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2 Dynam;es of Hon~elessness INTRODUCTION As the committee reviewed descriptions and discussions of the causes of homelessness, two rather different concepts emerged. The first em- phasizes homelessness as the result of the failures in the support and service systems for income maintenance, employment, corrections, child welfare, foster care, and care of mental illness and other types of disabilities. Homeless people, in this view, are people with the problems that these systems were designed to help. The increasing extent of homelessness can be seen as evidence that these systems are ineffective for various reasons perhaps because of inadequate funding, excessive demand, or the intrinsic difficulties of responding to certain groups with special needs. An alternative formulation emphasizes economic factors in the homeless person's lack of a regular place to live. As the supply of decent housing diminishes, more and more people are at risk of becoming homeless. The tighter the housing market, the greater the amount of economic and personal resources one must have to remain secure. When the need for low-income housing exceeds the available supply, the question is: "Who gets left out?" Some seem to imply that home- lessness is largely a random phenomenon for those with the lowest incomes. Others, however, focus on a person's internal and external resources, arguing that when the housing supply is inadequate, those individuals and families with the least capacity to cope because they suffer from various disabilities, have the fewest supports, or are incapable of dealing with some of the rigors or exigencies of lifewill be the ones left out. 22

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DYNAMICS OF HOMELESSNESS 23 Each of these explanations is only partially accurate. Homelessness is a complicated phenomenon, in which the characteristics of local human services systems, public policies, and individuals all play important parts. PATTERNS OF HOMELESSNESS Homelessness does not take on a single form or shape. The ways in which housing markets, employment, income, public benefit programs, and deinstitutionalization interact to produce and perpetuate homelessness are complex and vary with the individual. The demographic factors described in Chapter 1 and the personal factors described in Chapter 3 are also important. For purposes of illustration as well as analysis of social service issues, however, it may be useful to categorize various patterns of homelessness: the temporarily, episodically, and chronically homeless. Temporary homelessness arises when people are displaced from their usual dwellings by natural or man-made calamities, such as fires. A family displaced by a fire or eviction subsisting on a marginal income from part- time employment may be rehoused relatively quickly if local employment and housing conditions are favorable. A regularly employed individual living in a single room occupancy (SRO) hotel or rental apartment who is laid off may rapidly run out of rent money and become temporarily homeless. Once a person becomes even temporarily homeless, reintegra- tion into the community is difficult and may become compounded by secondary factors (e.g., loss of tools, cars, or other prerequisites to finding employment; family breakup; reactive depression; or substance abuse). Episodically homeless people are those who frequently go in and out of homelessness. A recipient of monthly disability payments or other cash assistance who pays for housing on a weekly basis may be out of funds 2 or 3 weeks into the month. Another example is the chronically mentally ill young adult who lives with family members, but whose situation episodically becomes intolerable and who ends up on the street. A similar situation can develop with runaway and throwaway youths; several studies (Shaffer and Caton, 1984; Greater Boston Adolescent Emergency Network, 1985; Janus et al., 1987J indicate that adolescent running away is not an event but a process involving numerous running away incidents, often precipitated by physical abuse. Both spousal and child abuse also play a frequent role as a precipitant of homelessness for families (Ryback and Bassuk, 1986; Bassuk et al., 1986; Bassuk and Rubin, 19871. Individuals or families, with the latter usually composed of mothers and young children, may double up serially with several relatives or friends but experience episodes of homelessness in between;

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24 HOMELESSNESS, HEALTH, AND HUMAN NEEDS they are among the "hidden homeless" during periods when they are temporarily domiciled in other households. In a Los Angeles study, 15 percent of homeless people interviewed had spent more than a year on the streets without any intervening periods of residential stability (Farr et al., 19861. One-quarter of those interviewed in a Chicago survey had beer homeless for 2 years or more (Ross) et al., 19861. These people might be described as chronically homeless. They are more likely to suffer from mental illness or substance abuse than are those who are temporarily or episodically homeless (Arce et al., 19834. However, only rarely do even chronically homeless people remain homeless indefinitely (see Table 2-11; their state of homelessness typically is interrupted by brief domiciliary arrangements, including institut~onal- ization. Any attempt to estimate the relative proportions of these three patterns of homelessness is complicated by the fact that homelessness itself is a dynamic phenomenon. Many people live perilously at the socioeconomic TABLE 2-1 Chronically Homeless Individuals (current length of homelessness) City or State (Source) Period of Homelessness (years) Chronically Homeless as Percentage of Homeless Population Total Los Angeles (Farr et al., 1986) St. Louis (Morse et al., 1985) Ohio (Roth et al., 1985) Los Angeles (Robertson et al., 1985) Phoenix (Brown et al., 1983) Milwaukee (Rosnow et al., 1985) Chicago (Stevens et al., 1983) Portland (Multnomah County, Oregon, 1985)a New York City (Hoffman et al., 1982~6 31 32 15 16 21.8 22 27 28 28 41 57 aWomen only. bMen only.

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DYNAMICS OF HOMELESSNESS 25 margin and are at high risk of becoming homeless. A clear and rigid boundary does not exist between those who can fend for themselves and those who cannot; there is a large gray area occupied by millions who are only barely surviving. In the absence of interventions that help to reintegrate people into the community, the proportion of chronically homeless people can be expected to increase over time. On the other hand, intervention strategies that effectively reduce first-time homeless- ness would reduce the prevalence of chronic homelessness. Three factors contributing substantially to the recent increase in the numbers of homeless people are the low-income housing shortage, changing economic trends and inadequate income supports, and the deinstitutionalization of mentally ill patients. HOUSING There appears to be a direct relationship between the reduced availa- bility of low-cost housing and the increased number of homeless people. Since 198Q, the aggregate supply of low-income housing has declined by approximately 2.5 million units. Loss of low-incGme dwellings can be attributed primarily to the extremely slow rate of replacement of housing resources lost to the normal processes of decay and renewal. Each year, it is estimated that approximately half a million housing units are lost permanently through conversion, abandonment, fire, or demolition; the production of new housing has not kept pace (Hartman, 19861. From the end of the Great Depression until 1980, the federal government was the primary source of direct subsidies for the construction and maintenance of low-income housing. Since 1980, federal support for subsidized housing has been reduced by 60 percent, and most of the remaining funds reflect subsidy commitments undertaken before 1980. Federal support for development of new low-income housing has essen- tially disappeared (U. S. Congress, House, Committee on Ways and Means, 19871. Concurrently, there has been a failure to replace SRO housing lost to conversion, gentrification, and urban renewal. In many cities, SRO housing has been the primary source of housing for the elderly poor, for seasonally employed single workers, and for chronically disabled people (Hope and Young, 1984, 1986; Hopper and Hamberg, 19841. Since 1970, 1 million SRO unitshalf the national total have been lost to conversion or demolition (Mapes, 19854. For example, in New York City, from January 1975 to April 1981, the number of SRO units and low-cost hotel rooms fell from 50,454 to 18,853; the SRO unit vacancy rate dropped from 26 percent to less than 1 percent (Mair, 19864. In Chicago during the relatively short period from 1980 to 1983, SRO unit capacity declined by almost one-fourth (Ross) et al., 1986~.

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26 HOMELESSNESS, HEALTH, AND HUMAN NEEDS With less low-income housing to go around, the relative price of the remaining units has risen dramatically and with it the percentage of people who must pay a disproportionate share of their income for housing costs. Thirty percent of one's income is generally viewed by economists as the maximum one should pay for housing. But, according to the U. S. General Accounting Office (1985), the proportion of low-income renters paying 70 percent or more of their income for housing has risen from 21 percent in 1975 to 30 percent in 1983. The 1983 Housing Census reported that 7 million households lived in "overcrowded" conditions (more than one person per room); 700,000 lived in conditions described as "extremely overcrowded" (1.5 people per room). Almost 10 percent of all households with annual incomes of between $3,000 and $7,000 lived in overcrowded units (Dolbeare, 1983; Hartman, 19864. Overcrowded housing is directly related to the phenomenon of home- lessness. In a typical situation, two or more families are doubled up in a housing unit that should only accommodate one family. For example, the New York City Housing Authority, relying primarily on readings of water usage, estimated in 1983 that some 17,000 families were illegally doubled up in its 150,000 units and described the problem as growing geometrically (Rule, 19831. The stresses produced by that arrangement, including tensions in relationships among the various people who are living together, often lead to displacement of individuals, families, or both. These people may double up again, turn to the shelters, or find themselves on the streets. The nature of the housing market varies dramatically from one com- munity to another. For example, in the committee's site visits, the shortage of low-income housing for families was repeatedly cited as the single greatest cause of family homelessness in most cities, but service providers in Milwaukee reported an adequate supply of housing for families receiving Aid to Families with Dependent Children (AFDC). In Chicago, the loss of SRO units was perceived as being much more important, although concern was also expressed for the quality of family housing. The committee concluded that despite the regional variation, the lack of decent, affordable housing is a major reason why so many people are homeless in the United States. INCOME AND EMPLOYMENT Broad-based economic trends have also contributed to the growing numbers of homeless people. In the two decades between 1966 and 1985, the number of people in poverty in the United States rose from a low of 23 million in 1973 to a high of 34 million in 1984, declining slightly to 33 million in 1985, the last year for which figures have been published.

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DYNAMICS OF HOMELESSNESS 27 Concurrently, the composition of the poor population is changing: The proportion of the poor who are aged is declining, but nonaged adults and individuals living in female-headed families are both increasing (U.S. Congress, House, Committee on Ways and Means, 1987~. At the same time, there have been major shifts in the labor market. Total unemployment peaked at 10.7 percent in 1982 (Sebastian, 1985), but a decreasing demand for casual and low-skilled labor has kept the unemployment rate at or near 6-7 percent. Unemployment among minority men has remained at historically high levels (U.S. Bureau of the Census, 1986), and although the gap in wages between men and women has lessened, it still remains. This latter factor has specifically affected families headed by women. In addition, the national minimum wage has not been raised since 1981, even in the face of inflation. These factors have contributed to the recent emergence of a large group of working homeless. While the number of poor and unemployed people has increased, the availability and the real value of publicly financed benefits has declined. Because of the changes in the character of unemployment, fewer of the unemployed actually receive unemployment compensation benefits. Cur- rent estimates are that only one-third of the unemployed are eligible for such benefits. Welfare programs, such as AFDC and state-operated general assistance programs for single adults and two-parent families, have not kept pace with inflation. In terms of eligibility and enrollment, they have not kept up with the increased needs. Nationwide, between 1970 and 1985, median AFDC benefits declined by about one-third in real dollars; in only 3 of the 50 states do such benefits exceed the poverty level (U.S. Congress, House, Committee on Ways and Means, 19871. Similarly, for adult individuals during the 1970s, the real value of general assistance benefits, in states that provided them, fell by 32 percent (Hopper and Hamberg, 19844. In Massachusetts, general relief benefits for an adult individual are now $268.90 per month (Flynn, 19861; in Illinois, they are $144 per month. Those amounts, which are intended to cover all living costs, will not pay for even the most minimally adequate SRO housing in Boston or Chicago. Although these benefits are inadequate many homeless ne.onle. rho not even receive them: For example, only hall of the homeless in Chicago (Ross) et al., 1986) and only one-third in Boston (Flynn, 1986) receive them. Eligibility procedures in many jurisdictions are designed to dis- courage applications; but even when they are not, documentation re- quirements and waiting periods prevent or discourage people from applying. The simple requirement of a fixed address has kept many homeless people from applying or being approved for benefits to which they are entitled. State and local initiatives and, more recently, federal

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28 HOMELESSNESS HEALTH, AND HUMAN NEEDS legislation in 1986 and 1987 should reduce that problem; but there is as yet no evidence of substantially increased participation rates by homeless people in public assistance programs. A particularly controversial cash assistance program in relation to homelessness has been the Supplemental Security Income (SSI) program for the disabled and low-income aged adults. SSI had been a major source of income for the mentally disabled and psychiatrically impaired. Between 1981 and 1984, however, because of legislation that was passed in 1980 in order to clarify eligibility on the basis of disability, approximately 200,000 people were dropped from the SSI program. Many of these people were psychiatrically impaired. Approximately 75 percent of those people were subsequently restored to the program, and the relevant federal legislation has beenichanged again. However, even the current procedures for obtaining and maintaining SSI eligibility based upon psychiatric disability result in many potentially eligible people going without coverage (Bassuk, 1984; Hope and Young, 1984, 1986~. Some people become or remain homeless while they are enmeshed in the bureaucratic difficulties of obtaining and maintaining eligibility for various kinds of public assistance. In addition to the documentation and residency problems mentioned above, concern with budgetary control and the minimization of fraud and abuse in benefit programs has led to more frequent recertification requirements, greater demands for contin- uing documentation, and a greater willingness on the part of agencies to close cases for administrative reasons. Although benefits are usually restored, homelessness often occurs during the period when benefits are suspended (Dehavenon, 1985~. DEINSTITUTIONALIZATION Mental Health System For the most vulnerable among the adult individual homeless or potentially homeless, the barriers to receipt of cash assistance interact with another set of public policy pressures: deinstitutionalization. In the mental health system, this policy has resulted from three factors: (1) discovery and utilization of psychotropic drugs, (2) concern with the civil liberties of individuals confined in state psychiatric institutions, and (3) greater awareness of the dehumanizing aspects of institutional environ- ments. As a policy, it has been supported and encouraged by federal and local governments, and has led to the reduction of populations in publi mental hospitals from a high of 559,000 in 1955 to a low of 130,000 in 1980. It has also been blamed for the large numbers of mentally ill people on the streets of major cities in the 1980s.

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DYNAMICS OF HOMELESSNESS 29 To what extent are the actions of the reforms of the mid-1960s actually responsible for the plight of homeless mentally ill people today? The American Psychiatric Association addressed this issue in a special task force report (Lamb, 19841: "Problems such as homelessness are not the result of deinstitutionalization per se but rather of the way deinstitution- alization has been implemented." The term deinstitutionalization refers to two interactive and parallel processes. The first involves the transfer of care for individual patients from an institutional setting to the com- munity; the second involves the development of systems within the community that can provide the necessary array of services most important, housing and treatment, care, protection, and rehabilitation of seriously mentally ill people (U.S. Department of Health and Human Services, 1981~. As part of the movement to develop supportive service systems within the community and to avoid the ill effects of institutionalization, a philosophy evolved to reduce dramatically the number of inpatient days and, whenever possible, to avoid hospitalization altogether. As a result, a new group of chronically mentally ill adults has matured who, as a result of increasingly restrictive admission policies, have never been inside a psychiatric hospital. Additionally, for those adults who wish to admit themselves voluntarily into public psychiatric hospitals or psychi- atric units of acute-care hospitals, the resources are often unavailable. Finally, for those patients with mental illnesses severe enough to warrant involuntary commitment or for those who are voluntarily admitted, the rehabilitative value of extremely short hospital stays has been questioned. Despite all these problems, however, most patients can be maintained in the community if an adequate range of less restrictive alternatives is available. Deinstitutionalization and noninstitutionalization have become increas- ingly difficult to implement successfully because they depend heavily on the availability of housing and supportive community services. In reality, few communities have established adequate networks of services for the Reinstitutionalized mentally ill. Various specialized community facilities may be necessary to treat some individuals. This includes, for example, the "young adult chronic" patient, whose mental pathology, combined with a reluctance to acknowledge the illnesses and an aversion to a regular medication schedule, present serious obstacles to effective treat- ment (Pepper and Ryglewicz, 19841. There is general agreement that deinstitutionalization has contributed to the homelessness situation in the 1980s (Lamb, 1984~. The committee learned of many individual instances in which patients had been discharged from hospitals with inadequate or nonexistent plans for community care. Other cases were encountered in which there were no community mental

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30 HOMELESSNESS, HEALTH, AND HUMAN NEEDS health agencies to provide housing and necessary support or assistance to mentally disabled individuals. Service providers across the country expressed dissatisfaction with the extent of community-based mental health services. A critical point in the treatment of a person with a severe mental illness occurs at the time of discharge from a hospital. Extremely careful planning and coordination are necessary to ensure a smooth transition to outpatient care and community living; it is essential that there is an appropriate residence to receive the person. Some people have become homeless either because discharge planning has been inadequate or because plans that seemed adequate at the time of discharge broke down weeks or months later. In some cases patients have been discharged directly to the streets with no particular destination. In the past, large numbers of patients were discharged to SRO hotels or cheap apartments. A discharge plan of this sort seemed to afford a minimally adequate level of community- based housing, and in these situations many patients were able to manage some sort of tenuous adjustment. When the demand for housing in cities led to the destruction or redevelopment of low-cost accommodations, the mentally ill were least able to find alternatives and were at a particularly high risk of homelessness. Once a person ceases to have a fixed address, the community mental health service system is least effective in providing treatment, mainte- nance, and rehabilitation services. Thus, mentally ill people who have been discharged to the streets or who have been displaced from a housing situation are less likely to continue to receive the necessary array of services. As described more fully in Chapter 3, studies of homeless adult individuals in cities such as Los Angeles, New York, St. Louis, Phila- delphia, and Boston report that approximately one-third of the homeless people interviewed suffer from a major mental illness (e.g., schizophrenia or severe depression). Such findings do not indicate that all these people would have been considered appropriate for long-term hospitalization, even before the era of deinstitutionalization. However, psychiatric eval- uations of a selected group of homeless people in Philadelphia suggested that a substantial proportion of those interviewed would meet current criteria for involuntary hospitalization (Arce et al., 19831. Appropriate housing arrangements are essential for the successful maintenance in the community of a person with a disabling mental disorder. The prevailing professional view appears to be that a service system must include a range of relatively small residential facilities graduated according to the severity of the patients' problems and the extent of care and supervision needed, up to and including 24-hour-per- day support. In every community visited by the committee, this need

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DYNAMICS OF HOMELESSNESS 31 was felt, and service providers reported that there was a greater demand than could be met by existing facilities. For example, the state of Maryland, in its Five- Year Plan for Deinstitutionalization (Maryland Department of Health and Mental Hygiene, 1984), published a conservative estimate of a statewide need for 3,000 beds in community-based facilities and for 6,500 beds if projections were based on data from other states; current bed capacity in community-based residences in Maryland is approximately 1,000. In neighboring Washington, D.C., as a result of the recent transfer of control of St. Elizabeth's Psychiatric Hospital from the federal government to the municipal government, the District government will need 47 additional group homes over the ensuing 4 years for a total of 1,750 beds. Additionally, the District must establish and accommodate the court-ordered closing of an institution for the mentally retarded (133 homes), the court-ordered closing of a juvenile facility (10 homes), and the reduction of crowding at a correctional facility (214 new beds) (Washington Post, September 25, 19874. Other Systems Deinstitutionalization is not a policy limited to the mental health system. The general policy has come to be applied to many institutional settings. Many homeless individuals, particularly single young men, have histories of encounters with the criminal justice system. Many returned to the community without adequate housing or realistic hopes for reasonable incomes. More disheartening are the cases of adolescents and postadolescents who grow out of foster care or child mental health and mental retardation facilities because they are no longer eligible for residentially based services for their age group, yet they have nowhere to live. Some homeless people have been discharged directly from general acute-care hospitals to inadequate living arrangements after they leave the hospital. The most dramatic of such cases encountered by the committee involved people with AIDS (acquired immune deficiency syndrome) who, as a result of their illness, lost both housing and employment. In the only published report about homeless people with AIDS,* the Institute of Public Services Performance, Inc. (IPSP, 1986) reported that among the 377 people with AIDS in metropolitan New York area hospitals, 77 (including 7 pediatric cases) were homeless at the time of the study (June 19851. People with AIDS who were in the hospital and interviewed by IPSP indicated that they were currently living on the * A study of the problem in New York City done by the Institute of Public Services Performance, on contract with the New York State Department of Health.

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32 HOMELESSNESS, HEALTH, AND HUMAN NEEDS streets or in a shelter, and 19 percent listed the hospital as their current housing situation. Overall, 57 percent reported that they needed assistance locating permanent housing (IPSP, 19864. The issues raised in the original movement toward deinstitutionalization of the mentally disabled for example, the need to transfer treatment from the institutional setting to the community, the need to have in place community-based treatment centers, the need to provide assistance (both financial and professional) to those in the community when necessary to prevent inpatient admission or readmissionare the same as those in the current proposals that we Reinstitutionalize our correctional, youth services, and hospital systems. The critical element, the one without which any such efforts would appear to be preordained to failure, is that there must also be a place in the community for each person to live. Clearly, the size of the current system of shelters and welfare hotels indicates that such is not the case. SHELTERING THE HOMELESS Of those who become homeless, many turn to the nation's growing number of emergency shelter facilities. It appears that the demand for emergency shelter often exceeds the supply; of the 25 cities responding to the 1986 survey by the U.S. Conference of Mayors, 7 reported that people are routinely turned away from existing facilities (U.S. Conference of Mayors, 1986~. Advocates for the homeless have asserted that some homeless people were also turned away in many of the remaining 18 cities as well. Shelters Shelter facilities are extremely variable, ranging from 1,000-bed con- verted armories to church basements with a handful of beds. Many are traditional missions operated by religious groups in or near the downtown areas of large cities; others are recently converted public facilities. Whatever the stated formal capacity, most shelters are occupied at or in excess of capacity during peak nights, especially during cold weather. Although generalizations about shelters must be made with care, most facilities currently operating as shelters for the homeless were not designed or constructed for that purpose and are barely adequate for their current use. Rows of closely spaced cots or bunk beds in a large open room are common; this arrangement permits neither privacy nor any means of securing personal belongings. Being homeless means no regular place to sleep, no security for personal property, and often no assurance of personal safety. In the larger shelters, guests must often be protected

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DYNAMICS OF HOMELESSNESS 33 from physical assault. In many shelters, sanitary facilities are minimal. In a few states, minimal health and safety standards for shelters are mandated by state regulations (as in New York) or are a condition for receiving public subsidy (as in Massachusetts); in some communities, they have been established by court order (New York City). However, even in those communities, the relentless pressure of increasing demand makes compliance with even minimal standards difficult. Many shelters were established to provide shelter and sometimes food for only a few days. This was based on the assumption that homelessness resulted from an acute crisis that would be resolved in a short time. Shelters were not originally intended to be broad-based human service systems and are poorly designed to serve that purpose. Most shelters operate only at night; the most common practice is to require overnight guests to leave by 6 or 7 o'clock in the morning. In theory, such practices deter malingering and return people to the com- munity at a sufficiently early hour to seek daytime employment. However, such a practice also makes it difficult to provide services and exposes unemployed people to various hazards during the day. Hence, many communities have developed "drop in" or day centers where homeless people can safely spend daytime hours and where services for the homeless can be concentrated. Many shelters also limit the number of consecutive nights an individual can remain, reflecting again an ideology of providing temporary assistance but discouraging permanent reliance on such sup- port. For chronically homeless people, however, such policies not only limit their ability to develop relatively more stable patterns of activities of daily living (e.g., developing a personal grooming routine, maintaining the cleanliness of their clothes) but also impede their ability to find employment as a way out of homelessness (homeless people cannot inform a prospective employer where they can be contacted if they do not know where they are going to be). Some shelters provide a single meal, but for most homeless individuals food is obtained from soup kitchens and other organized food programs. During the last decade, an enormous network of such programs has sprung up across the United States; as with many shelters, most are organized and staffed primarily or exclusively by volunteers. These programs rely on some mix of donations, government surplus commod- ities, and purchased goods. The quality of the meals is extremely uneven, and many sites provide only certain meals, or operate only on specific days of the week or at certain times during the year. In most parts of the United States, shelter systems are organized exclusively to serve adult individuals; most are segregated by sex and are not appropriate places for children. Therefore, because many com- munities lack an adequate supply of emergency housing specifically for

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34 HOMELESSNESS, HEALTH, AND HUMAN NEEDS families, homeless families frequently must break up in order to obtain shelter. As a result, it is not uncommon for families to place their children in the custody of child welfare authorities. Many other parents avoid shelters and any contact with public agencies for fear that custody of their children will be placed in jeopardy by the parents' temporary inability to provide housing. Welfare Hotels and Motels Federal legislation has provided a program of emergency assistance (EA) to families receiving AFDC who are temporarily displaced from their usual living arrangements. EA has become the primary mechanism for financing family shelters in many communities, largely through payments for hotel and motel rooms or similar accommodations. States have had considerable flexibility in their use of EA funds, but EA can only be used for relatively short-term crises and not for permanent housing. Only 28 states have even elected to have EA programs (U.S. Congress, House, Committee on Ways and Means, 19871. In cities where the housing market for people with low incomes is not hopelessly tight, EA may effectively bridge the transition into permanent living arrangements. However, New York City's welfare hotels and similar facilities in other parts of the country exemplify the limitations of EA. Such hotels and motels were not designed to accommodate large families, nor were they designed to house families with children for extended periods. Most lack facilities for food storage and preparation. Providing nutritional meals to young children without refrigerators, stoves, or cooking utensils is almost impossible, and bottle-feeding young infants is very difficult. In addition to being inappropriate places to rear children, such forms of temporary housing are extremely costly. For example, in 1986, the Commonwealth of Massachusetts paid between $1,350 and $1,600 per month per family for this type of accommodation; the annual average was calculated at $16,000 per family (Gallagher, 19861. This amount would secure a spacious apartment in some of the better neighborhoods in many American cities. In addition to shelters and welfare hotels, other forms of shelter have been created. In many cities, churches have opened their doors to homeless people. Many homeless people prefer accommodations in churches over those in large public facilities. Some who refuse (or are turned away from) shelters use cars, tents, or cardboard boxes as temporary shelters. Homeless people have also described constructing rudimentary forms of shelter in public parks, from Fenway Park in Boston

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DYNAMICS OF HOMELESSNESS 35 to Balboa Park in San Diego. What is common to each of these forms of housing is that none are appropriate as short- or long-term housing. Extent of the Shelter System Various conclusions about basic services for the homeless can be drawn. First, in most cities there is no system. Some cities have established coordinating mechanisms to mobilize emergency efforts during periods of cold or otherwise dangerous weather. In fact, the emergency shelter system was founded on the assumption that the clients, needs and the services they required would be transient and intermittent. Indeed, like the growth of the homeless population itself, mechanisms for providing services to the homeless have mushroomed, but they still lag behind the constantly increasing demand. Effective planning has been the exception, and even communication among service providers frequently occurs only at the most rudimentary level (Wright and Weber, 19871. The magnitude and nature of the problem of homelessness are unprec- edented within the memory of most adults, so there are few past experiences that could guide planning efforts by public officials and community agencies. Adequate services must be provided, but without permanently institutionalizing homeless families and individuals through another human service system that inherently provides second-class services. Shelters are inappropriate substitutes for long-term housing, and attempts to respond to immediate needs can deflect energy and resources from longer term initiatives. Moreover, there are inherent dilemmas in the siting of facilities. There is a growing pressure from the business community to reduce the concentration of homeless people in central downtown areas. However, residents of neighborhoods that might be more appropriately residential tend to mobilize quickly and aggressively in opposition to the establishment of facilities for the homeless in their midst. Dispersion far from downtown areas may further isolate the homeless from such basic needs as, for example, transportation and access to health and social services. Another conclusion that can be made about existing services for the homeless is that a large proportion of those services rely on the efforts of volunteers. The selfless energy of volunteers and the magnitude and spontaneity of their endeavors throughout the nation have been central to the effective functioning of the shelter network. However, there are some drawbacks to the reliance on volunteer staffs. The continuity and reliability of services sometimes suffer. Many volunteers are associated with religious organizations whose values may conflict with some of the service needs of the homeless. Moreover, the presence of volunteer

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36 HOMELESSNESS, HEALTH, AND HUMAN NEEDS services, even if clearly inadequate in meeting the prevailing needs, may provide public officials with an excuse to avoid their responsibilities and obligations. One final point must be made about the existing shelter situation. At no point was it determined as a matter of policy that shelters were to be a substitute for other human service systems, such as those for mental health, education, foster care, and skilled nursing care. However, that is what seems to be happening in many parts of the country. As reported in the Greater Boston Adolescent Emergency Network study of Massa- chusetts shelters for adolescents, these facilities are not used for emer- gency shelter as much as they are used to address other problems or to fill service gaps. The committee concluded that the shelter system cannot substitute for other systems, nor can it be expected to address problems for which at least theoretically~ther systems have already been established. SUMMARY As has been seen in this chapter, the causes of homelessness are many and interrelated: the decline In the number of units of affordable housing, the increases in the number (albeit a declining percentages of people among the U.S. population who are unemployed, changes in the economy that have reduced employment possibilities for unskilled labor, a tightening of eligibility standards and a reduction in benefit levels for entitlement programs, the change in focus of the mental health system, and a change in emphasis from inpatient to outpatient treatment of both acute and chronic physical illnesses. The shelter "system," was never intended to address either the large numbers of homeless people or the complexities of homelessness in the 1980s. Various short-term emergency shelter approaches, including welfare hotels and motels for families, are inade- quate as responses to the long-term changes that have caused this problem to grow so dramatically. As will be seen in Chapter 3, the state of being that is called homelessness is intricately entwined with the aspect of the individual's well-being that is called health. Solutions proposed to remedy one cannot ignore the other. REFERENCES Arce, A. A., M. Tadlock, and M. J. Vergare. 1983 A psychiatric profile of street people admitted to an emergency shelter. Hospital and Community Psychiatry 34(9):812-817. Bassuk, E. L. 1984. The Homelessness Problem. Scientific American251(1):40-44. Bassuk, E. L., and L. Rubin. 1987. Homeless children: A neglected population. American Journal of Orthopsychiatry 5(2):1-9. Bassuk, E. L., L. Rubin, and A. Lauriat. 1984. Is homelessness a mental health problem? American Journal of Psychiatry 141 ( 12): 1546-1550.

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DYNAMICS OF HOMELESSNESS 37 Bassuk, E. L., L. Rubin, and A. Lauriat. 1986. Characteristics of sheltered homeless families. American Journal of Public Health 76(September): 1097-1101. Brown, C. E., S. MacFarlane, R. Paredes, and L. Stark. 1983. The Homeless of Phoenix: Who Are They and What Should Be Done? Phoenix, Ariz.: Phoenix South Community Mental Health Center. Dehavenon, A. L. 1985. The tyranny of indifference and the reinstitutionalization of hunger, homelessness, and poor health: A study of the causes and conditions of the food emergency in 1,506 households with children in East Harlem, Brooklyn, and the Bronx in 1984. Paper prepared for the East Harlem Interfaith Welfare Committee. New York: East Harlem Interfaith Welfare Committee. Dolbeare, C. 1983. The low income housing crisis. In America's Housing Crisis: What Is To Be Done?, C. Hartman, ed. Boston: Routledge and Kegan. Farr, R. K., P. Koegel, and A. Burnam. 1986. A Study of Homelessness and Mental Illness in the Skid Row Area of Los Angeles. Los Angeles: Los Angeles County Department of Mental Health. Flynn, R. L. 1986. Making Room: Comprehensive Policy for the Homeless. Boston: City of Boston. Gallagher, E. 1986. No Place Like Home: A Report on the Tragedy of Homeless Children and Their Families in Massachusetts. Boston: Massachusetts Committee for Children and Youth, Inc. Greater Boston Adolescent Emergency Network. 1985. Ride a Painted Pony on a Spinning Wheel Ride. Boston: Massachusetts Committee for Children and Youth, Inc. Hartman, C. 1986. The housing part of the homeless problem. Pp. 71-85 in The Mental Health Needs of Homeless Persons, E. Bassuk, ed. San Francisco: Jossey-Bass. Hoffman, S. F., D. Wenger, J. Nigro, and R. Rosenfeld. 1982. Who Are the Homeless? A Study of Randomly Selected Men Who Use the New York City Shelters. Albany: New York State Office of Mental Health. Hope, M., and J. Young. 1984. From back wards to back alleys: Deinstitutionalization and the homeless. Urban and Social Change Review 17(Summer):7-11. Hope, M., and J. Young. 1986. The politics of displacement: Sinking into homelessness. Pp. 106-112 in Housing the Homeless, J. Erickson and C. Wilhelm, eds. New Brunswick, N.J.: Center for Urban Policy Research, Rutgers, The State University of New Jersey. Hopper, K., and J. Hamberg. 1984. The Making of America's Homeless: From Skid Row to New Poor, 1945-1984. Working Papers in Social Policy. New York: Community Service Society of New York. Institute of Public Services Performance. 1986. AIDS Shelter Project: Final Report. New York: Institute of Public Services Performance. Janus, M.-D., A. McCormack, A. W. Burgess, and C. Hartman. 1987. Adolescent Runaways: Causes and Consequences. Lexington, Mass.: D. C. Heath, Lexington Books. Lamb, H. R., ed. 1984. The Homeless Mentally Ill. Washington, D.C.: American Psychiatric Association. Mair, A. 1986. The homeless and the post-industrial city. Political Geography Quarterly 5(October):351-368. Mapes, L. V. 1985. Faulty food and shelter programs draw charge that nobody's home to homeless. National Journal 9(March):474-476. Maryland Department of Health and Mental Hygiene. 1984. Five Year Plan for Deinstitu- tionalization. Baltimore: Department of Health and Mental Hygiene. Morse, G. A., N. M. Shields, C. R. Hanneke, R. J. Calsyn, G. K. Burger, and B. Nelson. 1985. Homeless People in St. Louis: A Mental Health Program Evaluation, Field Study and Followup Investigation. Jefferson City, Mo.: State Department of Mental Health.

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38 HOMELESSNESS, HEALTH, AND HUMAN NEEDS Multnomah County, Oregon, Department of Human Services. 1985. Homeless Women. Multnomah County, Oreg.: Social Services Division, Department of Human Services. Pepper, B., and H. Ryglewicz. 1984. Advances in Treating the Young Chronic Patient. San Francisco: Jossey-Bass. Robertson, M. J., R. H. Ropers, and R. Boyer. 1985. The Homeless of Los Angeles County: An Empirical Evaluation. Basic Shelter Research Project, Document no. 4. Los Angeles: Psychiatric Epidemiology Program, School of Public Health, University of California, Los Angeles. Rosnow, M. J., T. Shaw, and C. S. Concord. 1985. Listening to the Homeless: A Study of Homeless Mentally Ill Persons in Milwaukee. Prepared by Human Services Triangle, Inc. Madison: Wisconsin Office of Mental Health. Rossi, P. H., G. A. Fisher, and G. Willis. 1986. The Condition of the Homeless in Chicago. A report prepared by the Social and Demographic Research Institute, University of Massachusetts at Amherst, and the National Opinion Research Center, University of Chicago. Roth, D., G. J. Bean, Jr., N. Lust, and T. Saveanu. 1985. Homelessness in Ohio: A Study of People in Need. Columbus: Office of Program Evaluation and Research, Ohio Department of Mental Health. Rule, S. 1983. 17,000 Families in public housing double up illegally, city believes. New York Times, April 21, Al. Ryback, R., and E. L. Bassuk. 1986. Homeless Battered Women and Their Shelter Network. Pp. 55-70 in The Mental Health Needs of Homeless Persons, E. L. Bassuk, ed. San Francisco: Jossey-Bass. Sebastian, J. G. 1985. Homelessness: A state of vulnerability. Family and Community Health 8(November): 11-24. Shaffer, D., and C. L. M. Caton. 1984. Runaway and Homeless Youth in New York City: A Report to the Ittleson Foundation. New York: The Ittleson Foundation. Stevens, A. O., L. Brown, P. Colson, and K. Singer. 1983. When You Don't Have Anything: A Street Survey of Homeless People in Chicago. Chicago: Chicago Coalition for the Homeless. U.S. Bureau of the Census. 1986. Statistical Abstracts of the United States: 1987. Washington, D.C.: U.S. Government Printing Office. U.S. Conference of Mayors. 1986. The Continued Growth of Hunger, Homelessness and Poverty in America's Cities: 1986. A 25-City Survey. Washington, D.C.: U.S. Conference of Mayors. U.S. Congress, House, Committee on Ways and Means. 1987. Background material and data on programs within the jurisdiction of the Committee on Ways and Means. 100th Cong., 1st sees., March 6, 1987. U.S. Department of Health and Human Services. 1981. Towards a National Plan for the Chronically Mentally Ill. Committee on the Mentally Ill. DHHS Publication No. (ADM) 81-1077. Washington, D.C.: U.S. Department of Health and Human Services. U.S. General Accounting Office. 1985. Homelessness: A Complex Problem and the Federal Response. Washington, D.C.: U.S. General Accounting Office. Washington Post. September 25, 1987. City seeks affluent areas for group homes. Al. Wright, J. D., and E. Weber. 1987. Homelessness and Health. New York: McGraw-Hill.