Elmer L. Struening

On stigma and its consequences: evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse.

Numerous studies have demonstrated a strong connection between the experience of stigma and the well-being of the stigmatized. But in the area of mental illness there has been controversy surrounding the magnitude and duration of the effects of labeling and stigma. One of the arguments that has been used to downplay the importance of these factors is the substantial body of evidence suggesting that labeling leads to positive effects through mental health treatment. However, as Rosenfield (1997) points out, labeling can simultaneously induce both positive consequences through treatment and negative consequences through stigma. In this study we test whether stigma has enduring effects on well-being by interviewing 84 men with dual diagnoses of mental disorder and substance abuse at two points in time--at entry into treatment, when they were addicted to drugs and had many psychiatric symptoms and then again after a year of treatment, when they were far less symptomatic and largely drug- and alcohol-free. We found a relatively strong and enduring effect of stigma on well-being. This finding indicates that stigma continues to complicate the lives of the stigmatized even as treatment improves their symptoms and functioning. It follows that if health professionals want to maximize the well-being of the people they treat, they must address stigma as a separate and important factor in its own right.

Mortality among homeless shelter residents in New York City.

OBJECTIVES This study examined the rates and predictors of mortality among sheltered homeless men and women in New York City. METHODS Identifying data on a representative sample of shelter residents surveyed in 1987 were matched against national mortality records for 1987 through 1994. Standardized mortality ratios were computed to compare death rates among homeless people with those of the general US and New York City populations. Logistic regression analysis was used to examine predictors of mortality within the homeless sample. RESULTS Age-adjusted death rates of homeless men and women were 4 times those of the general US population and 2 to 3 times those of the general population of New York City. Among homeless men, prior use of injectable drugs, incarceration, and chronic homelessness increased the likelihood of death. CONCLUSIONS For homeless shelter users, chronic homelessness itself compounds the high risk of death associated with disease/disability and intravenous drug use. Interventions must address not only the health conditions of the homeless but also the societal conditions that perpetuate homelessness.

Adverse childhood experiences: are they risk factors for adult homelessness?

OBJECTIVES We tested the hypothesis that adverse childhood experiences are risk factors for adult homelessness. METHODS We interviewed a nationally representative sample of 92 US household members who had previously been homeless and a comparison group of 395 individuals with no prior homelessness. We assessed childhood adversity with a structured protocol that included a previously validated scale indicating lack of care from parents and single-item measures of physical and sexual abuse. RESULTS Lack of care from a parent during childhood sharply increased the likelihood of subsequent homelessness (odds ratio [OR] = 13), as did physical abuse (OR = 16). Sexual abuse during childhood was associated with a nonsignificant trend toward homelessness (OR = 1.7). The risk of subsequent homelessness among individuals who experienced both lack of care and either type of abuse was dramatically increased compared with subjects reporting neither of these adversities (OR = 26). CONCLUSIONS Adverse childhood experiences are powerful risk factors for adult homelessness. Effectively reducing child abuse and neglect may ultimately help prevent critical social problems including homelessness.

Factors affecting the use of medical, mental health, alcohol, and drug treatment services by homeless adults.

This study describes use of medical, mental health, alcohol, and drug services by 832 adult residents of the New York City homeless shelter system and examines associations between service use during the past three months and an array of predisposing, enabling, and need factors. Utilization rates were 23% for medical services, 13% for mental health services, and 10 and 7.5% for alcohol and drug treatment services, respectively. Service contacts were more often hospitals than ambulatory care clinics. Logistic regression analyses revealed that need factors were stronger predictors of all four types of service use. Predisposing factors other than education and black ethnic status were not significant, and the enabling factor of enrollment in Medicaid and/or Medicare was significant only for use of medical and drug services. Among the need factors, measures of mental health status were analyzed as indices of distress to test a stress-utilization model of prediction for all four types of service use. While these measures did not predict use of nonmental health services, physical health problems were associated with use of all four types of services. Implications for future health services research and for service delivery to the homeless are discussed, including the need for more information on availability of services and on psychosocial and cultural characteristics of homeless persons that may affect their help-seeking behavior.

On Describing and Seeking to Change the Experience of Stigma

Abstract The stigma of mental illness has been shown to be a strong negative feature in the lives of many people with mental illnesses and their families. As a consequence it makes sense to undertake efforts to reduce the negative impact of stigma on the lives of people who experience it. In keeping with this idea we set out to develop and evaluate an intervention designed to encourage successful coping with stigma. Specifically, we constructed measures designed to assess the experience of stigma and to develop a pilot intervention designed to interrupt some of the negative consequences of stigma. To achieve this goal we studied people attending a clubhouse program, randomly assigning participants to intervention and control groups in the context of pretest-postest design. In a unique feature we also followed up the participants two year following the pre-test when all participants had the opportunity to experience the intervention. We found that people perceive and experience stigma and that these perceptions and experiences are associated low self-esteem and depressive symptoms. However, we found little evidence to suggest that the pilot intervention we mounted had a positive impact on any of the stigma measures we assessed, or on self-esteem or depressive symptoms. Our study contributes to the literature on stigma by providing refined measurement of the stigma experience but fails in terms of changing that experience in a manner that can be detected with our measures. The challenge of mounting efforts to reduce the consequences of stigma remains pressing.

Victimization among homeless women: Implications for service delivery

This article focuses on the experience of victimization among a representative sample of 141 homeless women interviewed in a single-adult shelter in New York City. The frequency of victimization experiences, specifically aggressive sexual and physical assault, was high. Twenty-one women reported being raped, 42 women reported both rape and physical abuse, and 62 women reported physical abuse without sexual abuse. Shelter women reporting frequent experiences were likely to experience high levels of depressive symptoms; psychotic symptoms; and hospitalization for psychiatric, medical, alcohol, and drug problems. These results further indicate that assault experiences cluster in specific ways and are associated with different clinical outcomes. These findings are seen as underscoring the need for service delivery programs to respond to the experience of vicitimization among homeless women and suggest some future research directions.

Predictors of emergency room use by homeless adults in New York City: The influence of predisposing, enabling and need factors

Employing data from a 1987 shelter survey of 1260 homeless adults in New York City, multivariate models of emergency room (ER) use are developed which include an array of risk factors for visiting a hospital ER including health and mental health problems, victimization and injuries. The studys primary goal is to identify factors that predict ER use in this population. Multivariate logistic and linear regression models were tested separately for men and women predicting three outcomes: any use of the ER during the past 6 months, use of the ER for injuries vs all other reasons (given any ER use), and the number of ER visits (given any ER use). Lower alcohol dependence, health symptoms and injuries were strong predictors for both men and women; other significant predictors differed markedly by gender. Both models were highly significant and produced strikingly high risk profiles. A high prevalence of victimization and injuries underlies ER use among the homeless. Based upon the findings, we recommend expanded health and victim services as well as preventive measures. Until primary care becomes available for this population, we advise against policies that discourage ER use by the homeless.

Helpseeking and access to mental health treatment for obsessive-compulsive disorder.

Objective: To identify predictors of helpseeking and use of mental health treatment for obsessive‐compulsive disorder (OCD) using the behavioral model of health service use.

Posttraumatic stress disorder and treatment seeking in a national screening sample.

The behavioral model of service use was employed to identify predictors of mental health treatment seeking and treatment readiness among individual with PTSD (N = 2,713) in data from the 1996 National Anxiety Disorders Screening Day (NADSD). This model examines the contribution of predisposing (age, sex, marital status, race/ethnicity, education), enabling (employment, geographic location), perceived need (interference of symptoms with daily life), and evaluated need (other diagnoses) factors to treatment seeking and treatment readiness for individuals with PTSD. Results indicate that although need factors (interference by anxiety symptoms with daily life, diagnosis of panic disorder) are related to both receiving and readiness for treatment, predisposing (age, marital status, minority race) factors influence which individuals receive treatment for PTSD.

Diagnostic predictors of treatment patterns in a cohort of adolescents

Data on 776 American adolescents studied longitudinally were used to show treatment patterns related to psychiatric disorders. When DSM-III-R diagnoses based on mother and youth Diagnostic Interview Schedule for Children interviews were used prospectively to determine subsequent treatment seeking, it was found that consultation with mental health specialists, but not with pediatricians or general practitioners, was elevated in those with disorders. The specific diagnoses most associated with treatment seeking were conduct disorder and oppositional/defiant disorder. No compensation for differences in mental health service usage between children with internalizing disorders and those with externalizing disorders in the form of help from informal or other professional sources was present.