case study homeless person

Featured Topics

Featured series.

A series of random questions answered by Harvard experts.

Explore the Gazette

Read the latest.

Footnote leads to exploration of start of for-profit prisons in N.Y.

Moderator David E. Sanger (from left) with Ivo Daalder, Karen Donfried, and Stephen Hadley.

Should NATO step up role in Russia-Ukraine war?

It’s on Facebook, and it’s complicated

Why it’s so hard to end homelessness in america.

Front-end loaders take down tents and debris.

City of Boston workers clear encampments in the area known as Mass and Cass.

Craig F. Walker/The Boston Globe via Getty Images

Alvin Powell

Harvard Staff Writer

Experts cite complexity of problem, which is rooted in poverty, lack of affordable housing but includes medical, psychiatric, substance-use issues

It took seven years for Abigail Judge to see what success looked like for one Boston homeless woman.

The woman had been sex trafficked since she was young, was a drug user, and had been abused, neglected, or exploited in just about every relationship she’d had. If Judge was going to help her, trust had to come first. Everything else — recovery, healing, employment, rejoining society’s mainstream — might be impossible without it. That meant patience despite the daily urgency of the woman’s situation.

“It’s nonlinear. She gets better, stops, gets re-engaged with the trafficker and pulled back into the lifestyle. She does time because she was literally holding the bag of fentanyl for these guys,” said Judge, a psychology instructor at Harvard Medical School whose outreach program, Boston Human Exploitation and Sex Trafficking (HEAT), is supported by Massachusetts General Hospital and the Boston Police Department. “This is someone who’d been initially trafficked as a kid and when I met her was 23 or 24. She turned 30 last year, and now she’s housed, she’s abstinent, she’s on suboxone. And she’s super involved in her community.”

It’s a success story, but one that illustrates some of the difficulties of finding solutions to the nation’s homeless problem. And it’s not a small problem. A December 2023 report by the U.S. Department of Housing and Urban Development said 653,104 Americans experienced homelessness, tallied on a single night in January last year. That figure was the highest since HUD began reporting on the issue to Congress in 2007 .

Abigail Judge of the Medical School (from left) and Sandra Andrade of Massachusetts General Hospital run the outreach program Boston HEAT (Human Exploitation and Sex Trafficking).

Niles Singer/Harvard Staff Photographer

Scholars, healthcare workers, and homeless advocates agree that two major contributing factors are poverty and a lack of affordable housing, both stubbornly intractable societal challenges. But they add that hard-to-treat psychiatric issues and substance-use disorders also often underlie chronic homelessness. All of which explains why those who work with the unhoused refer to what they do as “the long game,” “the long walk,” or “the five-year-plan” as they seek to address the traumas underlying life on the street.

“As a society, we’re looking for a quick fix, but there’s no quick fix for this,” said Stephen Wood, a visiting fellow at Harvard Law School’s Petrie-Flom Center for Health Law Policy, Biotechnology and Bioethics and a nurse practitioner in the emergency room at Carney Hospital in the Dorchester neighborhood of Boston. “It takes a lot of time to fix this. There will be relapses; there’ll be problems. It requires an interdisciplinary effort for success.”

A recent study of 60,000 homeless people in Boston found the average age of death was decades earlier than the nation’s 2017 life expectancy of 78.8 years.

Illustration by Liz Zonarich/Harvard Staff

Katherine Koh, an assistant professor of psychiatry at HMS and psychiatrist at MGH on the street team for Boston Health Care for the Homeless Program, traced the rise of homelessness in recent decades to a combination of factors, including funding cuts for community-based care, affordable housing, and social services in the 1980s as well as deinstitutionalization of mental hospitals.

“Though we have grown anesthetized to seeing people living on the street in the U.S., homelessness is not inevitable,” said Koh, who sees patients where they feel most comfortable — on the street, in church basements, public libraries. “For most of U.S. history, it has not been nearly as visible as it is now. There are a number of countries with more robust social services but similar prevalence of mental illness, for example, where homelessness rates are significantly lower. We do not have to accept current rates of homelessness as the way it has to be.”

“As a society, we’re looking for a quick fix, but there’s no quick fix for this.” Stephen Wood, visiting fellow, Petrie-Flom Center for Health Law Policy, Biotechnology and Bioethics

Success stories exist and illustrate that strong leadership, multidisciplinary collaboration, and adequate resources can significantly reduce the problem. Prevention, meanwhile, in the form of interventions focused on transition periods like military discharge, aging out of foster care, and release from prison, has the potential to vastly reduce the numbers of the newly homeless.

Recognition is also growing — at Harvard and elsewhere — that homelessness is not merely a byproduct of other issues, like drug use or high housing costs, but is itself one of the most difficult problems facing the nation’s cities. Experts say that means interventions have to be multidisciplinary yet focused on the problem; funding for research has to rise; and education of the next generation of leaders on the issue must improve.

“This is an extremely complex problem that is really the physical and most visible embodiment of a lot of the public health challenges that have been happening in this country,” said Carmel Shachar, faculty director of Harvard Law School’s Center for Health Law and Policy Innovation. “The public health infrastructure has always been the poor Cinderella, compared to the healthcare system, in terms of funding. We need increased investment in public health services, in the public health workforce, such that, for people who are unhoused, are unsheltered, who are struggling with substance use, we have a meaningful answer for them.”

Kris Snibbe/Harvard Staff Photographer

Experts say that the nation’s unhoused population not only experiences poverty and exposure to the elements, but also suffers from a lack of basic health care, and so tend to get hit earlier and harder than the general population by various ills — from the flu to opioid dependency to COVID-19.

A recent study of 60,000 homeless people in Boston recorded 7,130 deaths over the 14-year study period. The average age of death was 53.7, decades earlier than the nation’s 2017 life expectancy of 78.8 years. The leading cause of death was drug overdose, which increased 9.35 percent annually, reflecting the track of the nation’s opioid epidemic, though rising more quickly than in the general population.

A closer look at the data shows that impacts vary depending on age, sex, race, and ethnicity. All-cause mortality was highest among white men, age 65 to 79, while suicide was a particular problem among the young. HIV infection and homicide, meanwhile, disproportionately affected Black and Latinx individuals. Together, those results highlight the importance of tailoring interventions to background and circumstances, according to Danielle Fine, instructor in medicine at HMS and MGH and an author of two analyses of the study’s data.

“The takeaway is that the mortality gap between the homeless population and the general population is widening over time,” Fine said. “And this is likely driven in part by a disproportionate number of drug-related overdose deaths in the homeless population compared to the general population.”

Inadequate supplies of housing

Though homelessness has roots in poverty and a lack of affordable housing, it also can be traced to early life issues, Koh said. The journey to the streets often starts in childhood, when neglect and abuse leave their marks, interfering with education, acquisition of work skills, and the ability to maintain healthy relationships.

“A major unaddressed pathway to homelessness, from my vantage point, is childhood trauma. It can ravage people’s lives and minds, until old age,” Koh said. “For example, some of my patients in their 70s still talk about the trauma that their parents inflicted on them. The lack of affordable housing is a key factor, though there are other drivers of homelessness we must also tackle.”

The number was the highest since the U.S. Department of Housing and Urban Development began reporting on the issue to Congress in 2007 .

Most advocates embrace a “housing first” approach, prioritizing it as a first step to obtaining other vital services. But they say the type of housing also matters. Temporary shelters are a key part of the response, but many of the unhoused avoid them because of fears of theft, assault, and sexual assault. Instead, long-term beds, including those designated for people struggling with substance use and mental health issues, are needed.

“You can either be admitted to a hospital with a substance-use disorder, or you can be admitted with a psychiatric disorder, but very, very rarely will you be admitted to what’s called a dual-diagnosis bed,” said Petrie-Flom’s Wood. “The data is pretty solid on this issue: If you have a substance-use disorder there’s likely some underlying, severe trauma. Yet, when we go to treat them, we address one but not the other. You’re never going to find success in the system that we currently have if you don’t recognize that dual diagnosis.”

Services offered to those in housing should avoid what Koh describes as a “one-size-fits-none” approach. Some might need monthly visits from a caseworker to ensure they’re getting the support they need, she said. But others struggle once off the streets. They need weekly — even daily — support from counselors, caseworkers, and other service providers.

“I have seen, sadly, people who get housed and move very quickly back out on the streets or, even more tragically, lose their life from an unwitnessed overdose in housing,” Koh said. “There’s a community that’s formed on the street so if you overdose, somebody can give you Narcan or call 911. If you don’t have the safety of peers around, people can die. We had a patient who literally died just a few days after being housed, from an overdose. We really cannot just house people and expect their problems to be solved. We need to continue to provide the best care we can to help people succeed once in housing.”

“We really cannot just house people and expect their problems to be solved.” Katherine Koh, Mass. General psychiatrist

Koh works on the street team for Boston Health Care for the Homeless Program.

Photo by Dylan Goodman

The nation’s failure to address the causes of homelessness has led to the rise of informal encampments from Portland, Maine, to the large cities of the West Coast. In Boston, an informal settlement of tents and tarps near the intersection of Massachusetts Avenue and Melnea Cass Boulevard was a point of controversy before it was cleared in November.

In the aftermath, more than 100 former “Mass and Cass” residents have been moved into housing, according to media reports. But experts were cautious in their assessment of the city’s plans. They gave positive marks for features such as a guaranteed place to sleep, “low threshold” shelters that don’t require sobriety, and increased outreach to connect people with services. But they also said it’s clear that unintended consequences have arisen. and the city’s homelessness problem is far from solved.

Examples abound. Judge, who leads Boston HEAT in collaboration with Sandra Andrade of MGH, said that a woman she’d been working with for two years, who had been making positive strides despite fragile health, ongoing sexual exploitation, and severe substance use disorder, disappeared after Mass and Cass was cleared.

Mike Jellison, a peer counselor who works on Boston Health Care for the Homeless Program’s street team, said dismantling the encampment dispersed people around the city and set his team scrambling to find and reconnect people who had been receiving medical care with providers. It’s also clear, he said, that Boston Police are taking a hard line to prevent new encampments from popping up in other neighborhoods, quickly clearing tents and other structures.

“We were out there Wednesday morning on our usual route in Charlesgate,” Jellison said in early December. “And there was a really young couple who had all their stuff packed. And [the police] just told them, ‘You’ve got to leave, you can’t stay here.’ She was crying, ‘Where am I going to go?’ This was a couple who works; they’re employed and work out of a tent. It was like 20 degrees out there. It was heartbreaking.”

Prevention as cure?

Successes in reducing homelessness in the U.S. are scarce, but not unknown. The U.S. Department of Veterans Affairs, for example, has reduced veteran homelessness nationally by more than 50 percent since 2010.

Experts point out, however, that the agency has advantages in dealing with the problem. It is a single, nationwide, administrative entity so medical records follow patients when they move, offering continuity of care often absent for those without insurance or dealing with multiple private providers. Another advantage is that the VA’s push, begun during the Obama administration, benefited from both political will on the part of the White House and Congress and received support and resources from other federal agencies.

The city of Houston is another example. In 2011, Houston had the nation’s fifth-largest homeless population. Then-Mayor Annise Parker began a program that coordinated 100 regional nonprofits to provide needed services and boost the construction of low-cost housing in the relatively inexpensive Houston market.

Neither the VA nor Houston was able to eliminate homelessness, however.

To Koh, that highlights the importance of prevention. In 2022, she published research in which she and a team used an artificial-intelligence-driven model to identify those who could benefit from early intervention before they wound up on the streets. The researchers examined a group of U.S. service members and found that self-reported histories of depression, trauma due to a loved one’s murder, and post-traumatic stress disorder were the three strongest predictors of homelessness after discharge.

In April 2023, Koh, with co-author Benjamin Land Gorman, suggested in the Journal of the American Medical Association that using “Critical Time Intervention,” where help is focused on key transitions, such as military discharge or release from prison or the hospital, has the potential to head off homelessness.

“So much of the clinical research and policy focus is on housing those who are already homeless,” Koh said. “But even if we were to house everybody who’s homeless today, there are many more people coming down the line. We need sustainable policies that address these upstream determinants of homelessness, in order to truly solve this problem.”

The education imperative

Despite the obvious presence of people living and sleeping on city sidewalks, the topic of homelessness has been largely absent from the nation’s colleges and universities. Howard Koh, former Massachusetts commissioner of public health and former U.S. assistant secretary for Health and Human Services, is working to change that.

In 2019, Koh, who is also the Harvey V. Fineberg Professor of the Practice of Public Health Leadership, founded the Harvard T.H Chan School of Public Health’s pilot Initiative on Health and Homelessness. The program seeks to educate tomorrow’s leaders about homelessness and support research and interdisciplinary collaboration to create new knowledge on the topic. The Chan School’s course “Homelessness and Health: Lessons from Health Care, Public Health, and Research” is one of just a handful focused on homelessness offered by schools of public health nationwide.

“The topic remains an orphan,” said Koh. The national public health leader (who also happens to be Katherine’s father) traced his interest in the topic to a bitter winter while he was Massachusetts public health commissioner when 13 homeless people froze to death on Boston’s streets. “I’ve been haunted by this issue for several decades as a public health professional. We now want to motivate courageous and compassionate young leaders to step up and address the crisis, educate students, motivate researchers, and better inform policymakers about evidence-based studies. We want every student who walks through Harvard Yard and sees vulnerable people lying in Harvard Square to not accept their suffering as normal.”

Share this article

Everything counts!

New study finds step-count and time are equally valid in reducing health risks

Five alumni elected to the Board of Overseers

Six others join Alumni Association board

Glimpse of next-generation internet

Physicists demo first metro-area quantum computer network in Boston

Law Center Litigation

7.25.2022 | NOTICE OF PROPOSED CLASS ACTION SETTLEMENT IN LAWSUIT AGAINST MONTGOMERY COUNTY, ALABAMA SHERIFF

Montgomery County, Alabama Sheriff

This notice was authorized by a federal court and is not a solicitation from a lawyer.

Have you ever been arrested or ticketed by the sheriff for panhandling in Montgomery, Alabama? If so, there is a lawsuit that might affect you. This notice explains your rights and the outcome of the lawsuit.

What is this notice about?

In 2019, three people in Montgomery filed a class action lawsuit against the Sheriff of Montgomery County, Alabama, the City of Montgomery, and the head of the Alabama Law Enforcement Agency. They challenged two laws that criminalized their ability to ask for help—including food and money—in public places. The case is called Singleton v. Taylor , Case No. 2:20-cv-99-WKW (N.D. Al.). The people who filed the lawsuit have reached an agreement to settle this case with the Sheriff.

Who is included in this class-action lawsuit and settlement?

In a class action lawsuit, one or more people bring claims for themselves and for others in the same legal situation. This lawsuit was filed on behalf of a class of all individuals who may ask for help (aka “panhandle”) in the future. Everyone in these groups is a Class Member. The proposed settlement will affect all Class Members.

If the judge in the federal case thinks the proposed settlement is fair, the judge may approve the settlement. Before that happens, Class Members have a right to provide feedback on the proposed settlement. If you think you are a class member, the following will apply to you.

What rights do Class Members have regarding the proposed settlement?

You may comment on or object to the proposed settlement. The Court will decide whether to approve or reject the proposed settlement after a final hearing, scheduled for September 8, 2022. You should submit your comments before September 4, 2022, to the lawyers for Class Members by email at [email protected] , by text or phone at (334) 679-6551, or through regular mail at the below address:

The Southern Poverty Law Center

c/o Singleton Settlement

400 Washington Ave.

Montgomery, AL 36104

You may choose to do nothing. If you do nothing, you will still be a Class Member and the settlement will apply to you.

What does the proposed settlement say?

The Montgomery County, Alabama’s Sheriff’s Office can no longer arrest or ticket people in Montgomery County, Alabama under two state laws—Ala. Code § 32-5A-216(b) and Ala. Code § 13A-11-9(a)(1)—that make it a crime to ask for help in public spaces. This settlement is only about the Montgomery County Sheriff’s Office. It does not address other law enforcement officers such as state or city police officers.

Will Class Members get any money as part of this case?

No. This lawsuit is to prevent future arrest or citations (or threat of arrest or citation) by the Montgomery County, Alabama’s Sheriff’s Office for asking for help.

What if I have been previously charged with a crime for asking for help?

This settlement does not address any prior charges or convictions for panhandling. It only prevents the Montgomery County Sheriff’s Office from enforcing (or threatening to enforce) Ala. Code § 32-5A-216(b) and Ala. Code § 13A-11-9(a)(1) in the future.

Bloom v. City of San Diego

With rapidly rising rent prices, many people facing housing insecurity or homelessness take shelter in their vehicles. Vehicles often provide benefits that traditional congregate shelter settings do not, such as autonomy, the ability to store belongings and maintain independence, privacy, proximity to services and community, and freedom to adjust and adapt one’s home to meet one’s needs. On November 15, 2017, a group of San Diego residents who resided primarily in their vehicles brought suit against the City of San Diego in the Southern District of California to challenge two municipal ordinances – one that prohibited living in vehicles and another prohibiting nighttime RV, or “oversized vehicle,” parking. The plaintiffs, a subclass of whom live with disabilities and are therefore unable to access congregate shelter settings because of inaccessibility, had been subject to costly tickets, vehicle impoundment, harassment by law enforcement, and threats of arrest.

On June 7, 2018, the federal judge denied the City’s motion t dismiss the disability-related claims, and in August of 2018, granted a preliminary injunction prohibiting the city from enforcing the challenged vehicle habitation ordinance. Following the issuance of the preliminary injunction, the City enacted a new version of the vehicle habitation ordinance that is not subject to the injunction, but which Plaintiffs believe is equally unconstitutional. The litigation is currently pending in the Southern District of California. The National Homelessness Law Center is co-counsel alongside Disability Rights California, Dreher Law Firm, Manfred APC, Bonnet Fairbourn Friedman & Balint PC, and Ann Menasche.

Singleton v. Montgomery

In 2019, three residents of Montgomery, Alabama filed a lawsuit on behalf of themselves and a class of similarly situated individuals against the Sheriff of Montgomery County, the City of Montgomery, and the head of the Alabama Law Enforcement Agency. The lawsuit challenged two laws that applied to Montgomery residents and made it illegal to panhandle, or ask for help, in public places. The plaintiffs made First Amendment claims and were represented by the Southern Poverty Law Center and the National Homelessness Law Center. In September of 2022, the Court approved a settlement agreement between the plaintiffs and the Sheriff and City of Montgomery, which provides that the Montgomery County Sheriff’s office can not enforce the challenged state laws (Ala. Code § 32-5A-216(b) and Ala. Code § 13A-11-9(a)(1)) pending a determination of the constitutionality of the challenged laws. The settlement applies only to the Sheriff’s office and the City of Montgomery, and not to the remaining defendants.

Status: As of March, 2023, the case is awaiting an order on summary judgment from the District Court for the Middle District of Alabama.

Byrd et. al. v. State of Missouri et. al.

Byrd v. Missouri : Law Center Leads Team of Amici Seeking to Strike Cicero Template from Missouri Law

In 2022, after failing to pass a Cicero Institute template as a standalone bill, the Missouri legislature passed it by quietly appending it to HB 1606, a bill originally about “county financial statements,” near the end of the legislative session. To ensure that laws of such significance do not pass without careful consideration, the Missouri Constitution guarantees that all legislation addresses a single subject, has a clear title, and retains its original purpose. Those constitutional safeguards were disregarded here, and the result was legislation of staggering importance, pushed by non-Missouri interests, passed without adequate debate and public scrutiny.

On June 20 th , the Law Center led a coalition of local and national organizations—ArhCity Defenders, Inc., Greater Kansas City Coalition to End Homelessness, Empower Missouri, the National Low Income Housing Coalition, the National Coalition for the Homeless, and the National Alliance to End Homelessness—in filing a “friend-of-the-court” brief before the Supreme Court of Missouri demanding that the Cicero template language be stricken from HB 1606. Special thanks to Joseph Begun and Alex Siemers, our pro bono counselors from HALT partner Latham & Watkins LLP, whose efforts resulted in one of the best amici briefs we’ve ever participated in. We will report the moment Missouri’s highest court rules.

Disability Rights California v. Gavin Newsom

On January 26, 2023, Disability Rights California filed a Petition for Writ of Mandate in state court to challenge the constitutionality of California’s CARE Act. The CARE Act, passed in September of 2022, was passed as a response to the rising homelessness and mental health crises in California, and creates a regime of involuntary and coercive treatment for Californians experiencing mental health-related concerns. In addition to forcing people int treatment against their wishes, the CARE Act system does not require any housing provisions for unhoused people referred to the CARE program, despite the fact that the program is touted by the Governor’s office as a solution to unsheltered homelessness in California.

In February, 2023, the National Homelessness Law Center, ACLU, and the law firm of Sheppard Mullin authored and sent an Amicus Letter to the California Supreme Court in support of DRC’s Petition, arguing primarily that the CARE Act violates due process, fails to adequately address homelessness, undermines the dignity and autonomy of people with disabilities, and perpetuates harmful stereotypes about homelessness and disability. The Amicus Letter was also signed by Public Counsel, Community Legal Aid SoCal, and the Lawyers’ Committee for Civil Rights of the San Francisco Bay Area.

Coalition on Homelessness v. City and County of San Francisco (Towing)

On July 22, 2021, the Coalition on Homelessness filed a petition for a writ of mandate and complaint in state court seeking relief from San Francisco’s policy and practice of towing, impounding, and selling vehicles when vehicle owners had unpaid parking violations. San Francisco routinely seized vehicles even when owners were using those vehicles as their primary form of shelter and did not have the means to pay parking tickets. The plaintiffs argued that the City’s towing scheme violated provisions of the California Constitution meant to protect residents against seizures of property and provide due process of law prior to a deprivation of property. The Coalition on Homelessness was represented by Bay Area Legal Aid, the Lawyers’ Committee for Civil Rights of the San Francisco Bay Area, and the law firm of Manatt, Phelps & Phillips, LLP.

In December, 2022, the National Homelessness Law Center, along with FreeForm, UNITE HERE Local 11, Western Center on Law and Poverty, Disability Rights California, the San Francisco Public Defender’s Office, Public Counsel, Legal Aid Foundation of Los Angeles, The Law Foundation of Silicon Valley, and the law firm of Milbank LLP filed an Amicus Brief in support of the Plaintiffs , arguing that vehicle impoundments of people living in poverty exacerbate street homelessness, impair access to resources, disproportionately target low-income communities, and are ineffective tools to recover debt owed to the City.

Denver Homeless Out Loud v. City and County of Denver

In 2020, Denver Homeless Out Loud brought suit against Denver to challenge the City’s encampment sweeps practices and policies. The district court granted the Plaintiffs a preliminary injunction, prohibiting the City from conducting its sweeps until and unless it could come into compliance with due process requirements under the Fourteenth Amendment to the U.S. Constitution. In March of 2022, the Tenth Circuit Court of Appeals vacated the injunction, raising sua sponte the issue of preclusion, based on a 2016 settlement between a different set of Plaintiffs and the City that included a release for the City from all future litigation based on sweeps. Denver Homeless Out Loud filed a petition with the Tenth Circuit for a rehearing en banc, a special kind of proceeding reserved for rare instances in which the Court has made a decision that conflicts with existing precedent and/or when the Court is considering an issue of exceptional importance. The Law Center filed this amicus brief in support of the Plaintiffs’ petition for a rehearing en banc. The Brief argues that because homelessness and encampments are increasing phenomena around the country, and because the preclusion decision forecloses the ability of unhoused Denver residents from accessing the federal court system to vindicate their constitutional rights, the question before the Court is one of exceptional importance.

Blake et al. v. City of Grants Pass

Amicus Curiae in Support of Plaintiffs-Appellees , Debra Blake, et al. v. City of Grants Pass, Nos. 20-35752 & 20-35881 (U.S. Dist. Ct. App. 2021).

On June 3, 2021, the Law Center, The University of Miami School of Law Human Rights Clinic, and Leilani Farha, submitted an amicus brief to the United States Court of Appeals for the Ninth Circuit in support of the plaintiffs-appellees, Debra Blake, et al. Our brief argued that by excluding people experiencing homelessness from public spaces and subjecting them to fines and fees, Grants Pass has violated fundamental human rights.

Debra Blake, Gloria Johnson, and John Logan, represented by the Oregon Law Center, filed the underlying lawsuit in district court to hold the City of Grants Pass accountable for its violation of the Eighth Amendment to the U.S. Constitution. By excluding people experiencing homelessness from public spaces and subjecting them to fines and fees, the City has created laws punishing the homeless which constitute cruel and unusual punishment under the Eighth Amendment. Ultimately, in order to address the underlying causes of homelessness, the city must recognize the right to adequate housing and affirmative measures to enable access to housing for people experiencing homelessness.

Status: Open

Citizens for Strong Schools v. Florida State Bd. of Educ.

Amici Curiae in Support of Appellants, Citizens for Strong Schools v. Florida State Bd. of Educ. , No. 1D16-2862 (Fla. Dist. Ct. App. 2016).

On November 4, 2016, the Law Center, Bassuk Center on Homeless and Vulnerable Children and Youth, Disability and Public Benefits Clinic of Florida Coastal School of Law, University of Miami School of Law Children and Youth Law Clinic and pro bono counsel Baker Donelson, submitted an amicus brief to the Florida 1 st District Court of Appeal in support of the appellants, Citizens for Strong Schools, represented by Southern Legal Counsel. Our brief argued that Florida is not meeting its constitutional mandate to address the educational needs of homeless Florida students.

Citizens for Strong Schools, represented by Southern Legal Counsel, the Law Center, and pro bono counsel Baker Donelson, filed the underlying lawsuit in state court to hold the state accountable for its failure to meet its constitutional obligation to provide high quality, uniform, safe, secure, and efficient public education to all Florida students. At trial, the Law Center and Baker Donelson argued that the state is failing to meet its obligations under the Florida Constitution to serve the educational needs of homeless students in Florida. After a 4-week bench trial, the trial court found in favor of the state and held that the constitutional provision was not enforceable in court.

On December 13, 2017, the Florida 1 st District Court ruled against the Appellants, who are appealing.

Amicus brief is due June 14, 2018.

Hooper v. City of Seattle

Amici Curiae in Support of Appellants, Hooper v. City of Seattle , Case No. C17-77RSM (U.S. District Court Western District Oct. 4, 2017)

The Law Center with pro bono counsel Dechert LLP filed an amicus brief in the Plaintiffs’ appeal from denial of class certification in lawsuit filed on behalf of two individual plaintiffs and a putative class of persons subject to sweeps in the City of Seattle. The case was filed in Western District Court of Washington and alleges that the City’s policy and practice in removing encampments violates the Fourth and Fourteenth Amendments.

The Law Center, Disability Rights Washington, and other non-profit advocacy groups submitted an amicus brief to the 9 th Circuit in support of Plaintiff-Appellant’s 23(f) appeal of the denial of class certification in Hooper v. City of Seattle, Case No. C17-77RSM (U.S. District Court Western District Oct. 4, 2017.) The case, brought by the ACLU-WA, challenges Seattle’s sweeps policy and practices on 4 th and 14 th Amendment grounds. The brief was filed on June 11, 2018.

Kohner Properties v. Johnson

Amici Curiae in Support of Appellants, Kohner Properties v. Johnson , No. SC 95944 (MO S.Ct. 2016)

On October 24, 2016 the Law Center, with assistance from pro bono partner, Dechert, LLP, and on behalf of ourselves, American Civil Liberties Union of Missouri Foundation, Housing Umbrella Group of Florida Legal Services, Lawyers’ Committee for Civil Rights Under Law, Legal Services NYC, National Alliance of HUD Tenants, National Housing Law Project, National Legal Aid and Defenders Association, and Sargent Shriver National Center on Poverty Law, filed an amicus brief to the Missouri Supreme Court. The underlying case regards a judicially-imposed requirement to pay rent into escrow before a tenant may use an affirmative defense under the warranty of habitability. For low-income renters, this could be prohibitive (e.g. if they have to pay rent into escrow and pay for a hotel due to an uninhabitable apartment at the same time). LaTasha Johnson, the Defendant/Appellant is represented by the Legal Services of Eastern Missouri against Kohner Properties.

Our brief highlights the literature addressing the historical importance of the warranty of habitability and its continued role for economically disadvantaged tenants, how other states have approached the warranty of habitability when used as a defense to an eviction and related due process concerns, the consensus in both domestic and international law regarding tenants’ rights to habitable housing, and the social science literature supporting the conclusion that judicially-crafted protections for (often) low-income renters are essential to protect tenants from housing abuses The case was argued on February 8, 2017 and awaits a decision.

Manning et. al. v. Caldwell

Amici Curiae in Support of Appellants, Manning et. al. v. Caldwell , No. 17-1320 (4 th Cir. 2017).

On June 19, 2017, the Law Center together with pro bono partner Latham & Watkins filed an amicus brief in the 4 th Circuit Court of Appeals. The underlying case was brought persons experiencing homelessness who are also addicted to alcohol against the city attorneys for Roanoke and Richmond, Virginia. The plaintiffs are represented by Legal Aid Justice Center in Virginia. Our brief supports Plaintiffs’ position that Virginia’s Interdiction Statute, which is used to classify alcoholics who are homeless (and thus more likely to drink in public view) as “habitual drunkards” and then repeatedly criminally prosecutes them for possessing, purchasing, or consuming alcohol, is both bad law and bad policy. The amicus reviews both Eighth Amendment case law and notes the outlier status of this statute as one of only two states with such a law, and the many more constructive approaches that could be taken to address the concerns of alcoholism and homelessness. The case was heard January 24, 2018. Skadden argued the case and reported the panel was very harsh, with one judge actively stating the position was wrong. Currently awaiting decision, though not optimistically.

Orange County Catholic Worker, et al. v. Orange County, et al.

Amici Curiae in support of Plaintiffs Emergency Stay Request, Orange County Catholic Worker , et al . v . Orange County , et al . Case No. 8:18-cv-00155-DOC-(KESx) (C.D. Ca 2018).

On February 12, 2018, the Law Center filed an amicus letter in the U.S. District Court for the Central District of California. The judge invited “written briefing from any amicus groups which may include. . .service providers . . . and housing organizations” regarding a request for a preliminary injunction against a sweep of the Santa Ana riverbed encampment. The Plaintiffs are represented by Carol Sobel, the Elder Law and Disability Rights Center, and Schonbrun, Seplow, Harris & Hoffman. At Carol Sobel’s request, our letter highlights standards from our encampments report and other information from Housing Not Handcuffs and the DOJ Statement of Interest brief. The motion hearing was February 13, 2018. The judge allowed the sweep to go forward with commitment from the county to ensure alternative shelter/housing for all who were displaced, and threatened a permanent injunction against enforcement of camping ordinances for cities who do not cooperate with resettlement.

G.S. v. Rose Media School District

Amici Curiae in Support of Appellee, G.S. v. Rose Media School District , No. 17-2886 (3d Cir. 2018)

The Law Center signed on to an amicus brief to the 3rd Circuit filed by the Education Law Center – PA. Homelessness disproportionately affects students with disabilities and parents experiencing homelessness often lack access to counsel and legal resources to protect their rights. After signing a settlement agreement that waived G.S.’s rights to future legal claims under the McKinney-Vento Homeless Assistance Act, the school disenrolled G.S. because it held that the family is no longer homeless even though there has been no changes in the student’s living situation. Education Law Center, the Law Center, and other legal advocates urged the 3rd Circuit to find in favor of G.S. because waiving a homeless student’s future educational rights goes against public policy and because state and local educational agencies cannot deny eligibility for McKinney-Vento supports and services based on an arbitrary limit on the length of time a student experiences homelessness. On Nov. 6, 2018, in a non-precedential opinion, the 3 rd Circuit ruled in favor of Plaintiffs affirming the family’s right to continue attending school and emphasizing that homelessness has no time limit under the Act. On Monday, January 7, 2019, the Amici filed a new motion requesting the opinion be converted to “precedential,” and await a decision on that motion.

Status: Closed, but motion pending

Nat’l Fair Housing Alliance, et al. v. Carson, et al.

Amici Curiae in Support of Plaintiffs’ Motion for Preliminary Injunction and Summary Judgment, Nat’l Fair Housing Alliance, et al. v. Carson, et al. Case No. 1:18-cv-01076-BAH (D.D.C. 2018)

June 5, 2018, the Law Center joined the National Housing Law Project and other amici to file an amicus brief in the District Court of DC. In the underlying case, NFHA, et al. are challenging HUD’s notice that allows jurisdictions to stop submitting Analyses of Fair Housing (AFHs), as required under the 2015 Affirmatively Furthering Fair Housing (AFFH) Regulation. The challenge is under the Administrative Procedure Act and the Fair Housing Act. The amicus looks at HUD’s responsibility to affirmatively further fair housing under the Fair Housing Act both historically and these current actions, to argue that the department is acting in purposeful disregard to the law.

Garcia et. al. v. City of Los Angeles

Amici curiae in support of Plaintiffs, Garcia et. al. v. City of Los Angeles, Case No. 2:19-cv-06182-DSF-PLA (9th Cir. 2020)

The Law Center supported Plaintiff’s at the Ninth Circuit Court of Appeals asking the Court to uphold a narrow injunction preventing Los Angeles from seizing and trashing “bulky property” of unhoused people based solely on its size. Arguments have not yet been scheduled.

Massachusetts Coalition for the Homeless v. City of Fall River, MA

Amici Curiae in Support of the Plaintiffs, Massachusetts Coalition for the Homeless v. City of Fall River, MA, No. SJC-12914 (Supreme Judicial Court 2020)

In Massachusetts Coalition for the Homeless v. City of Fall River, MA , the Law Center, with the pro bono assistance of Mintz, Levin, Cohn, Ferris, Glovsky and Popeo, P.C. supported the plaintiffs’ arguments against a statewide anti-panhandling statute in the Massachusetts Supreme Court. The Court will hear the case on November 2.

City of Seattle v. Long

Amici Curiae in support of the plaintiff’s application for certiorari, City of Seattle v. Long, No. 98824-2 (Supreme Ct State of WA 2020)

The Law Center, together with the ACLU of Washington, Washington Defenders Association, Seattle University School of Law Human Rights Advocacy Project, and LoGerfo Garella PLLC submitted a brief in support of the plaintiff’s application for certiorari to the Washington State Supreme Court. The brief asks the Court to review the constitutionality of tows and impounds of vehicle homes without any consideration of the fact that people live in them. The Court has not yet decided whether or not to hear the case.

Vigue v. Shoar

Amici Curiae in Support of the Plaintiff, Vigue v. Shoar, No. 3:19-cv-186-J-32JBT (Dist. Ct. Middle District of FL Jacksonville Div. 2020)

In a major First Amendment victory, the U.S. District Court for the Middle District of Florida has declared Florida Statutes 316.2045 and 337.406 —which prohibit the solicitation of charitable contributions on Florida roadways except by charitable organizations or when a local government permit has been issued— unconstitutional.

Closed Cases

Frank v. walker.

Frank v. Walker, 835 F.3d 649 (7 th Cir. Aug. 29, 2016)

Ruthelle Frank, and a putative class of individuals who could not obtain photo ID through reasonable efforts sued the State of Wisconsin for violating the Voting Rights Act, and the First and Fourteenth Amendments of the U.S. Constitution by requiring a photo ID in order to vote. The Law Center joined with the ACLU of Wisconsin and pro bono partner, Dechert LLP, to represent the Plaintiffs in the suit filed in the U.S. District Court for the Eastern District of Wisconsin.

In April 2016, the Seventh Circuit Court of Appeals held that anyone who is eligible to vote in Wisconsin, but cannot obtain a qualifying photo ID with reasonable efforts, is entitled to an accommodation. See Frank v. Walker , 819 F.3d 384 (7 th Cir. 2016). On remand, the district court issued an injunction that permits any registered voter to declare by affidavit that reasonable effort would not produce a photo ID. The Seventh Circuit then stayed that injunction pending appeal in a decision filed in August 2016, finding that the injunction would likely be reversed on appeal and that disruption of the state’s electoral system in the interim would cause irreparable harm. See Frank v. Walker , 2016 WL 4224616 (7 th Cir. Aug. 10, 2016). Plaintiffs petition for initial review en banc was denied. Ruthelle Frank died on June 4, 2017 and counsel did not move to substitute a party.

Martin v. City of Boise

Martin v. City of Boise (formerly Bell v. City of Boise) case has had an enormous impact across the United States, particularly in the western states, in protecting the rights of unhoused people to sleep and shelter themselves without facing criminal punishment for simply trying to survive on the streets. The Law Center, Idaho Legal Services Inc., and pro bono partner Latham & Watkins originally filed the case in October 2009. The case gained national attention in 2015 when the U.S. Department of Justice filed a Statement of Interest brief in the case, supporting Plaintiffs’ position that making it a crime for people who are homeless to sleep in public places unconstitutionally punishes them for being homeless. In September 2018, the United States Court of Appeals for the Ninth Circuit affirmed that it is cruel and unusual punishment to criminalize the simple act of sleeping outside on public property when no alternative adequate shelter exists. In April, 2019, the Ninth Circuit denied a petition for rehearing en banc , and in December 2019, the U.S. Supreme Court denied a petition for certiorari brought by the City, letting the 2018 decision stand. The case settled in February 2021, with the city modifying its ordinance, agreeing implement guidance and training for law enforcement, devoting $1.3 million to constructive solutions to homelessness, $435,000 in attorneys fees, and $5000 in damages to plaintiffs.

Status: Settled

2021 02 08 (390) Joint Motion

2021 02 08 (390-1) Exhibit A

2021 02 08 (390-2) Exhibit B

2021 02 08 (390-3) Exhibit C

2021 02 08 (390-4) Exhibit D

Kohr v. City of Houston

On May 12, 2017, three named plaintiffs and a putative class of unsheltered homeless individuals filed suit against the City of Houston in the Southern District of Texas. Plaintiffs are represented by the Law Center, the ACLU of Texas, and pro bono partner, Dechert LLP. The complaint challenges Houston’s anti-camping and anti-panhandling ordinances and alleges that the City violated Plaintiffs’ First Amendment right to free speech, Fourth Amendment right against unreasonable searches and seizures, Eighth Amendment right against cruel and unusual punishment, and Fourteenth Amendment right to protection against vagueness.

Boyle v. City of Puyallup et al

On September 14, 2018, six homeless plaintiffs sued the City of Puyallup, Washington, and Pierce County for destruction of their property during sweeps of their outdoor encampments. The plaintiffs are represented by the Law Center and Perkins Coie. The complaint alleges that the City and County violated Plaintiffs’ Fourth Amendment right to be free from unreasonable interference with their property interests, and their Fourteenth Amendment right to due process. The Law Center, with support of Perkins Coie, later amended the complaint to include a violation of plaintiff’s right to privacy under the Washington State Constitution.

NLCHP et. al. v. Greensboro

In August 2018, on behalf of three Greensboro, North Carolina, citizens, the Law Center, together with the ACLU of North Carolina and Legal Aid of North Carolina, filed suit against the City of Greensboro for an ordinance to restrict panhandling. The City eventually relented and repealed the ordinance and agreed not to reenact a similar law, and the Law Center and partners withdrew the case in March 2020.

National Homelessness Law Center (Formerly NLCHP)

1400 16th Street NW, Suite 425 Washington, D.C 20036

Phone: 202.638.2535

Email: [email protected]

Web: homelesslaw.org

Back to main menu

Case study: understanding the lived experience of homelessness and housing challenges, in 2019, tacsi worked with the south australian housing authority to spend time with 93 people with lived experience of homelessness and housing challenges. our aim was to look at the systemic challenges that needed to be addressed in their housing strategy., the background.

Homelessness in Australia continues to increase and the definition of who is experiencing homelessness has broadened.

As of 2019, over 120,000 Australians are homeless, with that number predicted to increase by 13.7% in the next five years*. Out of those, 58% are male and 42% female, with people over 55 experiencing a 28% increase in homelessness. These demographics indicate we need a shift in how we live and provide a home for all people.

What we did

In 2018/2019, TACSI worked with the SA Housing Authority to look at the systemic challenges that needed to be addressed in their housing strategy. We spent time with 93 people with lived experience of homelessness and housing challenges, with the aim to look at the systemic challenges that needed to be addressed in their housing strategy.

A huge part of the work that we have done to date over the last eight years is to understand people’s lived experience of the housing system, including a wide range of cohorts across both older and younger people, vulnerable people and people living with disability, and help to surface their ideas for what would make a real difference.

“Oh my god you’ve been on a waiting list for a house longer than I have been alive.”

Younger homeless man commenting when an older attendee spoke about being on the public waiting list for decades

Reimagining the system

In 2018, we held face to face workshops with a number of people who identified as being homeless. Our framing around these workshops was partially about having the space to reimagine the system of housing and supports, and what that could look like.

This work formed part of a longer strategic partnership informing the SA Housing and Homelessness Strategy , which was released in 2019.

People from both ends of the ageing spectrum, including people with a chronic experience of homelessness, survivors of domestic family violence, people with disability and Aboriginal Torres Strait Islander people shared their experiences with us.

They articulated the issues they faced on a daily basis and were able to surface the ideas they saw as potential solutions to the system. Additionally we heard from men and women who had experienced homelessness and who themselves ideated a raft of inventive and engaging ideas that could provide the platform for a more holistic approach.

The insights

What we found was four identifiable assets powering their ability to see opportunities to build a better system.

Their experiences have meant they have to be highly resourceful and make scarcity go far.

They have honed skills in troubleshooting

They know what makes a good home beyond shelter, because of the absence of (other more material) important things.

They are aware of themselves, and that they cannot address some of the challenges alone.

What emerged from these workshops with people with lived experience, is not that we don’t know the problems the system has, but that these people should be part of shaping the solutions, and actively valued as pioneers in their own lives.

“Having a home is a springboard to stability, structure, community, physical and mental health.”

Workshop participant with lived experience of homelessness

The insights about housing and homelessness were collated and shared to inform the South Australian Housing Authority’s Housing, Homelessness and Support Strategy .

TACSI’s report contains people’s reflections on housing challenges, and their ideas about how the housing system could help them chart pathways to home, as well as economic and social participation. TACSI would like to thank everyone who so generously gave their time and insight to developing this work, including all who attended Lived Experience Workshops.

The systemic treatment of homelessness

Systemically, homelessness is approached in a cyclical way with homeless people experiencing multiple services, and can find themselves moving from one to the next due to a multitude of factors outside of their control. This is not new, this is known within the system and certainly has a deep impact on their ability to live life.

It is important to note that all these services are doing the best they can within the system, and frustration is often felt by employees within these services. A re-engineering of the system is well overdue, for all people engaging systemically.

Opportunities for change

There are, however, multiple opportunities for change. The system itself is experiencing many blockages preventing the flow of people into the best housing solution for them.

The system often views the response to homelessness in a siloed way by viewing all the components of housing and supports separately. We heard through lived experience that a fluid system that looks at the person as a whole does not currently exist as part of the challenge, and that trauma plays a deep role in people’s lives.

It’s not just about acquiring a home, it’s about the support and the relearning of how to have a home that is also an identifiable challenge for many homeless people. Add to that that many are well networked on the street with a move into housing a removal of those vital informal supports.

These are real people with real initiative, who can identify what their problems are and are able to articulate what challenges they face. These are people who face stereotyping about who they are and how they have come into this situation, when often the reality is far different. With public housing in short supply the removal of choice is also a factor in play within the system.

“I hope these people in power realise that this is about homes and helping us have a life, not just managing assets and problems.”

Workshop participant with lived experience of domestic and family violence

Removal of choice

Primarily, there are two issues that are well known within the community and the sector as defining problems for the system.

The issue of flow. Simply put, there are not enough suitable options of shelter in South Australia. This has perpetuated a state of crisis in relation to homelessness with the homelessness sector stalled through funding, increased demand for housing and inability to respond holistically to trauma and mental health barriers homeless people are experiencing.

Being able to respond. The inability of being able to respond in a crisis led system, when people are ready is leading to more crises. It’s a situation where the crisis itself is perpetuating the crisis, leading to a ‘stuck’ system.

The aspire model that is still being applied in SA is well regarded with people with lived experience, but is not available to everybody with the challenge of finding housing in the first place.

Stopping the spiral

With much to be done, how can we start to stop the spiral and address the increase of homelessness? With the face of homelessness changing and new reasons for being homeless emerging, we need to act.

The system can play a different role in people’s lives. We can reinvent solutions with the people experiencing these challenges, and build support for those experiencing homelessness.

What’s next

What was powerful about this engagement is the way that the people we spoke to started to express ideas around how the system could work. For them, it starts with really genuinely hearing who they are and their identity. They want realistic responses to their challenges and authenticity, not fake promises. They can be part of the solution.

Looking forward to opportunities and challenges in the way we approach our strategies. It’s about going beyond funding outputs and asset management, and creating pathways back into social and economic participation. It’s about restoring people back into meaningful connections and purpose.

There is a real opportunity for government and community in brokering the lived experience of people to create agency and tap into experience, to create better opportunities and pathways for change in the housing and homelessness system. It’s about rebuilding lives, not just providing shelter.

*2016 Census Australia

Read the summary of our lived experience workshops, which informed the South Australian Housing and Homelessness Strategy

Meet the team of this project, read more about our work in this area, see all our work.

Homelessness in US cities and downtowns

Subscribe to transformative placemaking, the perception, the reality, and how to address both, hanna love and hanna love fellow - brookings metro , anne t. and robert m. bass center for transformative placemaking @hannamlove tracy hadden loh tracy hadden loh fellow - brookings metro , anne t. and robert m. bass center for transformative placemaking @lohplaces.

December 7, 2023

Homelessness is not uniform. There are significant variations in the types, prevalence, and service delivery ecosystems of homelessness across U.S. cities and regions—requiring policies tailored to those people and places rather than a “one-size-fits-all” solution.
Despite perceptions of rising homelessness in the aftermath of the COVID-19 pandemic, homelessness rates in three of the four cities studied (New York, Philadelphia, and Chicago) declined over the past decade, including through the pandemic. Seattle was the stark outlier.
Above any other factor, regional housing market dynamics—particularly when rents rise by amounts that low-income residents cannot afford—drive geographic variations in the prevalence of homelessness and correlate with higher homelessness rates.
Evidence-based policy recommendations for reducing homelessness require root cause approaches, including reforming housing plans, scaling alternative crisis response models, stopping the jail-to-homelessness cycle, leveraging the capacity of place governance organizations, and taking a regional, data-driven approach to homelessness.
26 min read

A rare bipartisan consensus is emerging in many U.S. cities on one key issue: the need to address homelessness, particularly in downtown central business districts . Many on both the right and the left are calling for strategies such as encampment sweeps , increased enforcement of quality-of-life offenses , and even scaling back federal dollars for evidence-based “housing first” policies to quell rising fears of public disorder, homelessness, and crime in “hollowed out” downtowns.

Homelessness trends, types, and service delivery ecosystems vary considerably across US cities

Before diving into recent homelessness trends impacting U.S. cities and their downtowns, it is important to first distinguish between different types of homelessness that affect cities and regions, how the prevalence of homelessness varies considerably nationwide, and the vast differences in the local and regional ecosystems that coordinate homelessness services and funding (also known as “Continuums of Care” ) across U.S. metro areas.

The different types of homelessness affecting US cities and regions

Most fundamentally, the tenure of a city’s homelessness population (e.g., whether people are unsheltered or in other temporary housing situations such as emergency or transitional shelters) can hold significant and often underappreciated ramifications for local policymaking. For instance, the most visible form of homelessness—when people are unsheltered and live in public spaces like parks, subway stations, or streets—represents only one-third or less of the unhoused population in most cities, despite capturing the bulk of resident and media attention , as well as significant city resources .

In New York and Philadelphia, for instance, most homeless people are not unsheltered, but rather reside in temporary shelter or transitional housing (94% and 82%, respectively) (Figure 1). In Chicago, most of the homeless population resides in either emergency shelter (46%) or transitional housing (20%), with 33% living unsheltered. Seattle is the stark outlier in the sample: Over 57% of its homeless population is living without shelter. These variations matter because a city like Seattle that is struggling with over half of its homeless population living unsheltered will require a different set of policies than a city like New York, whose “right to shelter” mandate has helped secure temporary shelter for most people experiencing homelessness.

Variations in the prevalence of homelessness across the US cities and regions

Stark regional variations in the prevalence of homelessness across U.S. cities and regions also matter significantly for policymaking. As Table 1 demonstrates, cities on the West Coast have higher homelessness rates than other regions—representing seven of the 10 cities with the highest total homelessness rates per capita. San Francisco, for instance, has a total homelessness rate that is nearly 20 times higher than Houston’s. West Coast cities also stand out for higher shares of their homeless population living without shelter. In addition to Seattle, West Coast cities including San Francisco; Long Beach, Calif.; Los Angeles; Portland, Ore.; Oakland, Calif.; Sacramento, Calif.; San Jose, Calif.; and Fresno, Calif. all have unsheltered homelessness rates above 50%.

These findings generally align with research showing that above any other factor, regional housing market dynamics—particularly when rents rise by amounts that low-income residents cannot afford— drive geographic variations in the prevalence of homelessness across U.S. regions and correlate with higher homelessness rates (Figures 2 and 3). In Seattle, however, even pandemic-era reductions in asking rents were not enough to curb homelessness.

While these regional variations can make it difficult to adopt a “one-size-fits-all” approach to reducing homelessness in the U.S., they can provide insight into the local policies and socioeconomic conditions that work to facilitate homelessness reduction.

Different service delivery ecosystems for homelessness across US cities and regions

Finally, differences in regions’ Continuums of Care (CoCs) boundaries add another important layer to both understanding and solving the challenge. CoCs are the local or regional planning bodies that coordinate housing support, social services, funding, and reporting across service providers, hospitals, businesses, advocates, and government agencies (e.g., school districts, law enforcement, and public housing authorities).

As Figure 4 demonstrates, metropolitan areas such as Houston 2 and Seattle take a “regional approach” to homelessness , in which funding and service delivery are consolidated across an integrated CoC area that includes both cities and suburbs to eliminate redundancies across agencies, fill gaps for underserved populations, and match resources with the scale of the challenge. On the other hand, metro areas such as Chicago and Philadelphia divide their homelessness services across a more fragmented and localized patchwork of providers, which limits the potential for regional collaboration. Understanding these nuances in the resources and ecosystems for homelessness prevention and reduction is critical for crafting effective policy.

Why focus on homelessness downtown, specifically? Downtowns play a critical role in local economies—serving as regional job hubs for both high- and low-wage work, supplying an outsized share of tax assessable value that maintains city budgets, and supporting clusters of small businesses that represent opportunity for entrepreneurs, artists, and creatives. People experiencing homelessness concentrate in downtowns for many of the same reasons that others do: a combination of highly accessible transit services, great density of public spaces and other amenities, and the concentration of critical public-serving institutions. In many cities, downtowns represent the most visible hub for people experiencing homelessness to gather, and this uneven spatial distribution often places pressure on a small number of downtown leaders to “solve” homelessness—even when its causes are rooted in structural challenges that extend far beyond downtown boundaries.

Comparing perceptions and realities of homelessness trends in New York, Philadelphia, Chicago, and Seattle

When conducting qualitative interviews for the Future of Downtowns project in fall 2022, we asked nearly 100 residents, workers, visitors, and employers in four of the largest U.S. cities about the top barriers preventing them from returning downtown—spanning issues from the changing nature of office work to different preferences for commuting and in-person interaction. To our surprise, we heard remarkably consistent results across the four cities: Interviewees told us that increased fear of public disorder, crime, and homelessness in the wake of the pandemic was the primary barrier preventing them from returning downtown—not changing office or residential patterns. This section compares these perceptions with quantitative analysis of pandemic-era homelessness trends in each city.

Respondents across all four cities perceived significant increases in homelessness since the pandemic, often describing “new negotiations” in public spaces with unhoused people and rates of public disorder not seen since the late 20th century. They frequently made statements such as:

Homelessness wasn't even like this during the crack cocaine 80s. It is terrible. Interview Respondent in Philadelphia

There are more homeless people in more places now than there were pre-pandemic. I would say that's true of every city I've been in. Interview Respondent in Chicago

The top thing we hear from employers is about the experience on the street with safety and chronic homelessness. Interview Respondent in Seattle

In the pandemic, my neighborhood changed meaningfully in terms of the crime rate and just the level of homelessness Interview Respondent in New York

Yet when we crunched the numbers to determine how perceptions of rising homelessness during the pandemic bore out in data, we found a significant mismatch between perception and reality in three of the four study cities. Interview respondents in Chicago, Philadelphia, and New York perceived that homelessness was increasing exponentially and leading to a level of public disorder not seen since the 1990s. However, total homelessness rates in these cities actually significantly declined in the past decade (by 42%, 25%, and 16%, respectively). And it continued this decline during the pandemic (Figure 5). Seattle remained the stark outlier, with total homelessness increasing by 23% since 2015.

In New York, Chicago, and Philadelphia, we found a similar pattern with trends of unsheltered homelessness. They had not “ballooned” during the pandemic, as most interviewees supposed, but rather remained steady for the past decade and declined between 2020 and 2021 (Figure 6). Seattle, again, was a stark outlier—seeing an 88% jump in unsheltered homelessness since 2015, which continued during the pandemic.

Our findings from Chicago, Philadelphia, and New York generally align with recent research from the U.S. Department of Housing and Urban Development , which found that the nation was able to hold off a spike in homelessness during the pandemic due to federal relief authorized between 2020 and 2021, including eviction moratorium orders, emergency rental assistance, boosted unemployment benefits, and the expanded child tax credit. Seattle, however, demonstrates that even these vital federal supports were not always sufficient to reverse a decade-long spike in homelessness. The gap between perception and reality may in part be explained by significant changes in downtown foot traffic , which made unsheltered homelessness more visible given the relative reduction in other foot traffic.

Why fluctuations in homelessness—such as recent increases in unsheltered asylum seekers in cities like New York—can be difficult to capture: Because most CoCs conduct and report “point-in-time” counts annually or every other year, it can be difficult to measure temporary or seasonal changes in cities’ homelessness rates. Recently, this has presented a challenge in understanding the impact of new waves of migrants and asylum seekers arriving from Latin America on homelessness in cities such as Chicago, New York, and Washington, D.C. 3 For these data availability reasons and other more substantive ones—including the unique circumstances surrounding recent migration and its toll on a limited set of large U.S. cities —this report does not seek to respond to the intersection between homelessness and asylum seekers’ migration. Instead, we focus on the long-standing structural drivers of and evidence-based tools to address the persistent challenge of homelessness that cities have been wrestling with, even absent acute changes in global migration and asylum policies.

In addition to the fact that respondents perceived significant increases in homelessness during the pandemic, they also overwhelmingly conveyed a strong sense that homelessness was linked to criminality. Rather than discussing the challenge as one rooted in larger economic and regional market forces, respondents tended to focus on the behaviors of individual homeless people that made them uncomfortable (such as sleeping outside or public drug use), and thus were drawn toward interventions directed at individual behavior through the criminal legal system.

In fact, respondents often described crime and homelessness in the same breath, with statements such as:

There’s just lawlessness in the public realm. There’s garbage, there's a guy smoking pot, there's a homeless person I just stepped over, there's somebody who's crazy following me, there are vendors everywhere. Interview Respondent in New York

The homeless population has ballooned here, which makes people feel uneasy and unsafe. Crime has always existed in Chicago, but this is different. Interview Respondent in Chicago

There is a fair amount of violent crime that kind of emanates from those encampments. We see a lot more people unsheltered, a lot more drug use, a lot more organized retail theft. Interview Respondent in Seattle

There's a lady over there…She sits there all day. We tell her you can't sleep on a bench. She just sits on the bench. That's criminal. Interview Respondent in Philadelphia

It is notoriously difficult to determine whether a criminal offense involves a person experiencing homelessness (either as a victim or perpetrator), since most police departments do not track or report that data. However, research does suggest that the criminalization of homelessness is costly and counterproductive, as arrests make it more difficult for homeless people to get back on their feet and access housing due to the heightened barriers navigating employment, services, and housing with a criminal record.

Taken together, our analysis and existing evidence indicate that perceptions alone are insufficient to inform local decisionmaking on homelessness, and that a clear understanding of data, regional market variations, and local service delivery ecosystems is necessary to craft effective policy. The next section presents five recommendations to better align data and evidence and reduce homelessness through root-cause approaches.

An evidence-based policy framework for reducing homelessness and strengthening regional economies

The ability to spend time downtown without encountering public disorder such as visible drug use or harassment is a basic necessity of city life—as is the desire to have a safe place to sleep, bathe, and eat. Fortunately, there are evidence-based policies that can bring cities closer to this dual imperative in a humane, cost-effective, and sustainable manner. We offer five key recommendations below:

Ensure that housing policy is homelessness policy

Inadequate housing supply, particularly of affordable units, is consistently shown to be the primary driver of homelessness in the U.S.—significantly outweighing factors such as substance use, poverty, and mental health. Zoning and land use restrictions are examples of local governments’ dysfunctional fiscal and regulatory structures that disincentivize or prevent housing production and contribute to a widespread structural challenge in which the poorest people within cities cannot afford average asking rents for available apartments. Despite this evidence, a study from Community Solutions found that of the nation’s 100 largest cities, only 54% had homelessness plans, and of those, only 30% mentioned zoning and land use changes.

To craft policy that addresses the root causes of homelessness, we recommend that local governments align their long-term housing, land use, and homelessness plans to increase the supply of all types of housing, remove barriers to affordability and shelter construction (such as single-family-only zoning, parking minimums, and parcel shape regulations), and adopt evidence-based “housing first” models. For shorter-term solutions, cities should adopt and scale the pandemic-era preventative measures that helped avoid a spike in homelessness, including investments in emergency rental assistance, eviction defense, tenants’ rights, and economic stimulus, as well as mitigation measures such as converting hotels into temporary housing. For cities such as Seattle, where shelter bed capacity is incredibly overburdened (Figure 7), the need for these measures is particularly acute.

Case study from New York: How ‘housing first’ programs can be a proven, humane, and cost-effective strategy for reducing homelessness

New York’s Housing First program has been in place for over three decades to provide housing supports for people experiencing chronic street homelessness without preconditions—a recognition that stable housing is a critical foundation for individuals struggling with psychiatric and substance use disorders to transition from homelessness. The program has a 70% to 90% success rate in maintaining stable housing for participants over two to three years, outperforming traditional housing programs. Additionally, it has proven to be a cost-effective strategy (Table 2) that reduces public expenditures in the criminal justice and health care systems associated with homelessness.

The Housing First program’s effectiveness can be seen in its Frequent Users Service Enhancement (FUSE) initiative , which has been successful in breaking the homelessness-to-jail cycle. FUSE provides long-term rental assistance and supportive services, resulting in 86% of participants remaining stably housed after two years and a 40% reduction in jail time , while also achieving significant cost savings in annual jail, shelter, and crisis health care costs.

Scale alternative crisis response models to better respond to people with behavioral health and substance use emergencies while improving public safety

Research indicates that punitive approaches to policing homelessness—such as criminal arrests or fees for public behaviors associated with homelessness (e.g., camping, sleeping in public, eating in public, sitting on sidewalks, etc.) or mental health episodes—make it more difficult to solve homelessness. These approaches heap a criminal record onto people experiencing homelessness, making it difficult for them to rent an apartment or get a job on top of other challenges, while also straining police resources.

Instead, an emergent and promising body of research demonstrates that non-police crisis responders—alternatives to 911 with trained mental health professionals—can better respond to lesser infractions involving homeless people. In places such as Denver, non-police crisis responders were more effective than even alternative crisis response models that deploy both social workers and the police together (sometimes referred to as “co-responder models”). Moreover, supportive housing programs such as those mentioned above have successfully reduced arrests and jail stays for people experiencing homelessness; for example, New York’s FUSE initiative lead to an average of 95 fewer days spent in jail for homeless New Yorkers.

Despite this evidence, a Community Solutions survey of mayors found that homelessness policy is intertwined with police enforcement in most cities. For instance, 78% of survey respondents said that police have influence over shaping homelessness policy in their city, 59% said police enforce quality-of-life charges against homelessness people, and 22% had their homelessness staff co-located in police departments. This has led to a phenomenon in which jurisdictions are using jails as substitute shelters. For example, in Atlanta, one in eight of all city jail bookings  in 2022 involved a person experiencing homelessness.

To better address safety concerns surrounding homelessness, mental health, and quality-of-life offenses, local leaders should act on evidence from Denver , Eugene, Ore. , and other cities to adopt and scale non-police alternative crisis response models. In doing so, they should take care to not only prioritize crisis response models that provide an alternative for low-level offenses (such as substance use or homelessness), but also include models that address intimate partner violence—another area where victims are disproportionately likely to experience homelessness as a result of the circumstances surrounding victimization .

Case study from Denver: How ‘alternative response models’ can reduce the homelessness-to-jail pipeline

In June 2020, Denver launched its Support Team Assisted Response (STAR) program to redirect nonviolent 911 emergency calls from police to a team of mental health specialists and paramedics. Inspired by the evidence-based CAHOOTS model in Eugene, Ore., the STAR program focuses on providing appropriate care and resources to individuals facing mental health crises, substance use issues, or homelessness—particularly in low-income and at-risk communities. Funded through the city’s general fund and a grant from the Caring for Denver Foundation , the STAR program aims to alleviate the burden on police resources, ensuring law enforcement can concentrate on more serious crimes.

The model has been found to produce effective results , with a 34% reduction in lower-level crimes in areas served by STAR, leading to 1,400 fewer criminal offenses. Furthermore, the direct costs associated with the STAR responses were found to be four times lower than those incurred with police-only responses, with the average direct cost per response being $151—significantly less than the $646 typically incurred for minor criminal offenses handled by the police.

Strengthen housing and employment supports for those reentering from incarceration

It is well established that homelessness and incarceration are inextricably linked in the U.S., with many people cycling between jails and prisons and homelessness on the front end (due to the criminalization of low-level “survival” crimes) and on the back end (due to the lack of support for returning citizens to access employment and housing because of the significant barriers that criminal records pose). But often, less attention is paid to preventing those being released from jail or prison from entering into homelessness.

In New York, for instance, over half of people released from prison move directly into the shelter system . In California , which does not require returning citizens to have a place to live upon release, many move directly into street homelessness. Nationwide, formerly incarcerated people are nearly  10 times more likely  to experience homelessness than the general population.

To better address the pipeline between incarceration and homelessness, study after study shows that bolstering reentry supports—particularly access to housing and employment—is critical to reducing recidivism and homelessness, while also improving public safety. Effective policies include reducing barriers for returning citizens to enter public housing , providing tailored services for those most at risk for homelessness prior to release (including workforce and housing supports), and explicitly addressing the unique needs of returning citizens in regional housing and homelessness plans, among other reforms .

Case study: How Cuyahoga County and Houston are curbing the prison-to-homelessness-pipeline through new supports for returning citizens

In response to growing evidence indicating the need to reduce the prison-to-homelessness pipeline, in 2023, Cuyahoga County, Ohio (where Cleveland is located) launched a  $37-million Housing Justice Plan that seeks to develop 105 housing units available to individuals with criminal backgrounds, provide short-term funding to subsidize housing costs for those leaving prison, and pilot a program to provide down-payment assistance or lease-to-own opportunities. For those in jail, Houston is operating a  Healthcare for the Homeless  jail in-reach program that provides intensive medical case management to incarcerated people, as well as counseling, psychiatry, substance use treatment, dental care, housing, employment, help with navigating public health benefits, and help obtaining identification.

Leverage the capacity of place governance organizations to humanely address homelessness, particularly in central business districts

While public sector officials hold the bulk of the power to address the structural causes of homelessness, downtown place governance organizations (such as business improvement districts and other special-purpose districts) also play an outsized role. 4 The International Downtown Association estimates that there are over 2,500 place management organizations in North America with the capacity to leverage millions of dollars in special tax assessments. Many of these organizations have high exposure to challenges associated with homelessness.

Special districts such as business improvement districts (BIDs) have at times been complicit in the act of displacing homeless people and embracing hostile architecture . However, they have also been pragmatic, effective leaders in innovating and implementing inclusive management practices aligned with a public health approach by employing community ambassadors; providing access to drinking water and public restrooms; supporting placemaking activities and other built environment improvements that enhance safety, vibrancy, and belonging in the public realm; and connecting residents to social services, employers, and workforce development providers.

Case study from Philadelphia: How place-based partnerships and place governance organizations can support and bolster city services for homelessness reduction and care

Most emergency shelters in Philadelphia are closed during the day, meaning that the homeless population transitions from being sheltered to unsheltered and back again on a daily basis. In 2011, Project HOME , a nonprofit homelessness service provider in Philadelphia, sought to tackle this challenge by creating a drop-in day center for homeless people close to transit and City Hall.

Through place-based, cross-sector partnerships with city government and the regional transit authority, Project HOME was able to open the day center, Hub of Hope , for people to access food, health care, social services, laundry, showers, and fresh coffee provided by Wawa. It is the only drop-in center on transit property in the U.S. and currently serves approximately 200 people per day .

As part of its cross-sectoral approach, Project HOME also collaborates with Center City District (Philadelphia’s downtown place governance organization) and other private and public sector partners on a street outreach effort, the Ambassadors of Hope , which fields interdisciplinary outreach teams on the streets of Center City Philadelphia to engage chronically homeless people and connect them to help customized to their needs. Since 2018, over 700 people experiencing homelessness have received services and transportation off the street.

Philadelphia, Penn. / Authors’ original photo

Take a regional, data-driven approach to homelessness

There is growing consensus among homelessness service providers and city and regional officials that no one institution, organization, funding source, or level of government can solve homelessness alone. To respond to the structural challenges that prevent people across a region—not just within city boundaries—from accessing affordable housing, there is a movement to establish regional homelessness authorities that correspond to merged, regional Continuums of Care and align resources and service delivery programs across a region.

Cities and counties from the East Bay area to Spokane, Wash. to Houston have adopted a “regional approach” to homelessness to coordinate on cross-jurisdictional challenges to addressing homelessness by aligning regional funding, communications, coordination, social delivery infrastructure, data collection, performance management, and training and capacity-building. This helps regions understand the extent of homelessness in their region and transparently report performance metrics, which are critical to assembling the collective will and funding necessary to end it.

Case study: How cities and counties are working together on a regional approach to homelessness

Since 1994, the Metro Denver Homeless Initiative has coordinated data and services regionally—an early national leader on the regional approach that includes building, maintaining, and using a single “Coordinated Entry System” with real-time rather than annual data. Similarly, service providers, governments, philanthropy, and more came together in the Houston metro area in 2011 to form the Way Home —another regional approach that has successfully implemented the “housing first” model. Recently, the King County Regional Homelessness Authority (KCRHA) was established in December 2019 through an inter-local agreement between King County and the city of Seattle—representing a consolidated and regional approach to tackle a critical homelessness challenge that has spiked in the last decade. Even in places with less jurisdictional fragmentation, Continuum of Care participants can come together in more collaborative ways to create a regional approach. For example, in 2015, Strategies to End Homelessness was named the “Unified Funding Agency” for the Cincinnati/Hamilton County CoC.

These leading and innovative regional approaches have more in common than just high levels of cooperation, data, and streamlined funding. These initiatives seek to address a spectrum of socioeconomic challenges associated with homelessness, including through homelessness prevention, particularly focusing on communities of color such as Black and American Indian/Alaska Native populations, which are disproportionately affected.

Their work is characterized by clear planning and performance metrics, such as the KCRHA inter-local agreement that provides a community-driven, racially equitable, and data-informed methodology and operates in alignment with the Regional Action Framework, which outlines clear visions, policies, strategies, and success metrics while striving to balance immediate actions with long-term solutions. Many emphasize the importance of input from individuals with lived experience of homelessness . These metro areas have shown that a “regional approach” requires system integration, coordinated service delivery, and performance management.

Public, private, and civic sector leaders have the evidence at their disposal to advance pragmatic solutions that can not only reduce visible homelessness in downtowns, but also chart a future in which all residents of a region have access to more effective and humane service delivery ecosystems for housing, employment, and reintegration. This holistic, place-based approach to homelessness creates a foundation for a strong labor market and vibrant regional economy. Understanding the why, where, and how of homelessness across and within regions is critical to not only respond effectively to the needs of people experiencing homelessness today, but also to prevent people from experiencing homelessness in the future.

While the state of homelessness in a city like Philadelphia is not the same as in Seattle, the recommendations provided within this report—from increasing the supply of all types of housing to strengthening organizations that provide holistic, place-based support to bolstering reentry services for returning citizens—provide a roadmap based on evidence and root-cause approaches that a jurisdiction of any size can adopt and scale, with the right support and resources, to come closer to the goal of solving homelessness . This will require sustained commitment and coordination from local, regional, state, and federal leaders. Initiatives such as the Biden-Harris administration’s “ALL INside” —which is accelerating local efforts to reduce homelessness in Los Angeles, Dallas, Phoenix, and several other cities—are promising examples of how federal funds can be leveraged to escalate the response.

A large, unsheltered homeless population is not an inevitable part of human or urban life, and there is real harm and risk involved when solutions are not implemented early or are underfunded: both the harm to individuals experiencing the profound traumas of homelessness and incarceration, as well as the damage to regional economies and institutions that is visible in downtowns, emergency rooms, transit systems, and courthouses every day. Allowing the root causes to continue unabated creates the real “doom loop” : a homelessness challenge that becomes harder to solve the longer we wait.

All residents of a region deserve to feel safe walking free of public disorder within their central business districts, but so too must all people within a region have access to the opportunity for stable housing, food, and services. To this end, federal, state, and local leaders must deploy investments and interventions in a manner that is most effective and humane in achieving that goal.

The authors would like to thank Jira Trinetkamol for his excellent research assistance on this piece. They also extend their sincere gratitude to Alan Berube, Annelies Goger, Glencora Haskins, Paul Levy, and Joy Moses for reviewing earlier drafts of this piece. Any errors that remain are solely those of the authors.

All qualitative interviews capture respondents’ perceptions from fall 2022—reflecting a point in time that may not capture improvements or heightened challenges that have happened since.
Houston was included in Figure 4 to provide an example from a city that has intentionally embraced a homelessness reduction framework rooted in coordinated service delivery for the past decade.
While preliminary data from a supplemental PIT Count conducted by the city of Chicago in light of increased migration reports a significant recent increase in homelessness since the 2022 PIT Count, it will be difficult to gauge how sustained the impact will be moving forward.
For more on place governance organizations and homelessness, see Madison, E. and J. Moses. (2022) “How Should Place Governance Support People Experiencing Homelessness?” in Hyperlocal: Place Governance in a Fragmented World. Washington, DC: Brookings Institution Press.

Placemaking

Brookings Metro

Anne T. and Robert M. Bass Center for Transformative Placemaking

Online only

6:00 pm - 7:30 pm EDT

Joseph Parilla, Glencora Haskins, Mark Muro

May 21, 2024

Robert Maxim

4 Charts That Explain How People Slide Into Homelessness

P eople don’t usually become homeless suddenly. It’s often a chutes and ladders process, except with lots of chutes and hardly any ladders. And there’s a period right before they slide into having nowhere to live, during which, many experts believe, a couple of well-placed nets might be able divert them from being forced to sleep on the streets, in their cars, or other places that are not meant as homes.

A large new statewide study done by the University of California, San Francisco Benioff Homelessness and Housing Initiative takes a closer look at that period just before homelessness, by asking a representative sample of almost 3,200 homeless people from all over the state about the chutes they fell into, and what would have helped. (Marc and Lynne Benioff, funders of the UCSF initiative, are also co-chairs and owners of TIME.) The study, published on June 20, was conducted between October 2021 and November 2022, and is the largest of its kind since the 1990s.

Some of the findings of the California Statewide Study of People Experiencing Homelessness , or CASPEH, were unsurprising: in the state with the nation’s largest homeless population , people are unhoused because they don’t have enough money, and their lives and health and safety get much worse after homelessness strikes—a quarter of all participants had experienced sexual violence at some point. But some of the report’s data runs counter to popular perception: most homeless people were not from out-of-state, contrary to the myth that people lacking housing move there because of the weather and policies, for example, and 40% of them were contending with homelessness for the first time.

The study also interviewed more than 300 of the participants in depth to get a more finely grained image of their situation and particularly the events that immediately preceded their misfortune. We asked the study’s lead author, Dr. Margot Kushel, a doctor and professor of Medicine at UCSF, to answer four questions about what the study found.

What Is the Link Between Homelessness and Mental Health?

The prevalence of mental illness and substance use among those experiencing homelessness is clear, but Kushel cautions that the vast majority of mental illness among the study participants is anxiety and depression. It’s likely the lack of resources exacerbates those conditions, rather than the illness causing the homelessness, she says.

“I think that the driving issue is clearly the deep poverty, that the median [monthly] household income for everyone in the household in the six months before homelessness was $960, in a state with the highest housing costs in the country,” she says. Other studies have noted that the end of pandemic stimulus payments and rising inflation has led to rents outpacing wages . The study notes that in 2023, California had only 24 units of affordable housing available for every 100 extremely low-income households.

Column: I Lived in My Car and Now I’m in Congress. We Need to Solve America’s Housing Crisis.

Nevertheless, Kushel also noted that treatment for substance addiction needed to be more available. Citing figures from the study, she notes that “one in five people who had a substance use problem while they were homeless wanted treatment, and couldn’t access it. That number should be zero.” Similarly the study found that two thirds of participants had mental health issues currently and only 18% were receiving any treatment. “That should be 100%,” says Kushel.

Where Were Homeless People Living Before?

There are three main places from which people tumble into homelessness: an institution like a prison, jail or drug treatment facility; a residence to which they had some legal connection, such as a mortgage or a lease; and a residence owned by somebody else, such as a family member or a friend.

The report suggests solutions include more—and more effective—halfway houses for formerly incarcerated people, and more— and more effective—eviction-prevention programs so people don’t lose the housing they have. But neither of those is going to help the large number of people whose penultimate stop is a relative’s or friend’s home. “You can’t build a homelessness prevention program only around eviction prevention,” says Kushel. “Those programs are important, but you’re going to miss a big chunk of people.”

Kushel points out that people who live with relatives and friends—and don’t have their name on the lease or mortgage—can’t, for example, provide a a notice of eviction. Their hosts are under no obligation to provide the 30-days notice that landlords have to provide. “That’s just not how it works,” says Kushel. “If you have no legal rights, your brother can kick you out at 3am if he wants to.” In response, the study suggests mediation services or other programs that can move more swiftly to catch people before they have to move out suddenly, as well as pilot programs for shared housing or for stipends to friends or relatives who open their homes.

Read more: Constance Woodson Worked Hard All Her Life. How Did She End Up Homeless During a Pandemic?

Why Did They Have to Leave Their Last Place?

Many people fall into what Kushel calls a “doom loop” of homelessness, where they have jobs, but those jobs don’t quite pay enough for them to be able to cover their expenses, so they lose their homes. Then they move into a family or friend’s home, which puts that living situation under pressure. “We’re talking about 10 people living in a one-bedroom apartment,” says Kushel. The chaotic sleeping, hygiene, and transport arrangements make it tough to keep working. And if they lose their jobs and can’t contribute any money, the tension ratchets even higher. Of the people living with relatives the researchers interviewed, 43% of them were paying no rent at all.

Kushel says there are off ramps on this loop that should be more widely used, pointing to “really exciting models of homelessness prevention, where in low income communities, they’ll have subway and bus posters saying, Are you at risk of becoming homeless? Call us. ” These programs might offer anything from infusions of cash and mediation services to a bunk bed and negotiations over cleaning. “What was really striking to us, was how little money people thought it would have taken,” says Kushel. Most participants suggested less than $500 a month or a one time payment of $10,000, would have kept them housed.

Where Did They Turn For Help Before Being Evicted?

The report found that two thirds of all the people interviewed did not seek help from anyone before they became homeless. And almost a quarter of those who turned to someone else for support, turned to families. In a perverse way, this might be good news, because it could mean that existing homelessness prevention services are working and people who seek help are able to stay housed. But it also suggests that the message that some help is available is not percolating to where it needs to go.

“What we know is that for prevention programs to work, there needs to be enough money and the right services,” Kushel says. “And also, they need to be targeted at the right people.” The CASPEH report recommends raising awareness about programs in places like local medical clinics, unemployment offices, public schools, churches, and bus stops in low income neighborhoods. It also advocates for educating those leaving institutional settings on their options for support. There aren’t currently enough services to meet the needs in California, says the report, and it calls for more. “But we also need to do a better job of getting the word out,” says Kushel. “We kind of know where people are at risk, and we need to meet them there.”

More Must-Reads from TIME

The New Face of Doctor Who
How Private Donors Shape Birth-Control Choices
What Happens if Trump Is Convicted ? Your Questions, Answered
Putin’s Enemies Are Struggling to Unite
The Deadly Digital Frontiers at the Border
Scientists Are Finding Out Just How Toxic Your Stuff Is
The 31 Most Anticipated Movies of Summer 2024
Want Weekly Recs on What to Watch, Read, and More? Sign Up for Worth Your Time

Real life stories

Here our clients share their experiences and their hopes for their recovery and the future. We would like to thank all the clients who have taken part.

Nicky’s story

Gary’s story

David’s story.

Caz’s story

Manuela’s story.

Lisa’s story

Sophia’s story

Denise’s story

Michelle’s story

Martin’s story

Stacey’s story

Chloe’s story

Mini’s story

Lee’s Story

Dumitru and Maria

3 Thomas More Square, Tower Hill, London E1W 1YW | 020 3856 6000 | [email protected]

Website by St Mungo’s. Maintained by Core Bid Management.

Resource Library

Appeals Policy Case Closure and Reopen Guidance Clearing House FAQs November 2022 Clearing House Nomination Policy & Procedure v1.1 Clearing House Sensitive Lets Policy & Procedure v1.1 Clearing House User Agreement v4 Complaints Policy Couples Referral Guidance Data Protection and Information Sharing Policy Eligibility Policy High Needs Quota Policy & Procedure Hostel Decant Policy & Procedure Nomination Guidance Nominations Appendix A – Allocations and Prioritisation NSNO Low Needs Staging Post Offer Policy & Procedure Policy Addendum Clarification 2019 Referral and Waiting List Policy & Procedure Referral Coaching Policy & Procedure – Volunteers v1.0 Referral Form Minimum Standards v1.2 Resettlement Policy & Procedure Tenancy Review Policy & Procedure Transfers Policy & Procedure

Clearing House Paper Copy of Online Form Client leaflet – Clearing House Client Privacy Notice Clearing House Client Portal Guide

Clearing House Borough stock map 2024 Guide Move-In Checklist Template TST Presentation for Referral Workers

RSAP Borough Bids User Guide

Booking a referral training session Landlord user guide Landlord video user guide Referral agency user guide Referral agency video user guide Tenancy Sustainment Team user guide Tenancy Sustainment Team video user guide CASA Referral guide CASA Referral video guide

A Case Study Using Shame Resilience Theory: Walking Each Other Home

Original Paper
Published: 08 January 2020
Volume 49 , pages 405–415, ( 2021 )

Cite this article

Tara Ryan-DeDominicis ORCID: orcid.org/0000-0003-1700-7287 1

1988 Accesses

4 Citations

3 Altmetric

Explore all metrics

Homelessness is an epidemic that affects thousands of people in the United States, the majority being single adults. Stigma and shame are emotions that can saturate the homeless experience. People who are experiencing homelessness can be subjected to shame from society, their community, and themselves, but also by the very organizations and social workers who are meant to help end their period of homelessness. When a person feels shamed and stigmatized by a social worker or organization, they are less likely to seek out or return and receive the services that can help them change their circumstances. Incorporating the key components of shame resilience theory (SRT) into the engagement phase with people who are experiencing homelessness can have an immense impact on that person’s ability to navigate their experience and build resiliency. The case presented is that of a woman who experienced homelessness for three years. Her experience highlights how shaming interactions with providers can lead to disengagement from services, while experiencing empathy and building shame resilience can lead to drastic change. By integrating the components of SRT into clinical practice with people who are experiencing homelessness, social workers will be informed regarding how to build a strong empathic relationship that is crucial to helping the individual build shame resilience and the ability to change their circumstances.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price includes VAT (Russian Federation)

Instant access to the full article PDF.

Rent this article via DeepDyve

Institutional subscriptions

Beyond a trauma-informed approach and towards shame-sensitive practice

Interventions with Survivors of Interpersonal Trauma: Addressing the Role of Shame

Working with Shame in Psychotherapy: An Eclectic Approach

American Psychological Association. (2010). The road to resilience . Retrieved November 13, 2019, from https://www.apa.org/helpcenter/road-resilience.aspx .

Allen, T. (1993). Someone to talk to: Care and control of the homeless (Doctoral dissertation, Simon Fraser University). Retrieved from https://www.worldcat.org/title/someone-to-talk-to-care-and-control-of-the-homeless/oclc/43574231 .

Bergen, A. (2008). A case for case studies: Exploring the use of case study design in community nursing research. Journal of Advanced Nursing, 31 , 926–934. https://doi.org/10.1046/j.1365-2648.2000.01356.x .

Article Google Scholar

Bowie, V. (2013). Trauma-informed care. Youth Studies Australia , 32 (4). Retrieved from https://www.youthpolicy.org/journals/youth-studies-australia/ .

Brown, B. (2006). Shame resilience theory: A grounded theory study on women and shame. Family in Society, 87 , 43–52.

Brown, B. (2007). I thought it was just me (but it isn’t) . New York: Penguin Groups.

Google Scholar

Brown, B. (2015a). Daring greatly: How the courage to be vulnerable transforms the way we live, love, parent, and lead . London: Penguin Books Ltd.

Brown, B. (2015b). Rising strong . New York: Spiegel & Grau.

Casida, J., & Lemanski, S. A. (2010). An evidence-based review on guided imagery utilization in adult cardiac surgery. Clinical Scholars Review . https://doi.org/10.1891/1939-2095.3.1.22 .

Dej, E. (2016). Psychocentrism and homelessness: The pathologization/responsibilization paradox. Mental Health & Distress as a Social Justice Issue, 10 (1), 1–19. https://doi.org/10.26522/ssj.v10i1.1349

Donley, A., & Jackson, E. (2014, January 1). Blending in: The presentation of self among homeless men in a gentrifying environment. Theory in Action , 7 , 46–64. https://doi.org/10.3798/tia.1937-0237.14003 .

Edwards, J. R. (1998). Person-environment fit theory: Conceptual foundations, empirical evidence, and directions for future research (Doctoral dissertation, University of North Carolina). Retrieved from https://public.kenan-flagler.unc.edu/faculty/edwardsj/edwardsetal1998.pdf .

Fall, K. L. (2015). Homeless men: Exploring the experience of shame (Doctoral dissertation, The University of Iowa). Retrieved from https://search.proquest.com/docview/165286794?accountid=13626 .

Farrell, D. (2012). Understanding the psychodynamics of chronic homelessness from a self-psychological perspective. Clinical Social Work Journal . https://doi.org/10.1007/s10615-012-0382-5 .

Gardner, T. (2010). Centralized intake for helping people experiencing homelessness: Overview, community profiles, and resources . Retrieved February 10, 2019, from https://files.hudexchange.info/resources/documents/HPRP_CentralizedIntake.pdf .

Gonzalez, V. (2018, March 29). For series on health threats facing homeless people, an emphasis on telling deeply human stories. Center for Health Journalism . Retrieved from https://www.centerforhealthjournalism.org/2018/03/27/series-health-threats-facing-homeless-people-emphasis-telling-deeply-human-stories .

Housing and Urban Development. (n.d.). Retrieved January 5, 2019, from https://www.hud.gov/ .

Jensen, P. R. (2018). Undignified dignity: Using humor to manage the stigma of mental illness and homelessness. Communication Quarterly, 66 , 20–37. https://doi.org/10.1080/01463373.2017.1325384 .

Kryda, A. D., & Compton, M. T. (2008). Mistrust of outreach workers and lack of confidence in available services among individuals who are street homeless. Community Mental Health Journal, 44 , 144–150. https://doi.org/10.1007/s10597-008-9163-6 .

Lewis, M. (2019). The self-conscious emotions and the role of shame in psychopathology. Handbook of Emotional Development . https://doi.org/10.1007/978-3-030-17332-6_13 .

Lorenzo, J., & Barbosa, A. (n.d.). Clinical social work with homeless people. Retrieved January 6, 2020, from https://www.naswnyc.org/page/173 .

Luhrmann, T. M. (2008). The street will drive you crazy: Why homeless psychotic women in the institutional circuit in the United States often say no to offers of help. The American Journal of Psychiatry, 165 (1), 15–25. https://doi.org/10.1176/appi.ajp.2007.0707116 .

Article PubMed Google Scholar

MacDonald, J., & Morley, I. (2001). Shame and non-disclosure: A study of the emotional isolation of people referred for psychotherapy. British Journal of Medical Psychology, 74 (21), 1–14. https://doi.org/10.1348/000711201160731 .

Mao, Y., Calder, M. J., Richter, S., & Burns, K. K. (2011). Framing homeless for the Canadian public: The news media and homelessness. Canadian Journal of Urban Research . Retrieved from https://www.thefreelibrary.com/_/print/PrintArticle.aspx?id=296951969 .

National Association of Social Workers. (n. d.). Retrieved November 13, 2019, from https://www.socialworkers.org/about/ethics/code-of-ethics/code-of-ethics-english .

O’Flaherty, B. (2009). What Shocks Precipitate Homelessness? Department of Economics Discussion Paper. Australian Social Work , 64 , 346–360. Retrieved from https://onlinelibrary.wiley.com/journal/14470748 .

Ogden, J., & Avade, T. (2011, May 1). Being homeless and the use and nonuse of services: A qualitative study. Journal of Community Psychology . https://doi.org/10.1002/jcop.20433 .

Salas, L. M., Sen, S., & Segal, E. A. (2018, May 3). Critical theory: Pathway from dichotomous to integrated social work practice. Families in Society, 91 , 91–95. https://doi.org/10.1606/1044-3894.3961 .

Shoai, S. (2014). Intake interview. In The clinical interviewing: Intake, assessment, and therapeutic alliance (pp. 26–28). Retrieved from https://www.psychotherapy.net/data/uploads/52d99900de254.pdf .

Stanhope, V., Tinderington, E., Henwood, B., & Padgett, D. (2012). Understanding how case managers use ‘sabotage’ as a frame for clinically difficult situations. Clinical Social Work Journal , 40 . https://doi.org/ https://doi-org.proxy.libraries.rutgers.edu/10.1007/s10615-012-0385 .

State of Homelessness. (2018). Retrieved January 6, 2020, from https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness-report/ .

The 2018 Annual Homeless Assessment Report to Congress. (2018). Retrieved May 9, 2019, from https://files.hudexchange.info/resources/documents/2018-AHAR-Part-1.pdf .

The Data Face. (2018). Retrieved December 2, 2019, from https://thedataface.com/2018/01/public-health/american-homelessness .

Tweed, R. G., Biswas-Diener, R., & Lehman, D. R. (2012). Self-perceived strengths among people who are homeless. The Journal of Positive Psychology , 7 , 481–492. Retrieved from https://www.tandfonline.com/loi/rpos20 .

United States Interagency Council on Homelessness. (n. d.). Retrieved February 16, 2019, from https://www.usich.gov/tools-for-action/homelessness-in-america/ .

Van Vliet, J. (2008). Shame and resilience in adulthood: A grounded theory study. Journal of Counseling Psychology, 55 , 233–245. https://doi.org/10.1037/0022-0167.55.2.233 .

Walker, R. (2014). The Shame of Poverty . Oxford, United Kingdom: Oxford University Press.

Book Google Scholar

Download references

Author information

Authors and affiliations.

Rutgers University, New Brunswick, USA

Tara Ryan-DeDominicis

You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Tara Ryan-DeDominicis .

Ethics declarations

Conflict of interest.

The authors declare that they have no conflict of interest.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Ryan-DeDominicis, T. A Case Study Using Shame Resilience Theory: Walking Each Other Home. Clin Soc Work J 49 , 405–415 (2021). https://doi.org/10.1007/s10615-019-00745-9

Download citation

Published : 08 January 2020

Issue Date : September 2021

DOI : https://doi.org/10.1007/s10615-019-00745-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Homelessness
Shame resilience theory
Find a journal
Publish with us
Track your research

Helpline 0808 800 0661

Real stories

We share the stories of those with lived experience of homelessness and those working to end it. Through these voices, we raise awareness, inform research and raise funds to support young people and to end youth homelessness.

If you would like to share your story - please submit it here

Addi's Story: I was labelled as naughty, but now I understand myself

Addi (22), who is neurodivergent, has been living at a Centrepoint service for eight months. He became homeless following a family breakdown. Now, he's preparing to move into his own place!

Independent Living
Jobs and employment
Sofa surfing

Zeph's Story: Don't be scared to ask for help

Zeph (18), who identifies as non-binary, was referred to Centrepoint’s therapeutic service for 16-18-year-old when they became homeless. They were able to attend a horticulture residential with the RHS ahead of the Chelsea Flower Show in 2023 and they are now studying Forensic Psychology at university and being supported by the Centrepoint Bursary.

Training and education

Idan's Story: A journey of healing

Idan (23) grew up in an unstable household. A particularly traumatic event resulted in her becoming homeless and led her to moving into a Centrepoint service. Now in her own place, Idan has started a journey of healing and stability.

Rough sleeping

Nadine's Story: Finding independence

Nadine (19) was in care for two and half years before returning to her mum's, but living together placed further strain on the relationship and she decided to move into semi-independent living. She received help from Centrepoint Works with key employability skills and has secured an apprenticeship with the organisation.

Care system

Yasmina's Story: Centrepoint's Independent Living Programme provided me with safety and stability

Yasmina became homeless after fleeing abuse. She is now living in one of Centrepoint's Independent Living properties where she has been able to focus on her future.

Aysar's Story: Finding acceptance and confidence at Centrepoint

Aysar became homeless after his family found out about a same-sex relationship. Centrepoint have supported Aysar with his mental health and finding employment. He hopes to move into his own accommodation soon.

Layla's Story: Dreaming of a stable life

Layla became homeless at 18. She called the Centrepoint Helpline who were able to arrange an assessment with the Homeless Prevention and Relief Service (HPRS) in Manchester. She is now living in a self-contained flat and supported by Centrepoint’s Floating Support Team.

Ben's Story: A lasting relationship

Ben became homeless at 15 and for the remainder of his teenage years, he moved between hostels, B&Bs, shelters and rough sleeping. At 19, Ben was placed into a Centrepoint hostel and from there a Centrepoint self-contained flat where he met staff members that were to have a lasting impact on his life.

Benjamin's Story: The impact of a volunteer

Benjamin became homeless aged 17 and was referred to Centrepoint through social services. He has been supported in a variety of areas including mental health and benefited from working with one of Centrepoint’s amazing volunteers, a chef called Ben Mariner. This is his story.

Georges' Story: Life after Centrepoint

Georges became homeless in 2016 and was referred to Centrepoint through social services. He originally shared his story back in 2018, but five years after leaving Centrepoint, we spoke with Georges again to share his experiences and learnings.

Joe's story: Leaving rough sleeping behind

Joe was supported by Centrepoint in Manchester on and off over a number of years, but it’s only recently that Joe has been ready to turn his life around. From sleeping in every doorway in Manchester City Centre, Joe is now in a stable place and looking forward to the future.g summary

Katy's story: Construction shouldn't be a male domain

The Centrepoint Bursary has made such a difference to Katy* throughout her carpentry course. It has provided funding for clothing, carpentry tools as well as travel to college and construction sites which has made it possible for Katy not only to access, but also sustain her training. She is hopes to go on to work in construction management.

Health & Homelessness Case Studies

Added 16 February 2023

People experiencing homelessness experience some of the worst health outcomes in society. Following on from Homeless Link's recently published ' The Unhealthy State of Homelessness' report, this briefing shares good practice case studies from organisations who have developed new ways of working to improve the health outcomes of the people they support.

The case studies include short videos and links to toolkits to provide further depth and context about how organisations have designed programmes, alongside quotes from people who have benefited from them.

Who is this briefing for?

Frontline Homeless Services
Local Authorities

Health Case Studies

Research article
Open access
Published: 22 May 2021

Women in a situation of homelessness and violence: a single-case study using the photo-elicitation technique

Clara Isabel Posada-Abadía 1 ,
Carolina Marín-Martín ORCID: orcid.org/0000-0001-6628-9669 2 ,
Cristina Oter-Quintana ORCID: orcid.org/0000-0002-2192-5120 3 &
María Teresa González-Gil ORCID: orcid.org/0000-0002-8935-3528 3

BMC Women's Health volume 21 , Article number: 216 ( 2021 ) Cite this article

8132 Accesses

6 Citations

4 Altmetric

Metrics details

Violence against women places them in a vulnerable position with regard to homelessness. Although sometimes invisible, women’s homelessness is a complex reality shrouded in dramatic biographies that should be sensitively addressed to avoid revictimization.

With the aim of understanding the chaotic discourse of homeless women’s experiences of violence, a qualitative single-case study was conducted using the photo-elicitation technique. Data were analyzed in accordance with grounded theory.

The participant’s discourse could be summarized in the following categories: “Living in a spiral of violence”, “Confronting vulnerability and violence”, “Being a strong woman”, “New family networks”, “Re-building mother–child relationships”, and “Nurturing spiritual wellbeing”.

Conclusions

Supporting homelessness women requires an approach that focuses on the prevention of re-victimization and the consequences of violence in terms of physical and mental health. Shelters are spaces of care for recovery and represent referential elements for the re-construction of self.

Peer Review reports

There are processes and situations that define women’s life paths and place them in extremely vulnerable scenarios. An example of this is homelessness. In recent decades, the study of the phenomenon of female homelessness has made it possible to ascertain the relevance of any form of violence against women in the lives of homeless women [ 1 , 2 , 3 ]. As adults, domestic violence may lead them to homelessness as they leave their homes to escape abuse [ 4 , 5 ]. In other cases, when women are unable to access housing, they are forced to endure abuse and violence [ 6 ]. In addition, women who remain on the streets are regular victims of rape, sexual assault, robbery, insults, and threats. Shelters for homeless people are not safe spaces for them, as they are then at risk of being physically or sexually assaulted by other residents [ 7 ].

Even though being a victim of certain forms of violence, such as intimate partner violence, makes it possible for women to access specific housing resources, sometimes women’s biographies involve victimization accounts of certain types of “violence” for which there is a lack of a specific network of care. In other instances, their experiences of violence may remain invisible in the eyes of professionals [ 8 ], which is when their homelessness is seen as the primary problem and they are thus housed in specific residential facilities for this population.

Homelessness has emerged as a growing concern in a number of countries, irrespective of the continent or the per capita income of cities, suggesting that the phenomenon may be a more structural and/or social problem. For instance, in Madrid, Spain, the most recent nightly survey of homeless people identified 2998 individuals living in shelters, shelters for immigrants or social housing, or sleeping rough. Of those 2998 individuals, 11.2% were women. According to the same survey, 55.1% of homeless people said that they had been victims of some type of violence on the street. Gender-based violence was mentioned by 2.3% of the women as one of the main reasons for sleeping on the street, by 3% in the case of women living in a shelter, and by 7.4% of women living in social housing [ 9 ].

A number of studies report the role of structural and interpersonal gender-based violence in the trajectories of homeless women [ 10 , 11 , 12 ] and the relevance of gender-based violence in their pathways to homelessness. Understanding and looking deeper into biographies shaped by violence and the effects of said violence on the different aspects of the individual is thus extremely relevant and necessary for the design of policies and strategies to be able to meet demands for care. However, it is important for research to be conducted in a sensitive manner to avoid revictimizing women and for it to promote their empowerment using a trauma-informed approach to research [ 13 , 14 ] and the emancipatory nursing praxis (ENP) as a nursing theory of social justice.

In line with the considerations set out above, this case study aims to unravel the chaotic discourse of a suffering woman who is repeatedly subjected to gender-based violence. Furthermore, on a methodological level, this study aims to demonstrate the experience of working with photo-elicitation [ 15 ], a tool with great potential when it comes to guiding and facilitating discourse production in individuals in a situation of extreme vulnerability. This technique offers us the possibility to facilitate the production of meaningfully rich data while empowering participants and keeping them safe from revictimization.

Contextualization of the case study

This case study is part of a larger study that aims to determine how homeless women perceive the violence they are exposed to and/or have experienced. To this end, a qualitative study was conducted under the theoretical proposal of symbolic interactionism and the methodological approach of grounded theory [ 16 ].

Maria (her name has been changed for anonymity) was recruited in the context of an observation program conducted using in-depth interviews in different shelters belonging to the municipal resource network of the Madrid City Council, Spain. Her account was identified as especially meaningful among the experiences of the 20 homeless women who were interviewed, exhibiting experiential characteristics relevant to the understanding of the phenomenon under study. It is for this reason that we set out to work from a single case study approach of an intrinsic nature.

Case studies focus on the uniqueness and complexity of a single case, gaining an in-depth understanding of it. Qualitative case studies are thus characterized by their intense nature, providing a deep, dense, and holistic description of a specific phenomenon from a naturalistic perspective.

In particular, we chose to conduct a unique case study of an instrumental nature, that is, the study of a critical or revealing case with its own suggestive characteristics that illustrates an exemplary situation. Our objective and reasons for doing so were, beyond simply understanding this individual’s particular situation, to contribute to the understanding of a broader phenomenon and to refine theoretical proposals [ 17 ].

The participant

One of twenty women interviewed, Maria provided highly valuable data to clarify and shed light on certain aspects, key for the overall understanding of the adaptive processes of homeless women who are victims of violence and their struggle to move on and become highly resilient survivors. Maria is a middle-aged woman immigrant with primary education who arrived in Spain fleeing a situation of domestic violence in which she had been suffering since childhood, leaving her two children in her country of birth. Since her arrival in Spain, she has gone through different scenarios and situations of gender-based violence that have led her to homelessness. Despite the consequences that the experiences of violence had on her physical and mental health, Maria was able to develop coping strategies to give meaning to her life and keep her hope alive.

Data collection

Data on Maria’s narrative were collected in different stages. The first stage consisted of conducting an in-depth interview in parallel with the interviews conducted with other participants in the study. An interview script was developed as a supporting element for the researcher (main author) (Table 1 ). The dynamic interview questions were designed based on the objectives, and the specific research questions were adapted to the participant’s level of understanding. Special attention was also paid to aspects related to the amplitude versus the specificity of the questions and the sensitivity and intimate nature of their content. The interview had a duration of 100 min and was recorded on audiotape for subsequent analysis with Maria’s permission.

During data analysis, some meaningful elements emerged, inviting us to return to the field to delve deeper into and explore nuances, attributes and characteristics. One of these core elements that shaped Maria’s experience was artistic creation as an expressive resource and as a tool to work on coping and resilience. We met with Maria again to invite her to participate in our proposal to collect data on artistic activities, which were important in providing her with motivation.

Specifically, she was asked to continue to elaborate on her experiences through photo-elicitation. In this methodological proposal, first described by Collier in 1957 in the field of visual anthropology, photographic images are to be used as an evocative and provocative element of the informant’s experience, stimulating deep emotional aspects of their experience and rescuing visual metaphors as expressive and discursive elements of great potential [ 15 , 16 , 17 ]. In addition, Wang and Burris [ 18 ], allude to this technique with the term “photovoice” in the context of community research. These authors understand that the potential of this technique lies in giving people a voice through photography in what constitutes a creative and empowering process for them. Through photovoice, the individual identifies, captures, and visually represents aspects of their environment and daily experiences using photography, which then makes it possible to analyze the problems, strengths, and ups and downs of daily life through critical and reflective dialogue.

Previous studies have reported different experiences in the field where photography has been used as a provocative element in the sensitive discourse of individuals in particularly vulnerable situations, such as those of individuals with mental health problems [ 19 ], women who are victims of gender-based violence [ 20 ] and homeless women [ 21 ].

In this second meeting, Maria was told about the photo-elicitation technique, and she chose to use the camera on her own cell phone to take the pictures. It was explained to her that she could take pictures of things, objects, actions, places, or people (with their consent and without taking pictures or capturing elements that might reveal the person’s identity) that she considered significant in relation to her experience of recovery, coping, and resilience. She was also asked to write a brief commentary on each of the photographs, briefly summarizing why she chose to take that photo and explaining its significance. Maria took the photographs over a period of four weeks, which consisted of a total of 24 pictures. She decided to print them herself and write her reflections on the back in her own handwriting. Once the task was completed, the principal investigator collected the iconographic material to prepare the subsequent discursive meeting. In order to prepare this second interview using the photographs as an evocative element, a script was made using one of the photographs as an example (Table 2 ). The script was designed by two researchers individually, who agreed on a single proposal based on 14 of the 24 pictures taken by the participant (Table 3 ).

The interview was conducted in a meeting room of the shelter itself by the two researchers (main author and corresponding author) and had a duration of 100 min. During the interview, the interviewers sat on either side of Maria, keeping a distance of about 20 inches from her, and without any other elements in between (at a round table). The researcher was to show the photographs in the order suggested by the participant’s discourse, introducing the questions as appropriate. This task required a certain level of concentration and capacity of interrelation between the evocative resources and the evoked discourse. The second interviewer, on the other hand, focused on registering significant discursive aspects (as field notes) and introducing clarifying and explanatory questions in this respect. The interview was recorded on audiotape and transcribed in its entirety for subsequent analysis.

The analysis of the discourse produced during the first in-depth interview was performed by the main author following the grounded theory proposal [ 22 ], that is, an open coding of the interview was performed by identifying significant elements, the meaning of which, in relation to the study objectives, was condensed by means of free codes and in-vivo codes. Each of these codes was defined to form a glossary of codes. Some of these comments on the codes gave rise to incipient interpretative memos when compared to the analysis of interviews with other women. Subsequently, all the codes identified were interrelated in the form of a network in order to build a guide map to further deepen our understanding of Maria’s experience. This first phase of coding as assisted by Atlas.ti software (version 8.0).

The analysis of the photographs and the discourse produced during the interview was performed in different phases, as shown in Table 4 , by main and corresponding authors. Firstly, an iconographic analysis of the images was carried out from the point of view of the manifest content, that is, from an essentially descriptive perspective of the element photographed [ 16 ]. This description was then linked to the written reflections written by Maria on the back of the picture and the discourse she produced during the interview with the picture in question. Once the materials had been interrelated, we proceeded to work on the open coding, taking as a reference the previously prepared glossary of codes, incorporating new codes and redefining others that were pre-existing. Codes were regrouped to create semantic groups that, little by little, gave shape to those categories that summarizes Maria’s process of coping, revealing the latent content of her discourse [ 16 ].

Ethical considerations

This study was approved by the Clinical Research Ethics Committee of Autonomous University of Madrid, Spain, under file number CEI-84-1555. Maria’s decision regarding whether or not to participate in the study was respected at all times and she was provided with all the information regarding the objectives of the research and the purpose, conditions, and possible benefits of her participation in it by means of an informed written consent form. Maria’s privacy and the confidentiality of her data were safeguarded by assigning codes and fictitious names to the individuals mentioned in her discourse. The provided participant name is fictitious and other possible in identifiers such as age and country of origin have been avoided. In addition, iconographic data have been pixelated guaranteeing participant anonymity.

Throughout the data collection process, special care was also taken to manage the emotional vulnerability of the participant through constant reflexivity and flexibility [ 23 ], by maintaining a sensitive attitude during the interview (using active listening, empathy) aimed at perceiving painful aspects and generating confidence and calm. In addition, the interview script questions, developed by themes and dynamic questions, were ordered using the “exploratory funnel” strategy, starting with questions of a more general nature and ending with the more specific and sensitive ones [ 24 ], supported by recovery models such as the “Tidal model”, by Phil Barker and Poppy Buchanan-Barker [ 25 ] and the “Self-transcendence” model, by Pamela Reeds [ 26 ].

Quality criteria

Different strategies were considered to ensure the internal validity of the findings in terms of reliability and verifiability. Thus, during the research process, we worked on triangulating the researchers, both for the planning of the interviews and for the analysis of the data. In addition, study reports have been periodically produced and have been reviewed by an external expert. His recommendations, comments, and questions have served to delve deeper into some key aspects for their clarification.

Once the data had been analyzed and the report on the findings had been prepared, it was presented to Maria, so that she could read it and judge how her experience was reflected in it.

A sustained effort has been made to provide a detailed description of each of the processes undertaken in order to ensure the transparency of the research process and its methodological rigor.

Finally, a critical and reflective attitude has been maintained at all times by the researchers as a result of their commitment to considering themselves to be research tools [ 23 , 27 ].

Maria’s experience has allowed her to provide an example of and illustrate very concrete and significant aspects of the experience of gender-based violence, homelessness, and the process of coping with vulnerability as a homeless woman. Her discourse may be summarized in the categories explained and illustrated below:

Living in a spiral of violence

Gender-based violence in its different forms is present throughout Maria’s biography. Maria was born and lived her childhood and adolescence in a dysfunctional family environment where family violence was a part of everyday life. In her daily life, the maternal figure is blurred, without any female figure representing a reference point. She refers to her mother as both a recipient and giver of violence, fulfilling roles of submission and domination at the same time, maintaining power relationships that, in themselves, structure, normalize, and perpetuate violent relationships. Maria grew up in a hostile environment where she was socialized in a culture of abuse and violence and internalizes some attributes and characteristics of the female gender role that are very much tainted and conditioned by these values and beliefs. Maria grew up in the shadow of a negligent upbringing model, with no emotional ties, attachment relationships, or solid network to support her.

Then... among the members of my family everything was dirty because of drug trafficking, cocaine from drug trafficking; I was already being abused by my father, by my mother […]. I was sexually abused in my childhood repeatedly by the lovers my mother brought home! She’d sneak them into the house behind my father’s back... I remember that they used to touch my legs, my privates... up here as well (touching her breasts) [...].I was sexually abused many times in my childhood [...]. I do not have one nice memory, everything [I remember] is awful!

During adolescence and early adulthood, as a consequence of this culture of violence against women, Maria was subjected to sexual violence, raped by people in her family environment, resulting in two unwanted pregnancies. It is then that she began to experience first-hand the objectification of women. Sexual violence engulfs her everyday life and pushes aside the notion of healthy interpersonal relationships to an unreachable place. Relationships were constructed by and identified with violence; violence became, therefore, Maria’s way of relating to her environment.

[…] Neither was adolescence. I was raped and had two children who are not the fruit of love, but of rape... So what life have I had? An awful life, a hard life! […]. I was sexually abused, sexually abused by uncles, nephews, cousins […].

Maria then decided to put distance between herself and the violence and flee from this scenario, leaving her two very young children behind. During her escape, she unknowingly entered a network of women traffickers where gender-based violence against women made her an “item of merchandise”. For almost ten years, she was sexually exploited and, at the same time, she was forced to use narcotics to be able to keep up with carrying out sex work 24 h a day, due to being in an intensive and alienating production system. It was at this stage that sexual violence became linked to economic violence. Violence became the only element that linked her to her surroundings, trapping her in a dead-end spiral where violence feeds on violence, with the exercise of violence being the only way to survive this situation.

[…] I was pimped [...]. I was sold off for two horses [...]. I was practically trafficked, [that was] human trafficking, sex slavery. I didn’t choose that life, it chose me, I didn’t choose it.

At this moment, Maria says that she lost her sense of self. Her identity is blurred to adopt blurred, indecipherable, unrecognizable strokes. With nothing left to lose, but still with the hope of regaining her identity and her lost life, Maria decided to put an end to this situation and escaped again.

Leaving the previous situation meant entering a situation of structural violence. In spite of having been able to report the situation she has experienced, Maria found herself without the necessary resources to support herself in her situation of real vulnerability, which is when her experience of homelessness and begging started. The streets became a place to live in and from which to live and, little by little, begging was replaced by theft, which eventually led to another scenario of violence: prison. Maria’s discourse invites us once again to reflect on the structural violence (administrative-legislative) that relocated her to a new scenario where freedom was taken away from her.

[…] Once on the streets, I started serving jail time, all because of petty theft, nothing violent [...]. It was all because of stealing for my sustenance, that’s when I became a criminal.

In prison, Maria found a hostile environment where symbolic violence was exercised by both the institution and her peers. According to her discourse, this last experience was the straw that broke the camel’s back, overwhelmed her, and accelerated a series of health-illness processes in her physical and mental spheres. Far from being able to be considered, to a greater or lesser extent, a rehabilitative resource, prison ended up devastating Maria’s identity, stripping her of all traces of dignity, self-recognition, and hope. Maria’s entire life journey through violence manifests itself explicitly with signs and symptoms consistent with post-traumatic stress disorder.

After serving her sentence, Maria took to the streets, where she once again faced homelessness, this time without intrapersonal or interpersonal resources and in a situation of extreme vulnerability and social exclusion. It is at this point that she entered the social support network through the street services and began her life experience in the shelter.

[…] I was on the streets like a ‘loony’, for almost two and a half years... [...] ... stealing. I went to prison for three years... I’m screwed; I have post-traumatic stress, with bipolar disorder [...], many diseases... [...]... I’m celiac... [I have] problems with my breasts...

Some time after being in the shelter, after intense work and important advances in the recovery process, Maria met her partner with whom she built a life project outside the shelter, as a result of her interaction with her peers in the shelter and her search to establishing emotional bonds. This relationship is understood by Maria as a bid to build a full and meaningful life, with the loved one as the core element. However, intimate partner violence emerged to complete the spiral of gender-based violence and sent her back to the streets, forcing her to return to the shelter, to the comfort and support of what she understands as her only family.

[…] He approached me as a friend and I began to fall in love with him... I had never felt anything like that about anyone before... He asked me to leave [the shelter] and so we did... He had an income and we lived on it in a room... and we got married. […].Over time, he began to mistreat me, to insult me... shocking jealousy and from there to the arguments, fights... hitting... and after two years, one day he threw me out of the room and I was back on the street with my luggage...

Confronting vulnerability and violence

Faced with a life full of violence and in a situation of extreme social vulnerability, Maria reflects on her strength and capacity to overcome obstacles. Different coping strategies are identified in her discourse such as: the redefinition of herself as a strong woman; the creation of new family networks; the strengthening of a maternal role in her own identity; and the nurturing of her spiritual wellbeing. The development of these strategies has allowed her to advance in her recovery process, that is, to advance in the redefinition of herself and in the recovery of her capacity of self-determination and ability to make decisions about her own life, so that she can achieve a sense of fulfillment, a sense of personal wellbeing and health, and of social involvement and good quality of life. Maria’s discourse, however, does not allow us to identify procedural aspects that clarify when these strategies were developed or what factors may have facilitated or promoted their development. Instead, her narrative, which is viewed through a certain retrospective lens, touches on these resources in terms of results. Nevertheless, one can sense a decisive event that marks a change in her path, which is her leaving the streets and taking refuge in the shelter.

[…] I think you have to have like a... how should I put it?! I can’t explain it, be myself! To be, to continue with what I have to do, not being involved in prostitution, drugs... [Now I feel] that I am kind of free, I am free in spirit [...], that I can do what I want: eat, paint, sleep; nobody harasses me, I’m not on drugs, I have my freedom, I can go to church, paint, be in the shelter; I can talk, it’s like… something that’s very beautiful, it’s something wonderful, something I don’t know how to explain; I am now kind of free from where I was for so long; I was pimped for many years, forced to be with various men, I was like that back then and now I am free from anyone telling me to do this or that; when they tell me something here they tell me nicely, and, to me, that means freedom, I am finally free.

Being a strong woman

Maria understands herself as a strong woman, interpreting strength from the notion of vigor, vitality, drive, nerve, or energy. At the same time, in her discourse one can glimpse the idea of strength as a bastion or bulwark, that is, as a solid and strong space for defensive tasks. Without a doubt, the case of Maria metaphorically responds to the idea of a bastion within a defensive stronghold in the face of continued attacks on her person, the various forms of violence.

[…] I say I don’t know if I’m strong or if I’ve been touched by a star or... what has touched me? Tell me! […]. I found it (see Table 3 , picture 9) around Príncipe Pio and I brought it and kept it in my room [...]. Ah, yes, how beautiful, I don’t know, this picture is impressive [...]. I see her as being very angelic, with a very angelic face, I see her as being natural [...], I consider her to be strong. In all that I do… here, for 24 years, I’ve kept holding on and I consider myself strong; I think I am strong; I don’t know if I may be strong to other people, but I think I am strong.

She recognizes a gift, a star, in this strength, and is aware of the other women who, having shared experiences similar to hers, have fallen by the wayside. She sees in feminine attributes and characteristics a great capacity for self-improvement and resilience with which she identifies and builds herself by rebuilding and strengthening her identity.

New family networks

In her discourse, Maria refers to the creation of new support networks and the establishment of new bonds, which she understands as her new family.

Her process of re-affiliation through new social bonds became her main material and emotional resource for her subsistence and adaptation to daily life. The establishment of networks not only with other homeless individuals, but also with personnel from the shelter, people from neighboring areas, religious institutions, and support associations, allows her to improve her self-esteem and sense of belonging by reducing her isolation and feelings of loneliness.

[…] My family couldn’t be bothered to look for me or anything, I pulled through by myself and with the help of the shelter. Your family is where you live! This is my family!

The shelter thus became her reference point, her emotional family, her home. Therefore, her home is interpreted as a relational space that provides her with protection against the dangers of the streets. Maria refers to the shelter as her formal adaptive psychosocial support network, where she has established special bonds with the center’s staff and other users. Interaction with what surrounds her and those around her allows her to build new meanings around the reality she has come to live, by sharing beliefs and values, ways of doing and understanding things, which link her to the shelter, even to the point of considering it as “her home”. The shelter, and her belonging to it, takes on meaning by becoming that which she never had at her side, her family. In addition, Maria also makes the space her own by decorating rooms with her works, which shows how our home shapes our identity and vice versa.

Freedom is what I have always longed for, what I am looking for; I came here from my country looking for that freedom, to get out of the horror of my family..., I came here to bring order to my life, to see what a home really is, in spite of everything, and all this is the next best thing... paintings of mine that I have been doing as therapy to get out of my system everything that I had inside, all that anger, fear, pain, and I wear it like a tattoo so that I don’t forget my country, to which I will never return, not even to meet my children.

Re-building mother–child relationships

For Maria, the fact that she missed out on raising her children generates frustration and pain. Her childhood experiences of lack of love and care became learned behaviors from her mother’s role as a model of insecurity in her relationships and, consequently, deficiencies in her supporting role for her children. The loss of all contact with them over many years leads her to work on redefining mother–child relationships and maternal roles in order to justify a vital motivation and overcome “the pain of an unfulfilled role”. She alludes to the fact that it is violence which has deprived her of the opportunity to become a mother using the expression “the children that have been ripped out”. Maria feels motivated and hopes to establish emotional ties with her children and now grandchildren; to rebuild the emotional bond that was broken by time and space after years of separation.

I dream of all of us being together, meeting and touching my children. I haven't touched them for years, since I came here... My children were babies when I left them. Now they each have their own life and I have mine. […] I have so many aspirations in life… I aspire to many things... to get out of these rough patches. I would like to have my children by my side, to aspire to see them, to have them and be with my family... It is one of my main aspirations, to meet my three grandchildren... but it is impossible, I do not know why this has happened to me; it is impossible, the girl has another culture and the boy too; they already have different lives. [...] They are the children that have been ripped out, they were ripped out of me.

Nurturing spiritual wellbeing

Nurturing spiritual wellbeing by “seeking balance” refers to Maria’s willingness to experience and integrate the meaning and purpose of life by connecting with the self, others, art, music, literature, nature, or a higher power than oneself, which can be strengthened. In her discourse, Maria alludes to the search for this wellbeing through various aesthetic and creative resources. Thus, she refers to having found in artistic creation processes a way to represent and externalize her pain and suffering. Creative processes thus became a key element in her recovery process, with great therapeutic potential. Writing, painting and photography are understood as projective elements that allow her to explore her emotions, perceptions, and behaviors from within her freedom, providing opportunities for self-knowledge and personal growth.

When I paint I feel very happy, I forget about all my problems, my hand doesn't shake, I forget about terrible things [...]. I like to paint, to be calm, and to get out everything I have inside.

This intrapersonal knowledge opens up one’s consciousness to working on the spiritual dimension and encourages the development of new strategies and resources for self-transcendence. In Maria’s case, moreover, religious beliefs and practices (reading the Bible, praying, volunteering in a church) coexist to enhance and promote this spiritual work, which gives her self-confidence and hope.

(See Table 3 , picture 1) I’d sit there and say: My God, I must have a balance! When I leave here I have to be stable and not get into drugs, alcohol, prostitution... God give me that strength!

Maria’s case study had a twofold purpose: to understand the experience of a homeless woman who was a victim of gender-based violence, which was considered to be a particularly representative case because of her ability to cope with adversity; and to generate a space for free research where the participant and the researchers could test new discursive codes to explore the experiences she had lived.

Through photo-elicitation it has been possible to share a genuinely different experience, capable of expanding discursive possibilities when with words alone it is difficult to support the narrative of experiences because of their harshness and situations of extreme vulnerability [ 28 , 29 ]. Nevertheless, it is necessary to point out that this technique has required effort, time, capacity for introspection, as well as certain skills in the use of technical means from Maria. In addition, this technique has been expensive for the researchers themselves, since it has required a complex process of planning, monitoring, and analysis.

Through this case study, Maria was able to describe numerous situations throughout her biography where violence (in all its forms and aspects) was present in various situations occurring consecutively, from childhood to mature adulthood. Homeless women are a very heterogeneous group and, as a result, so are the paths that lead them to homelessness as well as their later trajectories. However, there are circumstances, such as violence, that put them in a particularly vulnerable situation. Violence in the family environment during childhood is pointed out in numerous studies as a common factor for many of these women [ 30 ].

These experiences of violence have resulted in serious physical and mental health problems. Consistent with Maria's experience, the evidence indicates that post-traumatic stress disorder is the most frequently developed mental health disorder among victims of various forms of emotional, physical and sexual violence in both childhood and adulthood [ 3 ] and that this condition strongly influences the development of coping styles [ 31 , 32 ]. Cumulative exposure to stressful events, mostly related to violence (with special emphasis on domestic violence and childhood sexual abuse), is also a factor related to substance abuse. Homeless women refer to the fact that, sometimes, substance abuse is closely linked to the relational environment in which they live. On other occasions, there is a therapeutic justification for substance abuse, such as the self-management of anxiety and emotional distress [ 33 ].

In addition, we see how Maria has been in and out of homelessness at different times in her life. In line with this, Broll and Huey [ 34 ] conclude that homelessness tends to be cyclical, with women entering and leaving this situation. The results of the monitoring of a cohort of 269 homeless women suggest that this trend is greater among women who have experienced multiple forms of violence (e.g. physical or sexual abuse) during different stages in life (childhood and adulthood).

In spite of the circumstances experienced and their impact on women’s physical and mental health, women still seek and find motivation to continue to fight and move forward [ 30 ]. The latter can also be clearly seen in Maria’s narrative. The identification and exploitation of internal resources, the strength she refers to, hint at coping from an adaptive approach, which is grounded in an exercise of restructuring and redefining one’s own self and one’s support environment [ 35 ]. The way in which she describes herself is from her encounters with others; it is from relationships that the individual is identified and reconstructed [ 36 ], tracing the path to move forward [ 37 ].

The lack of a family and affective ties makes Maria transform the shelter into her “home” by generating new networks that allow her social ties to be re-affiliated, thus reducing isolation and the feeling of loneliness. This experience is consistent with the findings of Groton and Radey [ 38 ], who mention the loss of primary social networks such as the family and violence in the relationships within one’s social networks as key elements leading to homelessness. They also conclude that building new social networks is a powerful coping mechanism and that willingness to help peers generates a strong sense of wellbeing. Other studies also mention that living together in shelters enhances empowerment and self-esteem [ 39 ] and individuals interpret their experiences there as positive, particularly with respect to staff. In general, the shelter is a place of respite, providing safety and warmth after having been abused and socially isolated [ 40 ].

Domestic violence in childhood and intimate partner violence are significant psychosocial contextual factors that affect the regulation of emotions, fostering the development of post-traumatic stress and compromising future parenting [ 41 ]. In addition, learned helplessness [ 42 ] and the distorted maternal role model, with no reference figures or child attachment, shape the individual’s future ability to provide safe parenting [ 43 ], defining a profile of vulnerability in one’s role as a mother. Similarly, maternal identity is compromised by not fulfilling one’s role as a mother [ 44 ]. The restoration of mother–child ties would not only allow her to learn about the fate of her relatives and children, but also to heal wounds and rebuild her relationship with them. These findings reinforce the importance of supporting maternal mental health and facilitating processes that allow women exposed to violence to recover [ 45 ].

Moreover, cultivating spirituality is another key aspect of recovery from trauma, focusing on oneself as a form of self-care, regaining control and empowerment [ 46 ] and God as a source of comfort and post-traumatic growth [ 47 ]. This echoes the findings of Ahuja et al., who conclude that levels of subjective wellbeing are lower among homeless people (“unhoused people”) compared to housed participants, especially in dimensions such as social connectedness, negative emotions, perceived stressors, and resilience. On the other hand, spirituality and religiosity are more developed among unhoused people, who experience a more pronounced need to search for meaning and connect with a higher being [ 48 ].

Finally, the exploration and expression of feelings through artistic creation, in the case of Maria, show that art therapy based on creative processes helps to improve the therapeutic relationship, restore balance, and channel emotions [ 49 ]. This finding demonstrates the importance of using art as therapy to improve self-esteem and provide more positive future prospects [ 50 ]. Creative processes facilitate the construction of escape spaces where one is able to “switch off”, to “change reality”, to “isolate oneself”, and they constitute a powerful strategy for the control of anxiety and emotional suffering. Through creative processes, emotions are identified, evoked, channeled, and transferred. At the same time, homeless people identify these spaces as safe and healing and as a tool for self-knowledge and for the transformation of their relationship with themselves. These are spaces that facilitate self-expression by recognizing oneself in one’s creations, exploring one’s own identity, and rediscovering facets of oneself that one did not think existed, but do exist [ 50 ]. The findings described in this study may have implications for both shelter policy and practice with respect to caring for homeless women, but also for addressing their mental health and social and family integration.

To conclude, it should be noted that the reality of the victimization of homeless women requires approaches along the lines of “trauma-informed care”, a philosophy of care that focuses on the recovery of women, taking into account their pathways of exposure to gender-based violence, emphasizing their physical and emotional safety, their recovery of self-control, their strengths versus their weaknesses or deficits, and, ultimately, strengthening their capacity for resilience and empowerment [ 51 ].

Gender-based violence, in its different aspects and representations, is a constant in the trajectories of homeless women. Welcoming and supporting them requires an approach that focuses on the prevention of re-victimization, as well as on the consequences of this violence in terms of physical and mental health. Shelters emerge as spaces of care for recovery and represent referential elements for the re-construction of bonding relationships, the creation of supportive environments, and the meeting point of development spaces in freedom and the capacity for self-determination. Sensitive, trauma-informed research should be used to inform the support offered to homeless women as part of narrative advocacy-based care.

Availability of data and material

The complete (de-identified) dataset generated and analysed during the current study can be made available from the corresponding author on reasonable request.

Abbreviations

Magister Scientiae (Master of Science. Master Degree)

Philosophiæ doctor (Doctor. The highest University Degree)

Philosophiæ doctor candidate

Psychologist

Registered nurse

European Federation of National Organisations Working with the Homeless FEANTSA. Homelessness and domestic violence. [Internet]. [Cited 25 Feb 2021]. Available from: https://www.feantsa.org/download/final_homelessness_and_domestic_violence39146818459563100.pdf .

Mayock P, Bretherton J, Baptista I. Women’s homelessness and domestic violence: (In)visible interactions. Women’s Homelessness Europe. 2017;6:127–54. https://doi.org/10.1057/978-1-137-54516-9_6 .

Article Google Scholar

Wong LH, Shumway M, Flentje A, Riley E. Multiple types of childhood and adult violence among homeless and unstably housed women in San Francisco. Violence Vict. 2016. https://doi.org/10.1891/0886-6708 .

Article PubMed PubMed Central Google Scholar

Murray S. Violence against homeless women: Safety and social policy. Aust Soc Work. 2011. https://doi.org/10.1080/0312407X.2011.552983 .

Tutty LM, Ogden C, Giurgiu B, Weaver-Dunlop G. I built my house of hope. Violence Against Women. 2013. https://doi.org/10.1177/1077801213517514 .

Article PubMed Google Scholar

Mayock P, Sheridan S, Parker S. “It”s just like we’re going around in circles and going back to the same thing …’: The dynamics of women’s unresolved homelessness. Housing Stud. 2015;5:6. https://doi.org/10.1080/02673037.2014.991378 .

Downtown Women’s Action Coalition (DWAC). The 2016 downtown women’s needs assessment. [Internet]. [Cited 25 Feb 2021]. https://homelesshub.ca/sites/default/files/attachments/2016DowntownWomensNeedsAssessment-web.pdf .

Huey L, Broll R, Hryniewicz D, Fthenos G. “They Just Asked Me Why I Became Homeless”: “Failure to Ask” as a barrier to homeless women’s ability to access services post-victimization. Violence Vict. 2014. https://doi.org/10.1891/0886-6708.VV-D-12-00121 .

Muñoz M, Sánchez Morales MR, Cabrera PJ, Rodríguez Moreno SI, La Roche Riesgo B, Alarcón Rodríguez I. INFORME IX RECUENTO DE PERSONAS SIN HOGAR EN MADRID- Ayuntamiento de Madrid. 28 febrero 2018. https://www.madrid.es/UnidadesDescentralizadas/IntegracionyEmergenciaSocial/SAMUR%20Social/ficheros/INFORME%20RECUENTO%202018_FINAL.pdf .

Milaney K, Lockerbie SL, Fang XY, Ramage K. The role of structural violence in family homelessness. Can J Public Health. 2019;110(5):554–62. https://doi.org/10.17269/s41997-019-00219-y .

Watson J. Gender-based violence and young homeless women: femininity, embodiment and vicarious physical capital. Sociol Rev. 2016;64(2):256–73. https://doi.org/10.1111/1467-954X.12365 .

Broll R, Huey L. “Every Time I Try to Get Out, I Get Pushed Back” : The role of violent victimization in women’s experience of multiple episodes of homelessness. J Interpers Viol. 2020;35(17–18):3379–404.

Voith LA, Hamler T, Francis MW, Lee H, Korsch-Williams A. Using a trauma-informed, socially just research framework with marginalized populations: practices and barriers to implementation. Soc Work Res. 2020;44(3):169–81. https://doi.org/10.1093/swr/svaa013 .

Walter RR. Emancipatory nursing praxis: a theory of social justice in nursing. ANS Adv Nurs Sci. 2017;40(3):223–41. https://doi.org/10.1097/ANS.0000000000000157 .

Davtyan M, Farmer S, Brown B, Sami M, Frederick T. Women of color reflect on HIVs-related stigma through photovoice. J Assoc Nurs AIDS Care. 2016. https://doi.org/10.1016/j.jana.2016.03.003 .

González-Gil T. El papel de la fotografía en la investigación cualitativa. El Ser Enfermero. 2008;5:5–11.

Google Scholar

Harper D. Talking about pictures: a case for photo elicitation. Vis Stud. 2002;5:6. https://doi.org/10.1080/14725860220137345 .

Wang C, Burris MA. Photovoice: concept, methodology, and use for participatory needs assessment. Health Educ Behav. 1997. https://doi.org/10.1177/109019819702400309 .

Sandhu A, Ives J, Birchwood M, Upthegrove R. The subjective experience and phenomenology of depression following first episode psychosis: a qualitative study using photo-elicitation. J Affect Disord. 2013. https://doi.org/10.1016/j.jad.2013.01.018 .

Frohmann L. The framing safety project: photographs narratives by battered women. VAW. 2005;1:1396–419.

Oter C, González T, Martín Á, Alcolea MT. Foto-elicitación: una herramienta útil para investigar la gestión de la vulnerabilidad de las mujeres sin hogar. Enfermería Clínica. 2017;27(5):308–13. https://doi.org/10.1016/j.enfcli.2017.05.003 .

Strauss A, Corbin JM. Basics of qualitative research: Grounded theory procedures and techniques. London: Sage; 1990.

González-Gil T. Flexibilidad y reflexividad en el arte de investigación cualitativa. Index Enferm. 2009;18(2):121–5.

Ruiz Olabuénaga JI. Metodología de la investigación cualitativa. Quinta edición. Bilbao: Universidad de Deusto; 2012.

Barker P. The Tidal Model: developing an empowering, person-centred approach to recovery within psychiatric and mental health nursing. Perspect Psychiatr Care. 2001;06(8):233–40.

Raile AM, Tomey MA. Modelos y Teorías en Enfermería. Séptima edición. Barcelona: Elsevier; 2001.

Posada Abadía CI. Una experiencia enfermera con personas vulnerables: Reflexiones sobre la investigadora como herramienta de investigación. Archivos de la Memoria. 2019; 16. [Cited 25 Feb 2021]. Disponible en: http://ciberindex.com/c/am/e12058

Evans-Agnew RA, Boutain DM, Rosemberg MAS. Reenvisioning the photovoice process across phenomenological, grounded theory, and critical theory methodologies. ANS Adv Nurs Sci. 2017;40(1):1–15. https://doi.org/10.1097/ANS.0000000000000159 .

Gaboardi M, Zuccalà G, Lenzi M, Ferrari S, Santinello M. Changing the method of working with homeless people: a photovoice project in Italy. J Soc Distress Homeless. 2018;2:5. https://doi.org/10.1080/10530789.2018.1446407 .

Phipps M, Dalton L, Maxwell H, Cleary M. Women and homelessness, a complex multidimensional issue: findings from a scoping review. J Soc Distress Homeless. 2018;28(1):1–13. https://doi.org/10.1080/10530789.2018.1534427 .

Aguirre P, Cova F, Domarchi MP, Garrido C, Mundaca I, Rincón P, et al. Estrés postraumático en mujeres víctimas de violencia de género. Rev Chil Neuro-Psiquiat. 2010;48(2):114–22.

Hirai M, Charak R, Seligman LD, Hovey JD, Ruiz JM, Smith TW. An association between perceived social support and posttraumatic stress symptom severity among women with lifetime sexual victimization: the serial mediating role of resilience and coping. Violence Against Women. 2020. https://doi.org/10.1177/1077801219892645 .

Padgett DK, Hawkins R, Abrams C, Davis A. In their own words: trauma and substance abuse in the lives of formerly homeless women with serious mental illness. Am J Orthopsychiatry. 2006. https://doi.org/10.1037/1040-3590.76.4.461 .

Broll R, Huey L. “Every Time I Try to Get Out, I Get Pushed Back”: the role of violent victimization in women’s experience of multiple episodes of homelessness. J Interpers Violence. 2017. https://doi.org/10.1177/0886260517708405 .

Charmaz K. Views from the margins: voices, silences, and suffering. Qual Res Psychol. 2008. https://doi.org/10.1080/14780880701863518 .

Sartre J-P. El ser y la nada: ensayo de ontología fenomenológica. Buenos Aires: Losada; 2017.

Hernando A, editor. La construcción de la subjetividad femenina. Madrid: Al-Mudayna; 2000.

Groton DB, Radey M. 2019 Social networks of unaccompanied women experiencing homelessness. J Community Psychol. 2019;47(1):34–48. https://doi.org/10.1002/jcop.22097 .

Haj-Yahia MM, Cohen HC. On the lived experience of battered women residing in shelters. J Fam Viol. 2008. https://doi.org/10.1007/s10896-008-9214-3 .

Asmoredjo J, Beijersbergen MD, Wolf JR. Client experiences with shelter and community care services in the Netherlands. Res Soc Work Pract. 2016;27(7):779–88. https://doi.org/10.1177/1049731516637426 .

Heim C, Shugart M, Craighead WE, Nemeroff CB. Neurobiological and psychiatric consequences of child abuse and neglect. Dev Psychobiol. 2010. https://doi.org/10.1002/dev.20494 .

Seligman MEP. Indefensión. Madrid: Debate; 1975.

Stacks AM, Muzik M, Wong K, Beeghly M, Huth-Bocks A, Irwin JL, et al. Maternal reflective functioning among mothers with childhood maltreatment histories: links to sensitive parenting and infant attachment security. Attach Hum Dev. 2014. https://doi.org/10.1080/14616734.2014.935452 .

Mercer RT. Becoming a mother versus maternal role attainment. J Nurs Scholarsh. 2004. https://doi.org/10.1111/j.1547-5069.2004.04042.x .

Condon EM, Sadler LS. Toxic stress and vulnerable mothers: a multilevel framework of stressors and strengths. West J Nurs Res. 2018. https://doi.org/10.1177/0193945918788676 .

Hopper EK, Bassuk EL, Olivet J. Shelter from the storm: trauma-informed care in homelessness services settings. 2010. https://doi.org/10.2174/1874924001003020080 .

Gall TL. Spirituality and coping with life stress among adult survivors of childhood sexual abuse. Child Abuse Negl. 2006. https://doi.org/10.1016/j.chiabu.2006.01.003 .

Ahuja NJ, Nguyen A, Winter SJ, Freeman P, Shi R, Rodríguez Espinosa P, Heaney CA. Well-being without a roof: examining well-being among unhoused individuals using mixed methods and propensity score matching. Int J Environ Res Public Health. 2020;17:7228. https://doi.org/10.3390/ijerph17197228 .

Article PubMed Central Google Scholar

Berberian M, Walker MS, Kaimal G. ‘Master My Demons’: art therapy montage paintings by active-duty military service members with traumatic brain injury and post-traumatic stress. Med Hum. 2018;5:66. https://doi.org/10.1136/medhum-2018-011493 .

Schwan K, Fallonbar B, Milne B. “The one thing that actually helps”: Art creation as a self-care and health-promoting practice amongst youth experiencing homelessness. Child Youth Serv Rev. 2018. https://doi.org/10.1016/j.childyouth.2018.08.002 .

Moore R. Women, family violence and homelessness: trauma informed care as a standard, not a specialty. Parity. 2016 http://search.informit.com.au.ezproxy.lib.uts.edu.au/documentSummary;dn=143323259143671;res=IELFSC .

Download references

Acknowledgements

For all the women who wake up every day growing up from ashes.

Not applicable.

Author information

Authors and affiliations.

Alcorcón Senior Residence, Madrid Social Care Agency, Madrid, Spain

Clara Isabel Posada-Abadía

Department of Personality, Evaluation, and Clinical Psychology, Complutense University of Madrid, Madrid, Spain

Carolina Marín-Martín

Nursing Department, Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain

Cristina Oter-Quintana & María Teresa González-Gil

You can also search for this author in PubMed Google Scholar

Contributions

P-A, C.I. Conceptualization, methodology, software, validation, formal analysis, investigation, writing-original draft, writing-review and editing, visualization, supervision, project administration and funding acquisition. M-M, C. Conceptualization, methodology, validation, writing-original draft. O-Q, C. Conceptualization, methodology, validation, writing-original draft. G-G, M.T. Conceptualization, methodology, software, validation, formal analysis, investigation, writing-original draft, writing-review and editing, visualization, supervision, project administration and funding acquisition. All authors read and approved the final manuscript.

Corresponding author

Correspondence to María Teresa González-Gil .

Ethics declarations

Ethics approval and consent to participate.

The Clinical Research Ethics Committee of Autonomous University of Madrid, Spain, under file number CEI-84-1555, approved this study. The participant was informed and voluntary gave written consent to participate in the study.

Consent for publication

Not applicable. The provided participant name is fictitious and other possible in identifiers such as age and country of origin have been avoided. Images have been pixelated guaranteeing participant anonymity.

Competing interests

The authors declare that there is no conflict of interest.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Posada-Abadía, C.I., Marín-Martín, C., Oter-Quintana, C. et al. Women in a situation of homelessness and violence: a single-case study using the photo-elicitation technique. BMC Women's Health 21 , 216 (2021). https://doi.org/10.1186/s12905-021-01353-x

Download citation

Received : 08 October 2020

Accepted : 11 May 2021

Published : 22 May 2021

DOI : https://doi.org/10.1186/s12905-021-01353-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Gender-based violence
Homeless persons
Psychological
Single-case study

BMC Women's Health

ISSN: 1472-6874

Submission enquiries: [email protected]
General enquiries: [email protected]

Judith L. Herman, M.D., and Frank W. Putnam, M.D.

Mental Health Stigma

What can be done about homelessness, laying a foundation for better mental health..

Posted May 20, 2024 | Reviewed by Michelle Quirk

Homelessness is a legacy of the aborted national policy of deinstitutionalization.
Housing First is a policy approach stressing the primacy of housing even before mental health stabilization.
The VA's Ending Veteran Homeless initiative has decreased veterans' homelessness by 55 percent.

“It’s the saddest sound in the world,” said Joey, a homeless veteran who was begging on the street. “The sound of footsteps speeding up as they hurry to get by me. For most people, it would be better if I didn’t exist.” 1

The Scourge of Homelessness

According to the most recently published official count, in January 2023, there were more than 650,000 homeless people in the United States, the highest number since annual surveys began in 2007. Some, particularly families with children, were dealing with transient life crises, but more than one-third of homeless individuals had a chronic pattern of living without shelter. 2 Many in this group suffer from severe and persistent mental illness, addictions, or both. Whatever their health conditions had been before they became homeless, life on the streets is guaranteed to make them worse. As one shelter director put it, “The longer they stay here, the crazier they become.” 3 A recent study found that the mortality rate for unsheltered homeless people in Massachusetts was 10 times that of the general population. 4

A Brief History of Homelessness

It wasn’t always this way. Homelessness as we know it began in the 1980s, during the presidency of Ronald Reagan. Reagan himself opined that many such people were “homeless by choice.” 5 In fact, the main contributors to this complex problem, which has become endemic in America, were his administration’s austerity policies, with deep budget cuts to disability benefits and social services and to the Department of Housing and Urban Development. These drastic cuts in the social safety net were implemented just as people with chronic mental illness were being discharged from state hospitals in record numbers.

Deinstitutionalization was adopted as a national mental health initiative during the Kennedy administration (see "Our Broken Mental Health System" 6 ). It was argued, plausibly at the time, that since antipsychotic medications had become widely available, people with chronic mental illness could be cared for both more humanely and more economically in their home communities, rather than being warehoused in isolated, prison-like asylums.

Federal seed money was appropriated for the development of model programs, including community-based halfway houses and day treatment centers. One of us (JLH) participated during the 1970s as a staff psychiatrist at a day treatment program, where the patients, many of whom had paced the back wards of the state hospital for years, gathered each day for a community meeting and an exercise class, followed by a hot lunch that they and the staff prepared together. The patients named the program “The House That Cares.”

Between 1960 and 1980, the number of patients living in state hospitals declined by about 75 percent, from 535,000 to 137,000. 7 The original expectation was that as the state hospitals closed, the state funding would be redirected to support community-based services. But since mental patients don’t exactly have a powerful lobby, that never happened. Once the federal grant money was gone, the patients were left to languish on the streets or in prison. Currently, the institutions housing the largest number of people with severe mental illness in the United States are jails in Los Angeles, Chicago, and New York.

Homes Provide a Foundation for Improving Mental Health

It may seem obvious that homeless people need homes. And, in fact, many studies over the past two decades have shown that a policy approach called Housing First significantly reduces homelessness. But Housing First doesn’t mean housing only. The chronically homeless population also needs all the wrap-around social and mental health services initially envisaged by the deinstitutionalization movement. This means that many agencies that usually work in their own silos need to work together in a well-coordinated program.

The Ending Veteran Homeless Initiative

One particularly successful model, the federal Ending Veteran Homelessness Initiative, began in 2010. The Veterans Health Administration (VA) partnered with civic leaders and community organizations to provide housing vouchers plus case management and other supportive and clinical services. Between 2010 and 2022, veteran homelessness decreased by 55 percent. Almost a million veterans and their families were either placed in permanent housing or prevented from becoming homeless. 8

Interviews with people who had leadership roles in the VA program identified the synergy between a Housing First approach and engagement with community partners as the key element of success. They reported that this policy initially encountered resistance from many who felt that homeless people had to “earn” the right to housing, by first being stabilized on psychiatric medication or getting sober. Having real-time outcome data was critical in convincing skeptics that the Housing First approach was working.

Successful programs aren’t cheap. To fund the homelessness initiative, the VA’s appropriation was increased from $400 million in 2010 to more than $1 billion in 2016. 9 But such costs are more than offset by the savings in hospital and emergency health and mental health care, emergency shelter, sanitation, and public safety. And nothing exceeds the taxpayer expense of housing people in prison.

As Joey, the homeless veteran observed, the public appears to wish that homeless people did not exist. Current public policy, to the extent that any can be discerned, seems to consist of malign neglect, punctuated by police sweeps when the encampments become too annoying. But ignoring the problem has not made it go away. We face a moral choice between implementing an effective, albeit imperfect, approach that has considerable upfront costs but also proven results and long-term savings or just kicking the can on down the road, leaving the enormous, accruing costs and missed opportunities to burden future generations.

1. Berndt J: Missing Persons: The Homeless . Wollaston, MA: Many Voices Press, 1986.

2. US Department of Housing and Urban Development: Fact Sheet: 2023 Annual Homelessness Assessment Report. 12/01/2023.

3. Berndt J: op. cit.

4. Roncarati JS et al.: Mortality Among Unsheltered Homeless Adults in Boston, Massachusetts, 2000-2009. JAMA Intern Med . 2018; 178(9): 1242–1248.

5. Boston Globe : 2/1/1984.

6. Judith L. Herman and Frank W. Putnam. Our Broken Mental Health Care System. Psychology Today. November 6, 2023.

7. National Academies of Science, Engineering, and Medicine: Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness . Washington, DC: National Academies Press, 2018.

8. O’Toole TP et al: Changes in Homelessness Among US Veterans After Implementation of the Ending Veteran Homelessness Initiative. JAMA Network Open ; 7(1): e2353778, January 2024.

9. Gibson L: The Homelessness Public Health Crisis. Harvard Magazine 2024; 126 (5): 25–31.

Judith Lewis Herman, M.D., is a semi-retired professor of psychiatry at Harvard Medical School. Frank W. Putnam, M.D. , is a professor of clinical psychiatry at the University of North Carolina School of Medicine.

Find a Therapist
Find a Treatment Center
Find a Psychiatrist
Find a Support Group
Find Online Therapy
United States
Brooklyn, NY
Chicago, IL
Houston, TX
Los Angeles, CA
New York, NY
Portland, OR
San Diego, CA
San Francisco, CA
Seattle, WA
Washington, DC
Asperger's
Bipolar Disorder
Chronic Pain
Eating Disorders
Passive Aggression
Personality
Goal Setting
Positive Psychology
Stopping Smoking
Low Sexual Desire
Relationships
Child Development
Self Tests NEW
Therapy Center
Diagnosis Dictionary
Types of Therapy

At any moment, someone’s aggravating behavior or our own bad luck can set us off on an emotional spiral that threatens to derail our entire day. Here’s how we can face our triggers with less reactivity so that we can get on with our lives.

Emotional Intelligence
Gaslighting
Affective Forecasting
Neuroscience

International edition
Australia edition
Europe edition

How I became homeless: three people's stories

The number of families affected by homelessness is expected to double by 2041. We asked people to share their experiences

The number of families affected by homelessness is expected to more than double in the next two decades, with a further 200,000 households affected by 2041, according to a report.

Those sleeping rough will soar by fourfold to more than 40,000 in the same period, according to research by Heriot-Watt University, commissioned by Crisis , the homelessness charity.

We asked people to share their experiences of homelessness.

Paul Curtis, 68, who lives on a narrowboat: ‘My home was repossessed because I could not pay my mortgage’

I became homeless when my marriage broke up. I had taken on a big mortgage and the interest rate went up. I became overstretched when my marriage ended. I had lost an income and then I also lost my job.

I was falling further and further behind with my debt repayments. Though I didn’t know it at the time, I think I was having a mental meltdown. I wasn’t able to cope and began drinking too much. I quit my job because I wasn’t happy with the way things were being run at the organisation. I imagined I would quickly find another job, but it didn’t work out that way.

My home was repossessed because I couldn’t afford my mortgage repayments. More than that, the will had gone. When you get hit by a few things at once it affects your ability to think clearly. You are firefighting all the time. Depression saps your energy: it makes it hard to get up in the morning and put together a rational plan.

As a stop-gap measure, I stayed with friends. What was supposed to be temporary ended up lasting a year. There was a long period when I was rudderless, moving from place to place.

To say I was lucky is an understatement – I never had to live on the streets. The people who put a roof over my head were unbelievably kind and generous and never once made me feel like I was an intruder. But I felt like an intruder. “We are going out, there’s food in the fridge. Help yourself. You know how the remote works. Don’t wait up,” they would say.

I was very aware it was not my home; my stuff wasn’t there and I made no decisions about anything. I was a guest. I would walk around the shopping centre and the streets for hours hoping to exhaust myself, looking at empty allotments and wondering if I could live there.

There’s a feeling of powerlessness when you’re homeless; you feel lost. My experience changed how I see homeless people. After a while I got over whatever it was that was going on in my head. I found a job and a flat and the friends who helped me are still, thankfully, my friends. But I have never got over the fear of homelessness, that feeling of being nowhere.

I am lucky that I now have a beautiful home in which I am very happy. I live on a narrowboat. I am warm and secure and it’s a lifestyle I enjoy – also, what with being retired, it’s a lifestyle I can afford. I know I couldn’t afford to go back into the world and pay rent; the system is rotten. Homeless people are victims of government policy over the past 20-30 years and it’s going to get worse.

Caroline, 44, from Leeds: ‘Mental illness, poverty and homelessness were interlinked’

I have been homeless twice – once when I was 23 and again at 30. Both times it was due to mental health problems.

The first time it happened I left my job because I wasn’t well. I went to stay with my parents, but it didn’t work out and my dad asked me to leave. Then I went to stay with friends.

I was still struggling and one night I had a panic attack. My friends said: “We love you but you’re starting to drive us mad.” So I left and wandered the streets.

I went to a local hostel but they turned me away, saying: “Men only, try a B&B.” My thoughts had gone haywire and I felt tormented. I just didn’t know where to go.

I went to a male friend who turned me away – until he realised I was desperate. Then he made me a bed on his living room floor. He arranged for me to stay with some of his female friends but in my unbalanced state I felt uncomfortable doing this.

I had been going to outpatient appointments at a local mental health hospital. At my next visit with the psychiatrist, I was so desperate I asked if they could take me in. I was admitted for six weeks and although it was tough, it did lead to a turnaround. They got me on medication. When I left, I got a rented room and rebuilt my life. I got part-time jobs and later went on to study.

The second time I became homeless it followed a similar pattern. I had been working part-time in a shop but ended up leaving. So I had no job and rent to pay. I applied for benefits but the money got sent to the wrong account. Eventually it got sorted out but I then became ill. I withdrew from the benefits system because I found it too complicated to handle in my confused state. I soon couldn’t afford the rent and had to leave my property.

A few friends tried to help me, and one tried to help me access benefits. I stayed at people’s houses for a few nights. My relationship with my family became strained and I was taken into a local mental health hospital. Thankfully, I never slept rough or on the streets but I was close to sleeping in a park.

The whole experience was terrifying both times, not knowing where I was going to spend the night. I felt abandoned and alone. At times I had no one to turn to. I would ask friends if I could sleep on their floor. They came through for me at first but then the help ran out.

I was warned off hostels so I didn’t want to go there. You get so many knockbacks. I remember all my belongings being stuffed into a few bags I carried around with me. Eventually things got better and I clawed my way back to sanity and got a good job.

Mental illness, poverty and homelessness were interlinked in my case – I’m sure that’s the situation for a lot of people. Safety nets can fall apart and I went into a downward spiral. I would like to see an end to the stigma attached to homelessness. It can be a terrifying and devastating experience that no one should go through.

Tony*, 57, from Somerset: ‘I was not working and taking heroin day in, day out’

I made a mistake when I was younger and got caught smoking dope. I ended up having to do a short prison sentence. After that I decided to leave my home town of Derby.

I ended up living in a London Fields tower block with a friend. I moved in with him but we fell out after a while and I couldn’t find anywhere else to go. I started squatting and travelling.

When I was in London I started taking drugs. That stopped me sorting myself out and finding a place. It wasn’t a nice time and there were not many jobs around.

I ended up being homeless on the streets on and off. I would sleep rough for a few weeks or a month. I served a few spells in prison but I would usually end up on the streets again as when I got out I had nowhere to live.

In the mid-1990s, I went into rehab and did OK for about four or five years. The recovery lasted until my son died; that sent me over the edge. After that I was not working and taking heroin day in, day out. It took me seven years to get back on track.

After another rehab stay I finally got it right and became involved with a local homelessness charity – first as a volunteer, and now as a full-time support worker.

Homeless people are just people. I will never promise a client anything because when I was homeless, some agencies said they would do X,Y or Z for me and then they’d come back with a valid reason why they couldn’t. That was tough.

My boss thinks I tend to be not too soft but maybe too understanding. It’s true that I empathise with the people I work with and see things more from their perspective.

* Not his real name.

Homelessness
Social exclusion
Communities
Mental health

“It wasn’t just one thing”: A Qualitative Study of Newly Homeless Emergency Department Patients

Kelly m. doran.

1 Department of Emergency Medicine, NYU School of Medicine, New York, NY

2 Department of Population Health, NYU School of Medicine, New York, NY

3 NYU Silver School of Social Work, New York, NY

Donna Castelblanco

4 At time work was conducted: Department of Emergency Medicine, NYU School of Medicine, New York, NY

Donna Shelley

Deborah k. padgett.

Author Contributions: KMD, DS, and DKP conceived of the study and developed the interview guide. DC and KMD conducted the interviews. DC, ZR, and KMD conducted data analysis, including coding the interviews. KMD drafted the manuscript and all authors provided critical feedback and approved the final version.

Objectives:

Emergency departments (EDs) frequently care for patients who are homeless or unstably housed. One promising approach taken by the homeless services system is to provide interventions which attempt to prevent homelessness before it occurs. Experts have suggested that health care settings may be ideal locations to identify and intervene with patients at risk for homelessness, yet little is known even about the basic characteristics of patients who might benefit from such interventions.

We conducted in-depth, one-on-one qualitative interviews with ED patients who had become homeless within the past 6 months. Using a semi-structured interview guide, we asked patients about their pathways into homelessness and what might have prevented them from becoming homeless. Interviews were digitally recorded and professionally transcribed. Transcripts were coded line-by-line by multiple investigators who then met as a group to discuss and refine codes in an iterative fashion.

Interviews were completed with 31 patients. Mean interview length was 42 minutes. Four main themes emerged: 1) unique stories yet common social and health contributors to homelessness, 2) personal agency versus larger structural forces, 3) limitations in help from family or friends, and 4) homelessness was not expected.

Conclusions:

These findings demonstrate gaps in current homeless prevention services and can help inform future interventions for unstably housed and homeless ED patients. More immediately, the findings provide rich, unique context to the lives of a vulnerable patient population commonly seen in EDs.

INTRODUCTION

Homelessness is a persistent and vexing problem throughout the United States. In many cities, the numbers of people who are homeless remain persistently high. 1 – 3 In New York City, for example, the homeless shelter census has risen over the past ten years—to over 60,000 in 2017—despite tens of thousands of people being provided with permanent supportive housing or rental subsidies. 4 As some people exit homelessness, however, others stream through the “front door” to take their place. Accordingly, policy-makers have increasingly focused on homelessness prevention as a key strategy for reducing homelessness, with growing proportions of homeless services budgets going toward efforts to prevent homelessness. 3 , 4

While homelessness prevention services are generally provided in community-based settings, some experts have suggested that hospitals may be important sites to identify people at high risk for homelessness and refer them to services. 5 Prior research has shown that emergency department (ED) patients have particularly high rates of housing instability and vulnerability for homelessness. 6 – 9 EDs may therefore be promising sites for homelessness risk screening and prevention services. Hospitals and health systems may be interested in preventing homelessness since copious prior research has shown that homelessness is associated with negative health outcomes and higher than average use of hospital-based care including ED visits. 10 – 15

Understanding how to best prevent homelessness requires knowing about why people become homeless in the first place. Prior research has found that homelessness is associated with poverty, interpersonal conflict and abuse, job loss, substance use, mental health, “life shocks” such as birth of a child or illness, and criminal justice system involvement, among many other factors. 16 – 26 Much of the past research on correlates of homelessness has been cross-sectional, limiting the ability to determine temporality and causality of the observed relationships. Given the complexity of interrelated factors that may lead to homelessness, qualitative research is particularly well-suited to exploring pathways to homelessness. There has been little prior qualitative research, however, that has specifically examined reasons for and precipitants of homelessness in the words of people who have been affected by it. 27 – 31 Further, to our knowledge no prior research has examined pathways to homelessness among ED patients, a potentially unique group. To fill this gap, we conducted a qualitative study using in-depth interviews with ED patients who had recently become homeless to explore their self-identified reasons for becoming homeless.

We conducted one-on-one, in-depth, semi-structured qualitative interviews with 31 ED patients who had recently become homeless. This study was part of a larger body of research aiming to develop homelessness prevention interventions for ED patients. Study methods and results are presented in accordance with the consolidated criteria for reporting qualitative research (COREQ). 32

Study Setting and Population

The study was conducted at an urban, public hospital ED and contiguous urgent care center. English-speaking patients eighteen years or older with a new onset homelessness (defined as living in a shelter or on the streets) episode in the past six months were eligible. We chose this timeframe because we felt that patients would be most likely to remember details about how and why they became homeless when it was a relatively recent experience. Patients were eligible regardless of whether this was their first time ever homeless or if they had past experiences of homelessness. Patients were ineligible if they were too intoxicated to provide consent, otherwise medically unfit (e.g., critically ill), psychologically distressed, in police or prison custody, or could not understand study consent (e.g., dementia).

Participants were recruited in two ways. First, ED care providers (doctors, nurse practitioners, physician assistants, nurses) were informed of the study and asked to alert the study team for any patients whom they learned had become homeless in the past six months. The majority of participants were recruited in this manner. A smaller number of participants were recruited via direct screening of ED patients for eligibility by study staff. Because one of the overall study’s goals was to examine the relationship of homelessness and substance use, we used purposive sampling to ensure that patients with unhealthy alcohol or drug use were adequately represented in addition to patients without substance use.

Interview Procedures

One of two study authors (KD, DC) conducted the interviews. KD is an emergency physician with formal qualitative research training and experience, and extensive past experience working on issues related to homelessness. DC was a study research coordinator with a background in bioethics. KD trained DC in qualitative research techniques and reviewed all interview transcripts to ensure interview quality. Neither interviewer was part of the participants’ medical care teams. All participants provided written informed consent. Participants received $20 to compensate them for their time. Each participant was interviewed only once. The study was approved by the NYU School of Medicine Institutional Review Board.

Interviewers used a semi-structured interview guide ( Figure 1 ) to ensure that key concepts were covered while allowing flexibility in question sequencing and probes to enhance interview flow. The interview guide was pilot tested with two ED patients prior to beginning the study. Interviewers also collected basic demographic information and recorded brief field notes immediately after the interview.

An external file that holds a picture, illustration, etc.
Object name is nihms-1003760-f0001.jpg

Not shown: interview guide questions on the relationship between homelessness and substance use and participant thoughts on ED-based homelessness prevention interventions, which were part of the larger research study and less central to the current paper.

Interviewers took steps to ensure participant privacy and comfort in the ED setting. When possible, interviews were conducted in private treatment areas such as a single room or single curtained bay without other patients nearby. Interviews were conducted with only the participant present; visitors were asked to leave the area.

Interviews were digitally recorded. A professional transcription company transcribed all interviews. One of the study authors (DC) checked each transcription against the digital recording for accuracy, making any needed edits prior to analysis.

We identified a list of seven key domains a priori based on the prior literature and our overall study goals, but allowed new codes and themes to emerge organically from the text in the grounded theory tradition. 33 , 34 A core team of 2–3 researchers reviewed transcripts independently and then met to discuss differences in code interpretations. All interviews were coded by KD and ZR (a research assistant with a background in social work); DC also coded the majority of interviews. All coders had prior professional experience working with homeless populations or with other populations vulnerable to homelessness.

Interviews were conducted and coded in blocks of 2–3 interviews. We used the constant comparison method, identifying new codes and refining existing ones in an iterative manner, and adjusting the code structure accordingly for each early block of interviews. 35 The codebook was solidified after the first 12 interviews had been coded and did not require further modification; the final codebook contained 27 codes. We continued interviews until theoretical saturation—the point at which no new major themes were emerging from subsequent interviews—had been achieved. 35 We used Dedoose (version 8.0.42) to assist in data management and organization. 36

In addition, we maintained a case summary matrix that collated demographic information; homelessness, substance use, work, and health history; and other interview notes for each participant. Following best practices for validity in qualitative research, we also maintained an audit trail including field notes taken after each interview, individually coded transcripts, and comments and revisions from group coding meetings. 34

Interviews were conducted April 2017 through June 2018. Sixty-six patients were screened for eligibility; 33 were ineligible (primarily due to not having a new episode of homelessness in the past 6 months), 2 were eligible but refused to participate, and 31 agreed and completed interviews. Participants were primarily male, represented a mix of race and ethnicities, and had a mean age of 50 years ( Table 1 ). The majority (67.7%) had at least one other episode of homelessness prior to the current episode.

Participant Characteristics (n=31)

Interviews lasted a mean of 42 minutes, with a range of 19 to 87 minutes. Four main themes emerged: 1) unique stories yet common social and health contributors to homelessness, 2) personal agency versus larger structural forces, 3) limitations in help from family or friends, and 4) homelessness was not expected. Table 2 summarizes the themes and provides illustrative quotes.

Summary of Themes.

Theme 1: Unique stories yet common social and health contributors to homelessness

Participants recounted a wide array of life stories and recent events leading to homelessness. Yet despite the uniqueness of each individual’s situation, there was significant commonality in the broad underlying factors contributing to homelessness. These factors encompassed both “traditional” health issues (i.e., substance use and physical health problems), as well as a variety of social factors that—in addition to contributing to homelessness—are also known to contribute to ED visits and overall health. 7 The most common contributors to homelessness mentioned by participants were job loss, not having enough money, not being able to live with family or friends, moving from another city or state, substance use, and other physical health problems. Less commonly endorsed were institutional discharge (e.g., jail/prison, hospital) and domestic or other violence.

More than half of participants reported job loss as a contributor to homelessness. Some described job loss as the main reason for their homelessness, including Participant 24 (woman in her 40s), who explained, “I had a job and an apartment and everything, and my employer lost their biggest client which was half their revenue. And they laid off like half the workforce and I was one of the people. After that I couldn’t pay my rent so I ended up having to lose my apartment.” Some participants had savings or could borrow money from friends or family, but those resources eventually waned. As Participant 3 (man in his 50s) explained, “I’ve been looking for work since the beginning of the year; it’s been very slow. What happened was, I went through my savings in January and mid-February and then I borrowed some financial help from family and friends and then that sort of ended and then by end of March-April, I had to find some other means of housing.” Other participants were already behind on rent and job loss was a “final straw.” Health conditions were common precipitants of job loss. Fewer participants reported being fired for lateness or interpersonal conflict. While job loss was the most common financial precipitant of homelessness, some participants reported other types of financial problems. A minority of participants noted trouble with spending or financial planning, or having bills—including for medications/medical care and telephones—limiting the amount of money they had for rent.

Participants commonly reported living with family or friends and then becoming homeless when those arrangements ended. Sometimes this occurred when friends or family members died. For example, Participant 8 (man in his 40s) recounted, “I had an apartment in Jersey. So I gave that up. I moved back home. I was taking care of my grandmother and my mom. And then my mother passed. My grandmother went to my aunt’s house. And I had no place to go….” In other cases, participants reported being “kicked out” by friends or family due to various disagreements or tensions. In some cases, participants seemed to have more choice in the matter, such as Participant 56 (man in his 60s), who was living with his mother and step-father but reported that his stepfather “had all this plan also, that once I was there, he was gonna make my life miserable,” so eventually he chose to leave.

Several participants moved into homelessness in NYC from other states in pursuit of jobs, better health care (including substance use treatment), public services/benefits, or to get away from friends or family. In most cases, participants were not in particularly stable situations in their prior locations, however. For example, Participant 33 (man in his 20s) had been living with his mother in Florida but moved away because he was caught up in illegal activity there: “I’m in this predicament because I moved from and I was doing horrible things there and I wanted to change my life. … We kinda knew we’re gonna be homeless if we came up here but we didn’t think it was going to be like this.”

Participants recounted that substance use contributed to homelessness via pathways including job loss, severed relationships with friends and family, lack of money due to spending it on substances, and what they identified as poor decision making. Around half of participants expressed other health problems as contributors to their homelessness, including via job loss as noted above. For example, Participant 4 (man in his 30s) reported that after he started treatment for Hepatitis C, his retail job “started noticing a difference in my look, how I look and acted, and they put me on medical leave.” He was on leave for 12 weeks—the maximum available time—and returned to work while still experiencing medication side effects and was subsequently fired. Participants noted inability to do certain types of work (e.g., construction) due to health conditions including back pain, vertigo, seizures, kidney disease, and partial paralysis. In some cases, participants wanted to work but were turned away. Participant 35 (man in his 30s) reported being told “you’re a liability” when looking for a job due to his seizure history. Other participants reported having been in accidents with injuries that either prevented them from working or—in two cases—led to opioid dependence, which ultimately contributed to homelessness. In a few cases, participants entered homelessness immediately after hospitalizations or nursing home stays. Overall, participants perceived little protection related to their health conditions in seeking and maintaining employment, even despite employment laws such as the Family Medical Leave Act (FMLA) that might be designed to provide certain protections.

When asked what caused their homelessness, participants often stated initially the one or sometimes two most prominent or proximal causes of their homelessness. In listening to their stories, however, it was clear that for most people homelessness resulted from a series of several different factors. Participant 12 (man in his 40s) explained, “It was a lot of factors. It was just hitting me all at once. I mean there was a million things.” Many participants described their homelessness as a rather sudden event, though careful analysis of their stories generally indicated that homelessness seemed at least several months or years in the making, with hardships sometimes beginning during childhood.

Theme 2: Personal agency versus larger structural forces

We observed a tension between narratives that highlighted personal agency, choice, or self-determination yet which also underscored the role of larger external structural factors—over which an individual would have little control—in contributing to homelessness. Twenty-three participants mentioned contributors to their homelessness that could be considered structural factors, in particular high rental costs and employment challenges. Several participants commented on the high price of rent. Participant 29 (man in his 60s) recounted, “I started looking for a place and you know apartments are $1,500 [for a] studio.” Related to the rental market, some participants reported unscrupulous—and in some cases illegal—landlord practices. Participant 1 (woman in her 50s) summarized that when new management took over her building, “They finally tried to evict us [because]…they want to raise the rent and move other people, tenants, in.” While she and other residents tried to fight for a while, she eventually “wound up leaving.” Other participants reported being forced out of their apartments after they complained about repair or safety issues, including Participant 56 (man in his 60s):

“When I call NYC, the city, to complain about my apartment then she [landlord]…started eviction procedures. And it took over a year for her to get me out. But when she finally did, the marshal came and then they took me out.”

Several participants reported living in informal “cash for room” type arrangements, in which they paid to live in a room in an apartment belonging to someone unrelated to them. Such arrangements could be more affordable than having one’s own apartment, yet participants also felt they had few options in these unofficial arrangements when they could no longer pay the rent.

The job market was another structural factor commonly brought up by participants. Some participants noted a lack of available jobs for people like them, whether due to age, medical conditions, or lack of particular qualifications. Participants noted losing jobs because of layoffs due to changing technology, because employers found cheaper labor, or simply because their prior companies had shut down. Participants who did manage to find work reported low pay and lack of job security or benefits. For example, Participant 24 (woman in her 40s) noted having had a “temp” job in which “they can fire you anytime they wanted.” Once losing their jobs, some participants reported difficulty receiving unemployment benefits. Overall, much as with the rental market, the job market appeared to be stacked against participants, who had comparatively little power or recourse.

Less commonly mentioned structural factors that appeared contributive to participants’ homelessness included insufficient government benefits, bureaucracy of child protective service cases, lack of social services, lack of insurance or health care, and eligibility restrictions of housing subsidy programs.

Despite the role of these external structural factors, some participants emphasized their own choices in recounting the stories of how they became homeless. For example, Participant 27 (man in his 60s) said he chose to leave a nursing home because “I’m tired of sitting in there doing nothing all day.” Two participants reported moving from more stable living situations in other states because they preferred NYC; Participant 10 (man in his 50s) reflected, “I don’t think North Carolina is ever gonna be ready for me. … The days are long and I’m a New Yorker.” As will be described with the next theme, several participants reported choosing not to live with friends or family even when such arrangements were available.

Theme 3: Limitations in help from family or friends

While many participants reported receiving help—most commonly financial assistance or a place to stay—from family or friends, nearly all reported significant limitations in the amount of assistance they received. Commonly, these limitations resulted from family/friends themselves having limited resources. For example, Participant 38 (man in his 50s) had an older sister who helped pay for him to move to NYC but could not provide other help “because she gotta pay her bills, you know?” Rarely, participants reported that family members had resources but did not want to help.

Some participants reported that they did not want to bother family members, whether because family members had their own struggles or, conversely, because they felt family members were doing well and they did not want to interfere. Participant 25 (man in his 50s) reported, “My nieces are doing great. I don’t need to be interrupting their lives.” Participant 65 (man in his 60s) had a sister nearby who he could stay with but “I don’t [want to] bother her,” which he explained was because she had children and he was also worried about her learning that he was HIV-positive. Some participants reported valuing their privacy over a place to stay. For example, Participant 64 (man in his 40s) said, “I got family all up in the Bronx, all over New York. It’s just that I don’t like having people all over my business.” Other participants expressed having too much pride or feeling embarrassment about their situation.

Several participants reported that they did not have family or friends to whom they could turn, sometimes due to deaths or because family lived in other states. Death of friends/family was described by approximately half of participants. In a few instances such death directly precipitated homelessness when a participant had been living with the person who died. In other cases, deaths of family/friends resulted in participants having fewer social connections upon whom they could draw for support. Participant 60 (man in his 40s) noted, “My mother is dead, my father is dead, my brother is gone, my other brother’s dead, my mom – my one brother’s, uh, moved up to Vermont like 12 years ago. I haven’t spoken to him in 12 years. I have no family. None.”

Interestingly, some participants who said initially that they had no family went on to describe multiple family members who actually lived nearby. Some participants may have felt that they functionally had no family given alienation from or other limitations in their relationships. As Participant 21 (man in his 40s) explained, he had family nearby but “They’re a bunch of creeps. Yeah, because if they got money and they doing good, they really don’t care about the next that’s messed up like me…so here I am.” Other participants reported being estranged from family, such as Participant 8 (man in his 40s) who said, “I’m the black sheep of the whole family, you know? I mean that’s on me too. I did 10 years in prison over heroin.”

Theme 4: Homelessness was not expected

Participants often noted surprise at finding themselves homeless, such as Participant 33 (man in his 20s) who reflected, “I did not expect for this to happen, not at all.” Others commented on how quickly homelessness seemed to fall upon them, such as Participant 12 (man in his 40s): “If this happened so quick, this can happen to anybody.” Similarly, Participant 50 (man in his 30s) reflected, “I can’t tell the future – well, like see, my story is I wasn’t gonna know that I was gonna be homeless in a short period of time.”

In fact, while some participants had clearly spent time ruminating on the factors leading up to their homelessness, others commented that they had never before been asked about how they became homeless or even really thought about it. When asked what led to him becoming homeless, Participant 10 (man in his 50s) remarked, “you have damn good questions. I wish I could give you an answer. I don’t know. I’ve never seen this. I’ve lived pretty decently, responsibly, and then this happened.” Such responses were surprising because from the perspective of an outsider, all participants recounted life stories and recent situations rife with risk factors for homelessness. For example, Participant 10 had a history of substance use, chronic health problems, incarceration for assault, and poor family relationships. Further, two-thirds of participants had prior episodes of homelessness, which makes it additionally surprising that so many participants reported that their homelessness was unexpected.

Relatedly, when participants were asked what might have prevented their homelessness or homelessness for other people, they had difficulty conceptualizing the idea of homelessness prevention. Participant 29 (man in his 60s) struggled to reply to a question on preventing homelessness:

“Help from becoming homeless? [pause]. Ah that’s a rough one because it just happens, you know? You don’t – these are things that, uh, people’s lives are not together in certain ways. So they would have to be able to see that they’re about to…not have a home…you’d have to be able to see that and a lot of times they don’t really know. It just happens, you know?”

Similarly, Participant 24 (woman in her 40s) reflected, “I was back on my feet. I was doing all the right things and I ended up losing everything anyway. So, you know, I don’t know what to tell you about how to help other people. I really don’t.” When asked how their homelessness might have been prevented, many participants reverted to providing critiques of existing shelters. Nearly universally, participants had not sought formal services available to help prevent their homelessness, either because they were unaware such services existed or because they had not expected to become homeless. Some participants noted, only in retrospect, that they saw signs that they might have been at risk for homelessness and wish they had been more prepared. Participant 7 (man in his 30s) admitted, “Yes and I kinda saw it. I just didn’t think it was gonna happen.”

Through in-depth interviews with recently homeless ED patients we identified four themes related to their pathways to homelessness: 1) unique stories yet common social and health contributors to homelessness, 2) personal agency versus larger structural forces, 3) limitations in help from family or friends, and 4) homelessness was not expected. Many of our findings affirmed prior quantitative research, which has suggested multi-factorial contributors to homelessness including substance use, job loss, structural factors such as high rents, relationship breakdown or challenges, and health issues. Our study contributes to the literature by providing more in-depth context to these reasons—in participants’ own voices—than possible via survey or other quantitative research.

Participants’ stories revealed multiple contributors to their homelessness. When asked directly about what might have prevented their homelessness, however, most participants struggled to answer. This difficulty is perhaps not surprising considering that experts also debate about the best ways to prevent homelessness. 37 It may also reflect a “present orientation” borne of immediate needs and an overall lack of awareness of homelessness prevention services. This speculation is supported by the fact that only a minority of people who enter shelters in NYC have previously accessed available homelessness prevention services. 4 Prior research has suggested high rates of traumatic brain injury and cognitive impairment among people who are homeless, 38 – 41 which may have also been somewhat contributory to our findings, though we did exclude patients who were not able to understand the study informed consent process.

A few prior studies have used qualitative research to examine pathways to homelessness among various subgroups of people. Padgett, et al. published a series of papers based on qualitative interviews with homeless and formerly homeless adults with mental illness. 42 – 44 Similar to the findings of our study, interview participants reported that family members had been able to offer only limited support because they were “in the same boat” themselves. 42 Also similar to our findings, and despite including only participants with mental health issues, Padgett, et al. found a notable lack of direct discussion of mental illness in participant interviews, with themes around substance use and other health problems taking more prominence. 42 For our study specifically it is also possible that we found less prominence of mental illness among our sample of newly homeless patients than if we had focused on people who were chronically homeless.

In another qualitative study, Metraux, et al. conducted interviews with post-9/11 era veterans and reported some similar findings to ours—including the centrality of unemployment and relationships—while also identifying specific challenges in post-military life and access to VA services. 29 Similarly, focus groups with homeless women veterans identified a constellation of contributors to homelessness both related and not related to military service, including unemployment, relationship problems, and lack of social support. 45 Qualitative research with homeless families in Canada and homeless adults in England also identified limitations in social support and relationship breakdown as central in pathways to homelessness. 27 , 31 Another study, of drug users in Connecticut, found that personal factors including lack of social support and substance use interacted with structural factors such as lack of housing subsidies to contribute to homelessness. 46

We were interested to observe a tension between what participants identified as broader structural factors contributing to their homelessness and personal narratives that often emphasized the role of choice. Such emphasis on personal agency and self-determination may be an ego-protection mechanism, and has been observed in prior research with homeless populations. In Sidewalk , an ethnography of NYC Street vendors, Mitchell Duneier observed that “the people I wrote about sometimes took complete responsibility for their own failures, unable to comprehend the obstacles and opportunities in their lives, the pressures and constraints they may have faced, and thus the probabilities of particular outcomes independent of their own actions.” 47 He therefore cautioned against taking participants’ stories solely “at face value.” 47 In our paper we have attempted to balance portraying participants’ own explanations for their homelessness while also being attuned to the deeper messages evident when taking a broader, holistic view of their stories. Our research included only the perspective of ED patients experiencing homelessness themselves; future research could triangulate qualitative or other research with social service providers, for example, to further elucidate barriers in the human services sector that might contribute to homelessness.

To our knowledge, no prior research has examined pathways to homelessness among ED patients. McCormack, et al. conducted in-depth life history interviews with chronically homeless, frequent visitors to the ED who also had alcohol dependence. 48 This study was conducted among a very unique subpopulation of ED patients and did not specifically explore pathways to homelessness. Homelessness plays an oversized role in U.S. EDs, in part due to the ED’s role as a medical and social safety net, and in part due to the greater than average health needs of people who are homeless. 13 , 15 , 49 , 50 Research spanning multiple localities and types of EDs has found that a disproportionate number of ED patients are homeless. 7 , 15 Other research has found that ED providers struggle to provide optimal care to patients who are homeless, which may lead to provider burnout. 51 , 52

In addition to seeing large numbers of patients who are already homeless, EDs also serve many patients who are unstably housed and at risk for future homelessness. 6 , 7 Some experts have proposed that EDs may, therefore, be important sites for homelessness risk screening and preventative interventions. 5 Such interventions are well-aligned with the health care system’s increasing emphasis on social determinants of health such as housing. 53 – 55 The current study was designed in part to inform the development of such an intervention, which will be studied in future research. For example, the finding that patients were often surprised at becoming homeless may explain prior observations that most people who become homeless have not sought homelessness prevention services, 4 and it speaks to the potential benefit of universal homelessness risk screening in the ED rather than relying on patients to self-identify a need for services. Also, we discovered in this sample of ED patients that health conditions were often strong contributors to homelessness; such cases may be particularly ripe for health system collaboration to help prevent homelessness. Our finding that patients had significant limitations in support from family or friends suggests that future interventions may need to provide material or other support to strengthen any existing relationships or provide new forms of social support such as through peer navigator or community health worker models. Finally, our finding that structural issues such as the job market and affordable housing availability were significant contributors to homelessness suggests that these issues must also be addressed in larger initiatives to prevent homelessness. While it may seem that such issues are outside the scope of health care, some health care institutions have actually attempted to change their communities by building affordable housing or providing employment opportunities to community residents. 53 , 56

Limitations

Our study was conducted among patients at a single NYC ED and thus may not be generalizable to other populations. Women were underrepresented in our study, potentially due to the study hospital’s proximity to a large men’s shelter. As we did not intend to compare experiences of women versus men in our study, we did not attempt to oversample women. In addition to experiences shared with men, women may have additional reasons for homelessness including pregnancy 24 and domestic violence 23 ; past qualitative research has specifically examined pathways to homelessness among women. 45 Further, unlike for quantitative research, qualitative research does not seek to be generalizable as much as it seeks to produce information that readers might find transferable to other contexts. 57 While we conducted our interviews in a busy ED, we took multiple steps to ensure participant comfort and generally were able to conduct interviews in a private manner. Finally, we did not perform participant checking of themes because we did not want to collect identifying or contact information given the sensitive nature of the interview questions; we did, however, follow multiple other best practices for rigor in qualitative research as described in the methods section. 34

In this qualitative study of recently homeless ED patients, we found multiple contributors to homelessness that can inform future homelessness prevention interventions. More broadly, our findings may help ED providers to better understand the life experiences of their patients which contribute to their health and ED use.

Acknowledgments

Financial Support: Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health (K23DA039179, PI Doran), the United Hospital Fund (PI Doran), and the Doris Duke Charitable Trust—NYULMC (PI Doran). The content is solely the responsibility of the authors and does not represent the official views of any funder.

Conflicts of Interest: KMD, ZR, DC, DS, and DKP report no relevant conflicts of interest. KMD received grant funding for this study from the NIH/NIDA, the United Hospital Fund, and the Doris Duke Charitable Trust—NYULMC as noted above.

Presentations: None

As the Supreme Court considers homeless encampments, D.C. clears one of its own

W ASHINGTON — In a city park, workers in hazmat suits were picking up the remains of someone’s life — a purse, bedding and whatever else had been left behind. They moved efficiently through the homeless encampment, shoveling everything left behind into a trash bag or nearby garbage trucks.

At 20th and E streets northwest in Washington, D.C., across from the State Department and Federal Reserve, residents of the encampment were still packing up.

Some had been offered a place to stay by the city, but some said they hadn’t.

“This is completely tame” compared with the last time resident Shelley Byars was removed from her home, she said. Byars, a resident of the homeless encampment at 20th and E, was one of dozens evicted during the last big encampment clearing in the district, at McPherson Square in February 2023. At that cleanup, some residents weren’t able to get back in to claim their belongings once they left, she said.

The Thursday scene, which unfolded just three blocks from the White House, was a stark reminder of how homelessness has become a critical issue in communities across the United States.

The clearing took place as cities and homeless advocates await a Supreme Court ruling that could redefine how local governments can respond to homelessness. Advocates for the homeless argue that overturning the 9th U.S. Circuit Court of Appeals’ decision — which prohibited cities from citing homeless residents for sleeping or “camping” on public property if there is no adequate shelter available for them to move to — would allow cities to effectively criminalize being unhoused. Lawmakers and city leaders across the country argue that the existing ban hamstrings their ability to limit where people who are homeless can sleep in public and restrict what’s allowed in the encampments.

The justices appeared inclined to agree with the cities seeking to crack down on encampments, but it’s still unclear how broad of a ruling the court might hand down.

San Francisco is among the cities that have asked the court for more latitude to police homeless encampments . A lawsuit restricting the city’s actions on encampments is on hold, pending the outcome of the Supreme Court case.

The city can’t clear encampments unless it offers their residents immediate and available shelter, and it cannot confiscate or destroy their personal property; or, unless there is a health risk, emergency need for access, or to ensure compliance with disability rights’ laws. The city can also ask people to move temporarily to clean.

Phoenix is under a similar injunction , but was also given a court mandate to clear its largest homeless encampment last year. The city created 482 temporary shelter beds in advance of the November 2023 clearing.

Other cities across the West are locked into legal settlements that dictate when and how they can clear encampments.

Washington, D.C., however, isn’t subject to many of the restrictions San Francisco and Phoenix face.

Once the district decides that an encampment is a health, safety or security risk, the city must provide at least 14 days’ notice prior to a cleanup. Residents at the 20th and E encampment were notified of the closure 33 days prior. The city can clean up an area on shorter notice, however, if there is an “immediate health or safety concern.”

Officials plan to clear out seven total encampments on D.C. and federal property in the next week, citing “fires, danger of traffic collisions, multiple assaults, and growing rodent issues,” D.C. Deputy Mayor of Health and Human Services Wayne Turnage said in a statement. Turnage told an observer Thursday that this encampment has had six assaults and two fires.

Compared with other encampments, however, this one “has always been an orderly, calm encampment where they kind of policed themselves,” Adam Rocap, deputy director of social services nonprofit Miriam’s Kitchen, told the Chronicle. That’s “why it’s so frustrating that it’s getting closed because it was not creating as (many) health and safety concerns.”

“They’re effectively destroying a neighborhood and the people that knew each other and watched out for each other,” said David Beatty, one of the residents.

Rocap said this encampment was likely being closed because it’s “highly visible,” located near several federal buildings and just off a highway, and because the National Park Service is restoring parts of the city for the 250th anniversary of the country’s founding.

“They’ve let us stay for a long time,” Beatty, who has lived there about nine months, said. “I think they’re just tired of having us here, not so much rehabbing the park. They just want to try to make it difficult for the people that are living here.”

D.C. may have used several of the methods San Francisco is barred from employing, including clearing people without having available shelter beds and destroying property.

Miriam’s Kitchen helped about 20 of the park’s nearly 50 residents move their belongings to nearby parks last Monday and Tuesday, Rocap said. The closure had initially been scheduled for Wednesday, but was postponed because of rain. Some of the residents decided to move into housing before the closure, and by Thursday morning, only nine or 10 people were still left.

“Encampment closures like this are ineffective and don’t do anything to end homelessness; they just move homelessness,” Rocap said. This type of displacement, however, can lead to Miriam’s Kitchen losing track of residents and breeds distrust in them, he said.

Last month, the U.S. Interagency Council on Homelessness — the federal agency focused on ending homelessness — up dated its guidelines t o states and cities on how they should address encampments. The agency called on local officials to close encampments in a “humane and trauma-informed way” that includes clear communication, at least two days’ notice to pack personal items, availability of shelter or housing, and notifying residents that personal belongings left behind would be removed and stored.

“Clearing an encampment without offering housing and support does not solve homelessness in the short or long term. Instead, it simply moves people experiencing homelessness from block to block and from streets to jails,” the guidance says .

Byars said she doesn’t want to go into a shelter because she knows people who have been maimed while they sleep, and you can’t take in your own food.

Byars was approved for a housing voucher, but she said it’s difficult to find places that are both willing to take one and are up to building and fire codes — a requirement of the program. She would like to see the government allow her to use a housing voucher for a tiny home.

Even if she wanted to go into a shelter, a bed may not have been available.

As of the week of May 6, only three shelter beds for single adults were available in D.C., according to materials reviewed by the Chronicle.

Turnage, the deputy mayor, told an observer during the clearing that additional beds had been added to two shelters in the city and that “we are never going to close an encampment without offering a bed.”

By noon, only one resident of the encampment remained. The man, who declined to speak with the Chronicle, was reluctant to engage with outreach workers from Miriam’s Kitchen or city employees. Eventually, he decided to move instead of facing arrest.

By the end of the day, the park had been fenced off and most of the residents of 20th and E streets had rebuilt their homes — at 21st and E.

Reach Shira Stein: [email protected]; Twitter: @shiramstein

IMAGES

Educating Homeless Children in Chicago: A Case Study of Children in the
Case study for homeless people
(PDF) A Case Study of a Homeless Woman in Wellington
Homeless Healthcare Case Studies
Case study: Homeless client with health issues
Tracking Australia’s homeless

VIDEO

ASMR Bible Study: Homeless Man Goes To War
Forum on Health, Homelessness & Poverty 2013- Panel 2: The Experience of Homelessness
Homeless case managers have no experience working with mental health issues! #subscribetomychannel
Caring for Others
Dr Lynne Friedli
New study looks at the health effects of homelessness in Oregon

COMMENTS

Why it's so hard to end homelessness in America
A recent study of 60,000 homeless people in Boston recorded 7,130 deaths over the 14-year study period. The average age of death was 53.7, decades earlier than the nation's 2017 life expectancy of 78.8 years. ... Historian traces 19th-century murder case that brought together historical figures, helped shape American thinking on race ...
Court Cases
The case is called Singleton v. Taylor, Case No. 2:20-cv-99-WKW (N.D. Al.). The people who filed the lawsuit have reached an agreement to settle this case with the Sheriff. ... Justice filed a Statement of Interest brief in the case, supporting Plaintiffs' position that making it a crime for people who are homeless to sleep in public places ...
Women in a situation of homelessness and violence: a single-case study
According to the same survey, 55.1% of homeless people said that they had been victims of some type of violence on the street. Gender-based violence was mentioned by 2.3% of the women as one of the main reasons for sleeping on the street, ... Case studies focus on the uniqueness and complexity of a single case, gaining an in-depth understanding ...
Case study: Understanding the lived experience of homelessness
As of 2019, over 120,000 Australians are homeless, with that number predicted to increase by 13.7% in the next five years*. Out of those, 58% are male and 42% female, with people over 55 experiencing a 28% increase in homelessness. These demographics indicate we need a shift in how we live and provide a home for all people.
Homelessness in US cities and downtowns
However, total homelessness rates in these cities actually significantly declined in the past decade (by 42%, 25%, and 16%, respectively). And it continued this decline during the pandemic (Figure ...
(PDF) Young people's accounts of homelessness: A case study of
Abstract. With the aim of informing counselling psychology practice with young homeless people, this. paper reports a qualitative stud y of psychological well-being and identity among four young ...
Effectiveness of Case Management for Homeless Persons: A Systematic
To our knowledge, 4 reviews on the effectiveness of case management for homeless adults have been published. 19,25-27 All 4 reviews underscore the effectiveness of ACT in producing positive outcomes for homeless people. Nevertheless, whether ACT is effective for all homeless subgroups in achieving more positive outcomes than other services, including other case management models, remains to ...
California Statewide Study Investigates Causes and Impacts of
The California Statewide Study of People Experiencing Homelessness used surveys and in-depth interviews to develop a clear portrait of homelessness in California, where 30% of the nation's homeless population and half of the unsheltered population live. The study found that for most of the participants, the cost of housing had simply become ...
4 Charts That Explain How People Slide Into Homelessness
Some of the findings of the California Statewide Study of People Experiencing Homelessness, or CASPEH, were unsurprising: in the state with the nation's largest homeless population, people are ...
The effectiveness of case management interventions for the homeless
All peer-reviewed studies that assessed case management interventions among homeless or vulnerably housed populations and that reported on relevant outcomes were included. We excluded articles where case management was delivered as a component of a permanent supportive housing intervention as this is covered by a parallel review [ 35 ].
The impact of the COVID-19 pandemic on people experiencing homelessness
Policy makers and public health communicators must learn from people experiencing homelessness to maximise effectiveness of future public health strategies. Housing providers and support services should recognise the implications of imposing a scarcity of choice on people who need accommodation during a public health emergency. The loss of usual support was destabilising for people ...
Homelessness And Health: Factors, Evidence, Innovations That Work, And
People experiencing homelessness have elevated rates of mental health conditions and substance use disorders. 20 The California study cited above found that 82 percent of homeless adults in ...
Effects of homelessness shown through real life stories
Case Closure and Reopen Guidance Clearing House FAQs November 2022 Clearing House Nomination Policy & Procedure v1.1 Clearing House Sensitive Lets Policy & Procedure v1.1 Clearing House User Agreement v4 Complaints Policy Couples Referral Guidance Data Protection and Information Sharing Policy Eligibility Policy High Needs Quota Policy & Procedure
A Case Study Using Shame Resilience Theory: Walking Each ...
A limitation of current research is the usage of stigmatizing terms such as "homeless person/client." Such phrasing is problem—not person—centric. This case study utilized the term "person experiencing homelessness" to minimize shame-inducing vocabulary.
PDF TACKLING HOMELESSNESS: CASE STUDIES
homelessness. The case studies include projects responding to all stages of homelessness, from those providing advice, support and advocacy for people in precarious private rented accommodation, to those that work with entrenched rough sleepers. Many of the case studi es have moved to, or are shifting towards a whole person centred,
Real stories
Zeph (18), who identifies as non-binary, was referred to Centrepoint's therapeutic service for 16-18-year-old when they became homeless. They were able to attend a horticulture residential with the RHS ahead of the Chelsea Flower Show in 2023 and they are now studying Forensic Psychology at university and being supported by the Centrepoint Bursary.
Homelessness and Public Health: A Focus on Strategies and Solutions
Globally, the problem is many times worse, making homelessness a global public health and environmental problem. The facts [ 1] are staggering: On a single night in January 2020, 580,466 people (about 18 out of every 10,000 people) experienced homelessness across the United States—a 2.2% increase from 2019.
Health & Homelessness Case Studies
People experiencing homelessness experience some of the worst health outcomes in society. Following on from Homeless Link's recently published 'The Unhealthy State of Homelessness' report, this briefing shares good practice case studies from organisations who have developed new ways of working to improve the health outcomes of the people they support.
Women in a situation of homelessness and violence: a single-case study
Violence against women places them in a vulnerable position with regard to homelessness. Although sometimes invisible, women's homelessness is a complex reality shrouded in dramatic biographies that should be sensitively addressed to avoid revictimization. With the aim of understanding the chaotic discourse of homeless women's experiences of violence, a qualitative single-case study was ...
PDF Narrative Case Studies Exploring Homelessness and Education a
The purpose of these narrative case studies was to understand the experiences of families encountering homelessness and how children experience formal and informal education. Families experiencing homelessness were defined as groups of persons living without regular, fixed, and adequate housing. Narrative case studies on four families living
What Can Be Done About Homelessness?
It may seem obvious that homeless people need homes. And, in fact, many studies over the past two decades have shown that a policy approach called Housing First significantly reduces homelessness.
News, sport and opinion from the Guardian's US edition
We would like to show you a description here but the site won't allow us.
Homelessness: A Case Study
Homelessness: A Case Study. "All my needs were met when I got here. The food, the shelter, and the fellowship. …. I tried to do it on my own, and I couldn't do it.". - Mike. Mike Baker is a self-described mountain man who, for a lot of years, preferred the company of trees to people. When he found himself living in his car in North ...
"It wasn't just one thing": A Qualitative Study of Newly Homeless
INTRODUCTION. Homelessness is a persistent and vexing problem throughout the United States. In many cities, the numbers of people who are homeless remain persistently high. 1-3 In New York City, for example, the homeless shelter census has risen over the past ten years—to over 60,000 in 2017—despite tens of thousands of people being provided with permanent supportive housing or rental ...
PDF How Health Systems and Hospitals Can Help Solve Homelessness
accessible to people, including street medicine, mobile care, and outreach services through Health Care for the Homeless programs. While most Health Care for the Homeless programs include physical clinics, they also often include street medicine and/or mobile care that delivers on-site care to people living in tents, vehicles, or
As the Supreme Court considers homeless encampments, D.C. clears ...
Byars, a resident of the homeless encampment at 20th and E, was one of dozens evicted during the last big encampment clearing in the district, at McPherson Square in February 2023. At that cleanup ...
Q&A with chief proponent of Pierce County homeless village
And you're in a village for chronically homeless people. ... according to study May 22, 2024 5:30 AM ... Ex-Tacoma officer acquitted in Ellis case files $47M damage claims against city, state ...

Featured Topics

Explore the Gazette

Footnote leads to exploration of start of for-profit prisons in N.Y.

Should NATO step up role in Russia-Ukraine war?

It’s on Facebook, and it’s complicated

Experts cite complexity of problem, which is rooted in poverty, lack of affordable housing but includes medical, psychiatric, substance-use issues

Inadequate supplies of housing

Prevention as cure?

The education imperative

Share this article

Everything counts!

Five alumni elected to the Board of Overseers

Glimpse of next-generation internet

Law Center Litigation

Montgomery County, Alabama Sheriff

Bloom v. City of San Diego

Singleton v. Montgomery

Byrd et. al. v. State of Missouri et. al.

Disability Rights California v. Gavin Newsom

Coalition on Homelessness v. City and County of San Francisco (Towing)

Denver Homeless Out Loud v. City and County of Denver

Blake et al. v. City of Grants Pass

Citizens for Strong Schools v. Florida State Bd. of Educ.

Hooper v. City of Seattle

Kohner Properties v. Johnson

Manning et. al. v. Caldwell

Orange County Catholic Worker, et al. v. Orange County, et al.

G.S. v. Rose Media School District

Nat’l Fair Housing Alliance, et al. v. Carson, et al.

Garcia et. al. v. City of Los Angeles

Massachusetts Coalition for the Homeless v. City of Fall River, MA

City of Seattle v. Long

Vigue v. Shoar

Closed Cases

Martin v. City of Boise

Kohr v. City of Houston

Boyle v. City of Puyallup et al

NLCHP et. al. v. Greensboro

National Homelessness Law Center (Formerly NLCHP)

Recent Posts

Back to main menu

What we did

Reimagining the system

The insights

The systemic treatment of homelessness

Opportunities for change

Removal of choice

Stopping the spiral

What’s next

Read the summary of our lived experience workshops, which informed the South Australian Housing and Homelessness Strategy

Homelessness in US cities and downtowns

Homelessness trends, types, and service delivery ecosystems vary considerably across US cities

The different types of homelessness affecting US cities and regions

Variations in the prevalence of homelessness across the US cities and regions

Different service delivery ecosystems for homelessness across US cities and regions

Comparing perceptions and realities of homelessness trends in New York, Philadelphia, Chicago, and Seattle

An evidence-based policy framework for reducing homelessness and strengthening regional economies

Ensure that housing policy is homelessness policy

Case study from New York: How ‘housing first’ programs can be a proven, humane, and cost-effective strategy for reducing homelessness

Scale alternative crisis response models to better respond to people with behavioral health and substance use emergencies while improving public safety

Case study from Denver: How ‘alternative response models’ can reduce the homelessness-to-jail pipeline

Strengthen housing and employment supports for those reentering from incarceration

Case study: How Cuyahoga County and Houston are curbing the prison-to-homelessness-pipeline through new supports for returning citizens

Leverage the capacity of place governance organizations to humanely address homelessness, particularly in central business districts

Case study from Philadelphia: How place-based partnerships and place governance organizations can support and bolster city services for homelessness reduction and care

Take a regional, data-driven approach to homelessness

Case study: How cities and counties are working together on a regional approach to homelessness

4 Charts That Explain How People Slide Into Homelessness

What Is the Link Between Homelessness and Mental Health?

Where Were Homeless People Living Before?

Why Did They Have to Leave Their Last Place?

Where Did They Turn For Help Before Being Evicted?

More Must-Reads from TIME

Real life stories

Nicky’s story

Gary’s story

Caz’s story

Lisa’s story

Sophia’s story

Denise’s story