Alan Felix

Risk Factors for Long-Term Homelessness: Findings From a Longitudinal Study of First-Time Homeless Single Adults

OBJECTIVES We examined risk factors for long-term homelessness among newly homeless men and women who were admitted to New York City shelters in 2001 and 2002. METHODS Interviews were conducted with 377 study participants upon entry into the shelter and at 6-month intervals for 18 months. Standardized assessments of psychiatric diagnosis, symptoms, and coping skills; social and family history; and service use were analyzed. Kaplan-Meier survival analysis and Cox regression were used to examine the association between baseline assessments and duration of homelessness. RESULTS Eighty-one percent of participants returned to community housing during the follow-up period; the median duration of homelessness was 190 days. Kaplan-Meier survival analysis showed that a shorter duration of homelessness was associated with younger age, current or recent employment, earned income, good coping skills, adequate family support, absence of a substance abuse treatment history, and absence of an arrest history. Cox regression showed that older age group P<.05) and arrest history (P<.01) were the strongest predictors of a longer duration of homelessness. CONCLUSIONS Identification of risk factors for long-term homelessness can guide efforts to reduce lengths of stay in homeless shelters and to develop new preventive interventions.

Risk factors for homelessness among schizophrenic men: A case-control study

OBJECTIVES To identify risk factors for homelessness among the severely mentally ill, we conducted a case-control study of 100 indigent schizophrenic men meeting criteria for literal homelessness and 100 such men with no homeless history. METHODS Subjects were recruited from shelter, clinic, and inpatient psychiatric programs in Upper Manhattan. Clinical interviewers employed standardized research instruments to probe three domains of risk factors: severity of mental illness, family background, and prior mental health service use. RESULTS Homeless subjects showed significantly higher levels of positive symptoms, higher rates of a concurrent diagnosis of drug abuse, and higher rates of antisocial personality disorder. Homeless subjects experienced greater disorganization in family settings from birth to 18 years and less adequate current family support. Fewer homeless subjects than subjects in the never-homeless comparison group had a long-term therapist. These differences remained when demographic variables were adjusted statistically. CONCLUSIONS Homeless schizophrenic men differed from their domiciled counterparts in all three domains we investigated; family background, nature of illness, and service use history. Findings are discussed in relation to policy and programs for the severely mentally ill.

Critical Time Intervention: An Empirically Supported Model for Preventing Homelessness in High Risk Groups

Critical Time Intervention (CTI) is designed to prevent recurrent homelessness among persons with severe mental illness by enhancing continuity of care during the transition from institutional to community living. After providing the background and rationale of CTI, we describe the elements of the model and summarize the status of existing research on its effectiveness. We then briefly illustrate how the CTI model has begun to be adapted and implemented by providing a case example of a homeless woman’s transition from shelter to housing. Finally, we consider plans for the further adaptation, testing and dissemination of CTI in other populations and service delivery settings.

A critical time intervention with mentally ill homeless men: impact on psychiatric symptoms.

We describe the impact of a psychosocial intervention, critical time intervention (CTI), on the cardinal symptom dimensions of schizophrenia, namely negative, positive, and general psychopathology. Ninety-six men with schizophrenia and other psychotic disorders who were discharged from a homeless shelter were randomly assigned to receive either CTI or usual services only. CTI is a time-limited intervention designed to enhance continuity of care during the transition from institution to community. Symptom severity at baseline and at 6 months was assessed using the Positive and Negative Syndrome Scale. Using data on 76 subjects for whom we have complete symptom data, we assessed the impact of CTI on change in symptoms. The results suggest that CTI was associated with a statistically significant decrease in negative symptoms at the 6-month follow-up, reflecting modest clinical improvement. There was no significant effect on positive or general psychopathology symptoms.

From the Couch to the Street: Applications of Psychoanalysis to Work with Individuals Who Are Homeless and Mentally Ill

Current-day psychiatric treatment of severely disturbed populations tends to focus on the biological, behavioral, and social dimensions of rehabilitation. This paper addresses the relative neglect of the complex psychodynamic and interpersonal aspects of treatment of individuals who are homeless and mentally ill by presenting two clinical cases that are discussed from various psychoanalytic frames of reference. Based on their clinical experiences, the authors conclude that psychoanalysis offers valuable frameworks to guide the treatment process and the structure of the treatment setting for individuals who are homeless and suffering from severe psychiatric illness.

CATON ET AL. RESPOND

We appreciate Alexander-Eitzman’s interest in our article and welcome the opportunity to respond to his letter. We take issue with his assertion that our approach in this study of risk factors for long-term homelessness is one where the “tools define the problem,”1(pXXX) with the implication that our predictor variables were heavily tilted toward the assessment of psychopathology. Although our assessment battery did include standardized assessments of health and mental health status, the tools did not define the results. Our overall findings underscored the heterogeneity of the contemporary homeless, but a Kaplan–Meier survival analysis showed that participants who were younger and those who had better psychosocial adjustment, recent or current employment, earned income, and adequate family support experienced shorter durations of homelessness than those without these characteristics. In the Discussion section of our article we concluded that these findings suggest that new shelter admissions presenting with such characteristics might be offered assistance with job searches, temporary income support, or other supportive services that might provide a fast track out of homelessness. We reject the argument by Meyer and Schwartz2 that epidemiological analyses of social problems such as homelessness should be avoided. The identification of individual-level risk factors for chronic homelessness has practical implications for service delivery in that it suggests new preventive intervention approaches. Other findings we reported, specifically the characteristics of living arrangements prior to shelter entry and upon exit from homelessness, illustrate the scarcity of housing options available to this economically disadvantaged population. Although not predictive of duration of homelessness, widespread and long-standing mental health and substance abuse problems among our study subjects indicate a substantial unmet need for public health and mental health services in the disadvantaged neighborhoods from which these newly homeless men and women emerged. We agree completely with Alexander-Eitz-man’s recommendation that the longitudinal study of homelessness be broadened to include multiple levels of analysis. A strategy for the prevention of chronic homelessness should encompass interventions at both individual and population levels and should address housing, health, and mental health policy and program development issues.