Combatting homelessness is about more than just finding people homes

Homelessness in Anaheim, California. Image: Getty.

Twenty years ago, Jim lived under a highway bridge in New Haven, Connecticut. He was in his 50s and had once been in the Army.

After an honourable discharge, he bounced from one job to another, drank too much, became estranged from his family and finally ended up homeless. A New Haven mental health outreach team found him one morning sleeping under the bridge. His neon yellow sneakers stuck out from underneath his blankets.

The team tried for months to get Jim to accept psychiatric services. Finally, one day, he relented. The outreach workers quickly helped him get disability benefits, connected him to a psychiatrist and got him a decent apartment.

But two weeks later, safe in the apartment, Jim said he wanted to go live under the bridge again. He was more comfortable there, where he knew people and felt like he belonged, he said. In his apartment he was cut off from everything.

As researchers in mental health and criminal justice at Wesleyan and Yale universities, we have been studying homeless populations in New Haven for the past 20 years. In that moment, when Jim said he wanted to leave what we considered the safety of an apartment, the outreach team, which co-author Michael Rowe ran, realised that, while we were capable of physically ending a person’s homelessness, assisting that person in finding a true home was a more complicated challenge.

Helping the most marginalised people in society feel comfortable in a new and alien environment, where they were isolated from their peers, required a different approach that went beyond finding them a place to live.

The people we worked with needed to see themselves – and be seen as – full members of their neighbourhoods and communities. They needed, in other words, to be citizens.


Record number of homeless deaths

Fueled by the opioid crisis, high housing costs and extreme weather, homelessness and its fatal costs are on the rise.

The U.S. Department of Housing & Urban Development estimates an increase in the homeless population in 2017 for the first time in seven years, with more than 500,000 Americans lacking permanent shelter.

In addition, in cities across the country, there has been a surge in deaths of homeless individuals. Last year, New Orleans saw a record 60 homeless deaths, a 25 per cent rise over two years. Denver saw an estimated increase of 35 per cent over 2016, while Rapid City, South Dakota, with a population of only 75,000, saw five deaths of homeless individuals just since December.

Complicating matters, about 25 per cent of the homeless population is severely mentally ill. Many are deeply distrustful of shelters and the service system, sometimes refusing to engage in services even when their lives are at stake.

We believe our research might provide a hopeful answer for the increasing number of homeless Americans whose lives are in jeopardy on the streets of our cities.

From outcasts to insiders

Jim’s story, and other similar ones, led us on a 20-year quest to create a formal mechanism to enhance a sense of belonging and citizenship among society’s outsiders.

Aristotle said that to be a citizen is to participate in the political life of a city. Much later, Alexis de Tocqueville linked citizenship to civic participation.

We defined citizenship as the strength of a person’s connection to the “Five Rs” – the rights, responsibilities, roles and resources that society confers on people through its institutions, as well as one’s relationships to and with friends, neighbors and social networks.

Fifteen years ago, we got a small grant and created the Citizens Project in New Haven for people with mental illness and criminal histories, including major felonies. Often, they had histories of homelessness. The six-month program meets twice a week at a soup kitchen.

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Two graduates of the Citizens Project, second and third from right, in a performance with the Theatre of the Oppressed NYC, at the International Festival of Arts & Ideas in New Haven in 2017. Image: Mara Lavitt/author provided.

There are four months of classes on the Five Rs of citizenship, covering pragmatic topics such as the capacity to effectively advocate for oneself, public speaking and conflict resolution. A community advocate and peer mentors – people with mental illnesses who are now doing well – teach, support and counsel participants, or “students,” as well as provide them with living, breathing proof that people can indeed change.

Then students undertake a meaningful project in the community, such as training police cadets how to approach people living on the streets in a non-threatening manner. Graduations are held at City Hall, with family, friends and public officials cheering on.

The results?

There were statistically significant reductions – 55 per cent – in alcohol and drug use among citizenship program participants (as compared to 20 per cent reduction in the control group). Additionally, participants’ self-reported indicators of quality of life – such as satisfaction with daily activities and with their employment for those who secured jobs – were significantly higher in the citizenship group than the control groups. We have published the results in peer-reviewed articles and a book, Citizenship and Mental Health.

Criminal charges decreased, as they did in the control group, which received “usual” mental health care. Perhaps most important, each class of students became a supportive community in itself. Participants have taken seriously their new role as students, one that many had not embraced before.

Over the period in which we have conducted the citizenship project, homelessness overall in New Haven has decreased, likely through many factors, including perhaps our own work.

Citizenship approach spreading

Interestingly, however, anxiety and depression increased at various points among our participants. Perhaps the challenge of the intervention had an impact on students. Perhaps also the courage to change brought with it a vulnerability to difficult thoughts and feelings: grief over lost opportunities, lost friends, or lost dreams, even while their quality of life increased.

The project has run for years now, graduating hundreds. We’ve received funding from federal and state government. A state-wide social service agency is making their primary focus the enhanced citizenship of its 6,000 clients. Citizenship projects, based on our our model, have been launched at a state forensic hospital in Connecticut and internationally; in mental health programs in Quebec, Scotland, and soon, Spain and New Zealand.

It seems our citizenship program born 20 years ago is now coming of age. The intervention is inexpensive and follows a straightforward manual. The costs of doing nothing are certainly higher.

And Jim? He did pretty well for a while, then one day ranted enough about a public official that it had to be reported as a threat. Though completely exonerated, he fired his treatment team and refused all help once again. The Citizens Project had apparently arrived too late to help him.

The stakes of full membership in society are indeed high as we undertake this work for people on the margins. But our graduates – as they are recognised at City Hall by the mayor, as they train the police, as they serve on boards of homeless shelters where they once lived – say that seeing themselves as citizens helps.

And when we see the smiles on our graduates’ faces, or when they talk about their new employment, or when they talk about their joy in getting away from drugs and alcohol, we know that their new-found citizenship helps others, too.

Michael Rowe, Professor, Department of Psychiatry, Yale University and Charles Barber, Visiting Writer, Wesleyan University.

This article was originally published on The Conversation. Read the original article.

 
 
 
 

What’s killing northerners?

The Angel of the North. Image: Getty.

There is a stark disparity in wealth and health between people in the north and south of England, commonly referred to as England’s “north-south divide”. The causes of this inequality are complex; it’s influenced by the environment, jobs, migration and lifestyle factors – as well as the long-term political power imbalances, which have concentrated resources and investment in the south, especially in and around London.

Life expectancy is also lower in the north, mainly because the region is more deprived. But new analysis of national mortality data highlights a shockingly large mortality gap between young adults, aged 25 to 44, living in the north and south of England. This gap first emerged in the late 1990s, and seems to have been growing ever since.

In 1995, there were 2% more deaths among northerners aged 25 to 34 than southerners (in other words, 2% “excess mortality”). But by 2015, northerners in this age group were 29% more likely to die than their southern counterparts. Likewise, in the 35 to 44 age group, there was 3% difference in mortality between northerners and southerners in 1995. But by 2015, there were 49% more deaths among northerners than southerners in this age group.

Excess mortality in the north compared with south of England by age groups, from 1965 to 2015. Follow the lines to see that people born around 1980 are the ones most affected around 2015.

While mortality increased among northerners aged 25 to 34, and plateaued among 35 to 44-year-olds, southern mortality mainly declined across both age groups. Overall, between 2014 and 2016, northerners aged 25 to 44 were 41% more likely to die than southerners in the same age group. In real terms, this means that between 2014 and 2016, 1,881 more women and 3,530 more men aged between 25 and 44 years died in the north, than in the south.

What’s killing northerners?

To understand what’s driving this mortality gap among young adults, our team of researchers looked at the causes of death from 2014 to 2016, and sorted them into eight groups: accidents, alcohol related, cardiovascular related (heart conditions, diabetes, obesity and so on), suicide, drug related, breast cancer, other cancers and other causes.

Controlling for the age and sex of the population in the north and the south, we found that it was mostly the deaths of northern men contributing to the difference in mortality – and these deaths were caused mainly by cardiovascular conditions, alcohol and drug misuse. Accidents (for men) and cancer (for women) also played important roles.

From 2014 to 2016, northerners were 47% more likely to die for cardiovascular reasons, 109% for alcohol misuse and 60% for drug misuse, across both men and women aged 25 to 44 years old. Although the national rate of death from cardiovascular reasons has dropped since 1981, the longstanding gap between north and south remains.

Death and deprivation

The gap in life expectancy between north and south is usually put down to socioeconomic deprivation. We considered further data for 2016, to find out if this held true for deaths among young people. We found that, while two thirds of the gap were explained by the fact that people lived in deprived areas, the remaining one third could be caused by some unmeasured form of deprivation, or by differences in culture, infrastructure, migration or extreme weather.

Mortality for people aged 25 to 44 years in 2016, at small area geographical level for the whole of England.

Northern men faced a higher risk of dying young than northern women – partly because overall mortality rates are higher for men than for women, pretty much at every age, but also because men tend to be more susceptible to socioeconomic pressures. Although anachronistic, the expectation to have a job and be able to sustain a family weighs more on men. Accidents, alcohol misuse, drug misuse and suicide are all strongly associated with low socioeconomic status.

Suicide risk is twice as high among the most deprived men, compared to the most affluent. Suicide risk has also been associated with unemployment, and substantial increases in suicide have been observed during periods of recession – especially among men. Further evidence tells us that unskilled men between ages 25 and 39 are between ten and 20 times more likely to die from alcohol-related causes, compared to professionals.

Alcohol underpins the steep increase in liver cirrhosis deaths in Britain from the 1990s – which is when the north-south divide in mortality between people aged 25 to 44 also started to emerge. Previous research has shown that men in this age group, who live in the most deprived areas, are five times more likely to die from alcohol-related diseases than those in the most affluent areas. For women in deprived areas, the risk is four times greater.


It’s also widely known that mortality rates for cancer are higher in more deprived areas, and people have worse survival rates in places where smoking and alcohol abuse is more prevalent. Heroin and crack cocaine addiction and deaths from drug overdoses are also strongly associated with deprivation.

The greater number of deaths from accidents in the north should be considered in the context of transport infrastructure investment, which is heavily skewed towards the south – especially London, which enjoys the lowest mortality in the country. What’s more, if reliable and affordable public transport is not available, people will drive more and expose themselves to higher risk of an accident.

Deaths for young adults in the north of England have been increasing compared to those in the south since the late 1990s, creating new health divides between England’s regions. It seems that persistent social, economic and health inequalities are responsible for a growing trend of psychological distress, despair and risk taking among young northerners. Without major changes, the extreme concentration of power, wealth and opportunity in the south will continue to damage people’s health, and worsen the north-south divide.

The Conversation

Evangelos Kontopantelis, Professor in Data Science and Health Services Research, University of Manchester

This article is republished from The Conversation under a Creative Commons license. Read the original article.