The Mental Health Unhoused Train: The Final Destination

Written by Desiree Frain, Psy.D., Erica Marshall-Lee, Ph.D., ABPP, Danielle Nelson, MBBS, M.S., D.M., and Teymbi Tannis, CRC, NCC, M.S. on behalf of the Atlanta Behavioral Health Advocates

I (Desiree Frain) completed my predoctoral internship at a state hospital in Georgia that treats primarily underserved minority populations with severe mental illness. During the internship, I learned a great deal about treating and understanding the difficulties these individuals face with regard to their symptoms and the impacts of their illness. I felt I was able to make an impact on my clients and saw myself as an effective clinician with regard to treating severe mental illness.

While in this role, I spent a significant amount of time working and building a relationship with an individual who had experienced chronic homelessness. I was able to see the efforts enacted by his treatment team and other staff (including myself) to improve his mental health in hopes that he would not experience homelessness yet again after leaving the hospital.

We were unsuccessful.

A few months after I finished my internship, I was on my way to a training when I saw a familiar face sleeping on the sidewalk. The experience was emotionally jarring—how could this happen again? As I continued to learn and expand my awareness of the disadvantages and systemic inequalities that affect this population, I realized this event really shouldn’t have been shocking. In fact, it is concerningly common, and the issues that these individuals experience go far beyond the symptoms we observe as mental health professionals.

Individuals with serious mental health conditions are disproportionately represented in the unhoused population (Corrigan et al., 2015). Those experiencing mental illness are 10 to 20 times more likely to face homelessness. The combination of being unhoused and having a mental illness is also linked to higher incarceration rates—both in the past year and over a lifetime (Greenberg & Rosenheck, 2008)—and to poorer health outcomes (Sullivan et al., 2000).

This phenomenon can be explained in part by the history of mental health treatment in the United States. Individuals with severe mental health conditions were previously treated and housed in long-term psychiatric facilities. These facilities often had poor and inhumane conditions, which resulted in pressures to close and transition individuals to community management in the 1950s and 1960s.

While the intentions behind this effort were good, it was executed poorly. Community treatment and housing options for individuals were inadequate to meet the needs of the substantial number of mentally ill persons being discharged from state-run institutions. The failures of the deinstitutionalization movement are partially responsible for the disproportionate numbers of individuals with severe mental illness represented in the unhoused or incarcerated population (Lamb, 1984).

A critical examination of the intersection between homelessness and severe mental disorders highlights significant diversity issues. People of color are disproportionately impacted by homelessness (Corrigan et al., 2017; Herring et al., 2020; Pruitt & Barile, 2022). When racial identity intersects with mental illness, disparities deepen. For example, Horvitz-Lennon et al. (2011) found that African-descended persons experiencing homelessness and mental illness were less likely to receive routine outpatient care than White persons. In a Canadian-based study of persons in unhoused status with mental illness, individuals who experienced discrimination due to mental health or substance use diagnoses, homelessness, or race or ethnicity were more likely to experience discrimination in multiple domains (Skosireva et al., 2014). Additionally, transgender individuals are 2.5 times more likely to experience homelessness than the general population (Herring et al., 2020).

Housing instability exacerbates challenges for individuals with serious mental health conditions, particularly in adhering to medication treatments, as their personal belongings and medications are often lost or displaced during forced relocations (Herring et al., 2020). These relocations, driven by public complaints and laws criminalizing homelessness, often expose individuals to traumatic experiences like sexual victimization and other forms of violence. For those with serious mental illness, such traumatic events can worsen psychiatric symptoms.

Beyond these systemic challenges, unhoused individuals with mental health conditions face stigma at multiple levels, including from healthcare providers, agencies, peers, and even themselves (Gronholm et al., 2017). This stigma creates barriers to accessing healthcare, particularly mental health services, and affects their ability to engage in therapy. The transient nature of their living situations also complicates efforts by health professionals to maintain consistent contact and provide follow-up care (Dykemann, 2011).

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What Psychologists Can Do

After I observed my past patient sleeping on the street again, I felt powerless. If my efforts to treat his illness were not enough to prevent this, how can I be effective in my role? Thankfully, rather than turn away from this uncomfortable reality, I was able to continue to learn and grow how I can better address the systematic issues those with severe mental illness face.

Advocate

One important strategy to support individuals with serious mental illness (SMI) who are unhoused is through improved training for professionals working with this population, utilizing a Justice, Equity, Diversity, and Inclusion (JEDI) framework. This training enhances both knowledge and practical skills at the micro (individual) and meso (community) system levels.

Changes in legislation around funding provide new opportunities for practitioner-advocates to help clients achieve housing stability and long-term tenure. They also allow for advocacy on policies that support community-based housing solutions rather than a focus on acute inpatient care. Practitioners must also push for broader access to effective, culturally-informed psychotherapy services that address the unique experiences of those who are or have been unhoused.

Research

Due to ethical and methodological challenges, research on psychotherapy and mental health services for unhoused individuals with severe mental illness remains limited. Future research should explore evidence-based practices and psychosocial interventions specific to this population, building empirical data on the effectiveness of current and new approaches. Additionally, there is a need for more research on how evidence-based treatments work across diverse populations, with a focus on culturally tailored interventions, trauma-informed care, engagement strategies, and peer support models.

Conclusion

As psychologists, we are trained to diagnose and treat mental health conditions. However, we are also trained to advocate and influence. Our skills in this area have a great deal to offer our patients, especially those who are unhoused and experiencing serious mental health concerns. I encourage the reader to consider using their unique skill set to promote change for individuals like my patient. As Malala Yousafzai stated, “When the world is silent, even one voice becomes powerful.”