lisboa, Lisboa, Portugal
• 2 Faculdade de Psicologia, Universidade de Lisboa, Alameda da Universidade, Lisboa, Portugal
• 3 Consulta de Esquizofrenia Resistente, Hospital Júlio de Matos (HJM), Unidade Local de Saúde São José (ULSSJ), Centro Clínico Académico de Lisboa (CCAL), Lisboa, Portugal
• 4 Clínica Universitária de Psiquiatra e Psicologia Médica (CUPPM), Faculdade de Medicina, Universidade de Lisboa (FMUL), Centro Académico de Medicina de Lisboa (CAML), Lisboa, Portugal
• 5 Homeless Outreach Psychiatric Engagement for Lisboa (HOPE 4 Lisboa), Santé Mentale et Exclusion Sociale (SMES) Europa, Lisboa, Portugal

Personality disorders in homeless people pose a challenge to the medical community and society, requiring specialized approaches for these super-difficult patients. The prevalence of personality disorders is higher in homeless populations than in the general population. However, there is a knowledge gap regarding personality disorders among people experiencing homelessness, and the implications of this lack of recognition are substantial. This paper provides a brief narrative review of personality disorders among homeless individuals. The primary importance and specificity of these disorders in this population remain unexplored. We searched PubMed and Web of Science databases in February and November 2023 using the keywords ‘homeless’ and ‘personality disorder’, and selected fifty-eight studies to be included in this literature review. The main themes of the results were personality disorders in homeless individuals and comorbid psychiatric disorders; risk factors and other psychological and behavioral data; clinical and intervention outcomes; and challenges linked to assessment, treatment, and intervention. The homeless population experiences significant diagnostic variability and the diagnosis of personality disorders is still evolving, contributing to difficulties in diagnosis, assessment, and treatment. A future challenge is to raise clinical awareness and optimize research knowledge, assessment, and intervention in personality disorders among homeless individuals with comorbid psychiatric disorders.

1 Introduction

Personality disorders (PD) among the homeless pose a challenge to medicine and society and are many times framed as difficult or super-difficult patients. Difficult, because they are prevalent in primary care settings, have more psychiatric disorders, functional impairment, health care utilization, and dissatisfaction with care ( 1 ). Super difficult, because besides all that, they are homeless, living and dying on the streets, neglected by society, lacking the appropriate health care from community psychiatry ( 2 ).

PD’s affect more than 10% of the population but are widely ignored by health professionals due to the associated stigmas ( 3 ). However, available data remain scattered; two recent meta-analyses reported varying prevalence estimates for lifetime PD of 25.4% ( 4 ) and, around 7.8% ( 5 ). Studies have shown that PD causes considerable morbidity, is associated with high service and societal costs, and usually has an adverse effect on the progress in the treatment of other psychiatric disorders ( 6 ). Challenges also include difficulty in approaching the patient because of poor pharmacological results and a significant treatment abandonment rate ( 7 ). According to some experts, PD should be recognized as a psychiatric priority and a major condition in mainstream psychiatry across the world ( 5 , 6 ). The principal challenge of the 21st century is determining the most efficient treatment for PD ( 7 ).

The prevalence of PD’s is much higher in homeless individuals than in the general population ( 7 – 9 ). A recent systematic review ( 10 ) highlighted that PD is very common in homeless individuals, with frequencies ranging from 64% to 79% for any PD. Some authors ( 9 , 11 , 12 ) have drawn attention specifically to the gap in knowledge about PD in individuals experiencing homelessness based on the absence of reliable and valid PD diagnoses. The implications of this lack of recognition of PD and the limited data about them in homeless populations are substantial ( 8 , 9 ).

Research on PD in homeless people is limited. This article briefly reviews the existing literature on PD in homeless population and intends to address the existing data based on the state-of-the-art research topic.

Our research was conducted with the terms ‘homeless’ and ‘personality disorder’, in searches managed on PubMed (search details: (homeless*[Title/Abstract]) AND (personality disorder [Title/Abstract])), and on Web of Science (search details: (homeless*[Title]) AND (personality disorder [Title])) – both without any time limit. On February 20 th and November 17 th , 2023, the results yielded 65 articles on PubMed and 66 articles on Web of Science based on the above-mentioned keywords. A book was included following a manual search. The two authors served as evaluators. Of the 131 entries, considering the exclusion criteria of duplicates and articles unrelated to the topic. Only English and French documents (with abstracts in English) were considered. Finally, a total of 58 articles were subjected to analysis in this narrative review.

3.1 Personality disorders in patients living homeless and comorbid psychiatric disorders

Fazel’s ( 8 ) systematic review and meta-regression analysis, drawing on data from 5684 homeless individuals, reported the prevalence of PD among the homeless in Western countries as 23.1% (CI 15.5%–30.8%). Similar data were observed in a population of 500 homeless patients in Portugal ( 13 ) and in Germany ( 14 ) both at 24%. While in Stockholm, a prevalence of 12% was reported in 1704 homeless patients receiving hospital care ( 15 ). In Japan it was 3.5% (≈114 homeless) ( 16 ). Conversely, a prevalence of 50% was observed in data from London with 560 homeless men ( 17 ) and 57% based on the Edinburgh survey (≈44) ( 18 ). The prevalence reached a record high of 80% in a French study using epidemiological measures (≈1200 homeless men) ( 19 ) and 88% (with a mean of 3.5 diagnoses per participant) in the United States of America (USA) (≈99) ( 20 ). These examples illustrate the extensive range and diversity of conditions analyzed, emphasizing the clinical relevance of data on the presence of the PD’s among homeless populations.

A substantial number of psychiatric disorders are well documented in homeless populations ( 13 ). Homeless people with multiple diagnoses have greater mental health needs and worse general health determinants ( 9 , 13 ). A general synthesis of the prevalence of comorbid psychiatric disorders in homeless patients, according to reports reveals the following figures: psychotic disorders among 4.4%–57% ( 8 , 13 , 14 , 16 ); major depression among 11.4% ( 8 ); bipolar disorders among 11.4%–17.5% ( 8 , 16 ); alcohol dependence among 14.3%–37.9% ( 8 , 13 , 14 , 16 ); drug dependence among 14.3%–34% ( 8 , 13 , 14 , 16 ); acute stress reaction among 23%–24% ( 13 , 14 ); and anxiety disorder among 2.3% ( 16 ). These references are based on studies carried out in the USA, France, Japan, Portugal, and Germany.

The findings from ten-year records of homeless patients attending emergency services (≈2750) in the USA show greatly increased rates of admissions for alcohol, substance abuse and psychiatric-related problems, particularly for schizophrenia (Odd Ratio, OR:16.6) and PD (OR:15.4) ( 21 ). Lipton’s study ( 22 ) of homeless patients at a hospital emergency department supported this finding: 96.6% of this patient population had a previous psychiatric hospitalization, 72% had been diagnosed with schizophrenia, and the second most common diagnosis was PD (13.3%). In another study conducted in Portugal by Bento and Barreto ( 23 ) with a reference population of 511 homeless patients, 94% of the overall sample included patients with psychiatric disorders, excessive alcohol/drug consumption, and PD’s.

A small number of studies have recognized the existence of specific PD among the homeless, including antisocial, schizoid, dependent, and borderline PD’s ( 12 ). Connoly et al. ( 12 ) reported that the rates of specific Axis II disorders exceeded the rates of specific Axis I disorders by 50%. However, few studies have conducted systematic assessments of the full range of PD or evaluated their relationship with the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) Axis I diagnoses, often relying on unstructured assessments ( 11 , 12 ). In this brief review, we identified only seven studies addressing the full range of PD diagnoses ( 7 , 12 , 19 , 20 , 24 – 26 ). For data systematization vide Table 1 , where we also included the geographic area and its respective climate type ( 27 ). All studies were done in both sides of North Atlantic Ocean: four in the East coast of the United States of America and three in the Western part of the European Union. We believe the harder winters in humid continental climates at the states of Massachusetts, New York and Connecticut may have an influence in how homeless people live, somehow different from what happens in Spain with Hot Summer Mediterranean and France Oceanic climate types ( 27 ). On the other hand, the cultural differences may not have such an impact, as all studies were performed in the prevalent and quite accepted homogeny of the Western world. Culturally speaking the White Anglo-Saxon Protestant (WASP) culture in the northeastern USA has little contrast with the Latin catholic culture in the western EU, in the impact how psychiatric homeless people live in the streets. Furthermore, in a systematic review ( 10 ) which is based on analysis of five of these studies ( i.e ., 7,12,24,25,26), it is globally reported that the most prevalent PD diagnoses in homeless populations were paranoid (14%–74%), avoidant (14%–63%), borderline (6%–62%), and antisocial (4%–57%).

Table 1 General data of the specific personality disorders among the homeless people in the studies included in the present review.

Other studies ( 28 , 29 ) identified the most prevalent diagnoses among the homeless population as substance abuse and PD’s, including antisocial PD ( 28 ). This population had higher rates of alcohol abuse disorder (men), drug abuse disorder (women), and antisocial PD (both men and women) ( 28 ). The only diagnosis that was more prevalent in homeless clinics than in communities was antisocial PD ( 28 ). Similarly, Caton ( 30 ) reported a significantly higher number of homeless individuals with a concurrent diagnosis of antisocial PD and borderline PD ( 9 ).

However, some authors have argued that among the homeless, many of the features of antisocial personality may be artifacts of homelessness and that strict application of the diagnostic criteria may be insensitive to nurture factors ( 11 ). A study among 600 homeless individuals ( 31 ), found that data support the appropriateness of the diagnosis of antisocial PD among these populations. Most adult symptoms of antisocial PD were associated with the number of childhood conduct disorder symptoms (nature), and the onset of symptoms usually preceded the onset of homelessness ( 31 ).

Other important findings suggest a higher-than-normal prevalence of schizoid PD potentially playing a role in treatment engagement and chronicity of homelessness ( 32 ) and schizotypal PD ( 33 ). Finally, the diagnosis of emotionally unstable PD appeared to be associated with homelessness referrals to an acute young adult psychiatric unit ( 34 ). Still, a single case report of a schizoaffective homeless man with a previous diagnosis of haltlöse PD highlights the need for more studies examining PD Not Otherwise Specified (NOS) ( 35 ).

3.2 Personality disorders related to risk factors among homeless people and associated psychological and behavioral outcomes

Personality disorders (OR: 2.2) are identified as a risk factor associated with an increased risk of homelessness. They along with severe psychiatric disorders, substance abuse, and pathological gambling constitute the most significant modifiable factor, as determined by a USA big data study examining risk and protective factors for homelessness ( 36 ).

Findings of a French research ( 19 ) (≈1200 homeless men) lead to the conclusion that PD increases the risk of substance abuse, subsequently increasing the risk of homelessness. This dual diagnosis has a high impact on homelessness. The comorbidity of drug abuse and PD multiplies the risk of homelessness by a factor of 7, accounting for 46% of the cases. Conversely, the association between PD and homelessness multiplies the risk of drug abuse by a factor of 13, accounting for 3/4 of drug abuse cases ( 19 ). Moreover, PD’s appear to have a basic role in the etiopathology of such a morbid constellation because the frequency of their observation is independent of the association between homelessness and drug abuse ( 19 ). Another study ( 37 ) highlighted the association between homeless individuals and a specific group of people - those with serious substance misuse and PD (39.3%).

In a two-year longitudinal study conducted in Canada ( 38 ) young adults experiencing first-episode psychosis, within the homeless group were more likely to have childhood abuse, forensic history, non-affective psychosis, negative symptoms, substance use disorder, and the DSM-IV Cluster B PD (referred to as bad PD). It is also associated with poorer symptomatic and functional outcomes despite having more long-acting injectable antipsychotics, community treatment orders, and hospitalizations ( 38 ). Poor prognostic factors were related to Cluster B PD in intensive outreach services dedicated to homeless youth experiencing first-episode psychosis and addiction in another longitudinal study ( 39 ).

Studies have reported that high rates of deliberate self-harm and suicide in the homeless are related to high rates of psychiatric disorders found in this population, predominantly schizophrenia ( 40 ). Among homeless individuals, those exhibiting high rates of drug and alcohol abuse and PD were most often those without a stable residence. They were more likely to be male, single, unemployed, recent victims of violence, prone to have violent behavior toward others ( 40 ), a criminal record, and to have a PD ( 40 , 41 ), as well as increased mortality from all causes ( 40 ).

Data focusing on gender and prevalence of psychiatric disorders among hospitalized homeless patients ( 15 ) revealed the following. Homeless women were at a higher risk for psychiatric disorders than homeless men (1.20), and younger homeless women had the highest risk (2.17). Alcohol use disorders were equally common, but women had a higher prevalence of drug use disorders (1.32). Women were at higher risk of schizophrenia (2.79) and PD’s (2.73). Indices of low quality of life include middle-aged homeless women living in temporary housing with criminal records, PD, and substance use disorders ( 42 ). Risk factor evaluation for homelessness among patients with severe psychiatric conditions ( 43 , 44 ) show distinct patterns. Among homeless women with schizophrenia, higher rates of concurrent diagnosis of alcohol abuse, drug abuse, and antisocial PD, including less adequate family support ( 43 ); Among homeless men with schizophrenia, there was widespread concurrent substance abuse and antisocial PD (42%), and 72% had a history of incarceration ( 44 ). In addition to childhood antecedents, data indicate that drug abuse and antisocial PD preceded homelessness ( 44 ). Notably, 4/5 male patients experiencing homelessness had a triple diagnosis – concurrent schizophrenia, substance abuse, and antisocial disorder–indicating the presence of these traits even before adolescence ( 45 ). Consequently, inadequacies in psychiatric service discharge planning are most apparent among homeless men with heavy tri-morbidity ( 30 ).

Furthermore, antisocial PD is associated with illegal economic activities (selling drugs, theft, and prostitution) for income generation among the homeless ( 46 ). This association extends to youth homelessness ( 47 ), which in combination with arrest history serves as a risk factor for recurrent homelessness ( 48 ). Moreover, it is coupled with gambling disorder ( 49 ), violent behavior ( 50 ), and HIV risk in homeless individuals ( 51 ).

Engaging in survival sex is over-represented within homeless populations ( 52 ), and data show robust associations with symptoms of borderline PD, childhood abuse, and post-traumatic stress disorder among homeless women ( 52 , 53 ), suggesting that older individuals with high levels of impulsivity symptoms may be especially at risk ( 52 ). Similar approaches among homeless men have shown that risky sexual behavior is accompanied by common symptoms of PD’s and predicts treatment outcomes and suboptimal achievements in health-promoting or prosocial behaviors ( 54 – 56 ). Nevertheless, a risk index comprising key symptoms of antisocial/borderline disorders plays an essential role in sexual risky behaviors in both sexes ( 57 ).

Another focus comes from the sheltered homeless families, with suspicions of probable child abuse or neglect, where it is observed that 1/4 of the mothers had the presence of major clinical psychiatric syndromes and 70% of the mothers had PD ( 25 ). In this follow-up on the relationship between homelessness, mental health, and motherhood, the findings showed that 2/3 of the young mothers with children in their care met the criteria for lifetime antisocial PD ( 58 ) and borderline PD ( 59 ). These were further associated with criteria for lifetime major depressive episodes, post-traumatic stress disorder, and drug abuse ( 58 ).

3.3 Personality disorders in relation to clinical and intervention outcomes among homeless people

The risk factors for unplanned hospital admission in homeless individuals have been reported ( 60 ). Enduring psychiatric conditions and/or PD (OR:3.84), establish themselves as the greatest risk factors increasing the likelihood of admission by almost four-fold. This impact on the likelihood of poor physical health outcomes, potentially because of a lack of engagement or late presentation to services. When homeless patients access health services, maladaptive behaviors are often associated with poor attendance, reduced effectiveness of therapeutic alliances, failure to follow through on referrals, noncompliance with medications for medical or psychiatric symptoms, and suicidal behaviors ( 24 ).

A congregation is characterized by high rates of PD’s among profiles of homeless individuals, and high overall medical service use ( 29 , 42 ). In contrast, homeless patients who underuse mental health services ( 24 , 30 , 61 ) are more likely to receive psychiatric treatment in hospitals rather than in outpatient services and have inadequately planned psychiatric hospital discharge. This is more likely if they have comorbidities of schizophrenia, substance abuse, and antisocial PD ( 30 ).

PD’s significantly influence the failure of homeless people to adhere to treatment ( 12 ). When homelessness and PD coexist, the likelihood of treatment non-adherence increases. Notably, Cluster B PD are associated with avoiding permanence in the treatment process, while Cluster C PD (referred to as sad PD) are connected to favored treatment adherence and improved prognosis ( 7 ). Specifically, borderline and passive-aggressive PD’s (another type of PD NOS) were reasons for treatment abandonment in 100% of the patients. Additionally, patients with antisocial, obsessive-compulsive, or paranoid PD seemed to be related to treatment abandonment ( 7 ).

Concerning factors associated with health service use, the literature reports that, in young homeless people, the presence of PD (OR:4.9) was estimated to be one of the factors that improved lifetime health service utilization or follow-up ( 62 ).

In addition, the presence of PD in the homeless is linked to several factors: poorer rates of adherence and completion of psychiatric and therapeutic treatment ( 63 ), worse outcomes for treatment of depression, and an increased risk of deliberate self-harm ( 8 ), insecure types of attachment that may impact intervention strategies ( 10 ), acting as a barrier to the formation of a therapeutic alliance ( 64 ), influencing the benefits of therapeutic approaches ( 19 ), and contributing to comorbidity in dual diagnosis that may benefit from pharmacist intervention to address medication-related problems ( 65 ).

3.4 Challenges linked to personality disorders in the assessment, treatment, and intervention for homeless people

Traditional models of service delivery in Western countries, which focus on those with severe psychiatric disorders, may not meet the mental health needs of most homeless individuals with substance dependence and PD ( 8 ).

Authors such as Bassuk et al. ( 25 ) drew attention to PD as a diagnosis of social dysfunction and did not consider the influence of environmental factors extrinsic to the organization of personality, such as poverty, racism, and gender bias. The criteria for these disorders are descriptions of behavioral disturbances that are long-term and predate homelessness. Thus, the labels should primarily be used to indicate severe functional impairment and the need for help rather than implying strict causality ( 25 ).

According to Ball et al. ( 24 ), some of the paranoid, hostile, and bizarre symptoms of the homeless may be adaptive or at least understandable, given the extreme challenges of living on the streets or in a shelter. Although a diagnosis of PD requires evidence of the early onset of maladaptive traits, it is difficult to rule out the possibility that some Cluster A PD (referred to as mad PD) may be better understood as a consequence rather than as a cause of homelessness ( 24 ).

Furthermore, there are very few studies on homeless populations that have systematically assessed the full range of PD’s using appropriate and rigorous methodologies and evaluation criteria for PD assessment, thus concluding that this is an important gap and challenge ( 11 , 12 ).

Mental health services for the homeless facing particularly high levels of factors associated with suicide and homicide, a significantly higher prevalence of PD, and targeting poor compliance and complexity of disorders, require significant input from multidisciplinary mental health team members ( 66 ). Managing mood in this population remains a major challenge and nonpharmacological treatments (including complementary agents and psychosocial interventions) should be evaluated to address this issue ( 50 ). Additionally, data indicate that PD’s in the homeless are probably more common among women emphasize an important factor for social and healthcare services to bear in mind ( 15 ).

Although it remains unclear whether this group of patients is amenable to individual or group psychotherapy, they have a profound need for other social services, and some may benefit from counselling or pharmacotherapy to help improve adaptive functioning or reduce Axis I symptoms ( 24 ).

Clinicians treating homeless outpatients may benefit from having special facilities for the diagnosis and management of PD’s and substance abuse along with expertise in other comorbid psychiatric disorders ( 28 ). Homeless treatment seekers might benefit from the specialized programming and services of clinicians who are especially proficient in recognizing and treating the disorders best represented in these populations, which are notoriously difficult to manage ( 28 ).

Highlighting that, early trauma experiences have lifelong consequences, so complex trauma, appears to be intrinsic related to psychopathology and personality disorders in the homeless persons ( 8 , 10 , 29 ). Within the developing of Trauma-Informed Care (TIC), an awareness of these issues in a range of services, should improve the establishment of Psychologically Informed Environments (PIE) first taking place in re-designed facilities for homeless people ( 29 , 67 ).

Nevertheless, we cannot be sure if paranoid, avoidant, or even obsessive-compulsive personality disorders are cause or consequence of being homeless. All these three personality disorders may be mimicked by survival street behavior. For example, a person experiencing homelessness can perfectly assume an avoidant and/or paranoid to avoid conflicts with other people. On the other hand, obsessive compulsive personality disorder can be mimicked by a hoarding behavior, especially with food or other essential items, in order to increase the chances of survival ( 10 ). Regarding the anti-social PD is even more difficult to distinguish cause/nature from consequence/nurture: was the homeless born genetically vulnerable to psychopathy or it was the street hard life than made that person a sociopath?

Further investigations are needed regarding homeless people with psychiatric disorders and their treatment, particularly those with multiple diagnoses that have worse health determinants ( 13 ).

As a main conclusion and guideline for further research, Salavera et al. ( 7 ) viewed PD as a prognostic factor in treatment. Therefore, reintegration processes, and prevention strategies must be clearly established, considering the subject’s personality as a basic element, and providing an individualized therapeutic process ( 7 , 29 ). Knowledge of these personality traits should be used to advocate for better healthcare services for supporting homeless individuals ( 7 ).

4 Conclusion

The homeless population suffers from major diagnostic variability and the diagnosis of PD’s is still evolving, contributing to difficulties in diagnosis, assessment, and treatment. However, further studies are warranted and should focus more on the causes and effects of events. It is important to highlight as a limitation that the percentages of personality disorders analyzed in this review are based on studies with a disparate number of participants.

Does PD predispose individuals to homelessness? Does precocious homelessness contribute to PD? Does antisocial psychopathy increase the probabilities of homelessness? Or is it the homeless lifestyle that produces antisocial sociopaths? Do obsessive-compulsive personality hoarding habits lead to people being expelled from home and condemned to street life? Or is it homelessness that produces hoarding behavior for better chances of surviving on the streets? How many PD’s are NOS, such as haltlöse or passive-aggressive, and are underestimated among homeless people? What is the importance of attachment dysfunctions? What is the role of PD’s secondary to organic conditions such as seizures or epilepsy, which is also common among homeless people ( 68 )?

A challenge for the future is to raise clinical awareness and optimize research knowledge, assessment, and interventions for PD’s among homeless individuals with comorbid psychiatric disorders and drug abuse. These individuals are often referred to as super-difficult patients, the subjects of Marontology, a new, unborn, medical specialty, suggested after the Greek word maron-tos , which means unwanted ( 69 ).

Author contributions

JH-C: Funding acquisition, Writing – original draft, Writing – review & editing. JGM: Writing – original draft, Writing – review & editing.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work received national funding from FCT -Fundação para a Ciência e a Tecnologia, I.P [Foundation for Science and Technology] through the Research Center for Psychological Science of the Faculty of Psychology, University of Lisbon (UIDB/04527/2020; UIDP/04527/2020).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

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Keywords: homeless, personality, psychiatry, psychology, psychopathology, mental health

Citation: Henriques-Calado J and Gama Marques J (2024) Homeless people: a review of personality disorders. Front. Psychiatry 15:1362723. doi: 10.3389/fpsyt.2024.1362723

Received: 28 December 2023; Accepted: 22 April 2024; Published: 08 May 2024.

Reviewed by:

Copyright © 2024 Henriques-Calado and Gama Marques. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Joana Henriques-Calado, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.