FEATURE — Fall 2005


The Struggle to End Homelessness

Researchers Carol North, David Pollio, and Edward Spitznagel work tirelessly to understand the causes and possible solutions to one of society’s most disturbing problems.

By Judy H. Watts

For most Americans who own or rent their homes, the thought of dwelling in a cardboard box, huddling in a downtown doorway or bus station, inhabiting a city park, or lying on a cot surrounded by night sounds of homeless strangers is frightening and almost unthinkable. Yet many citizens do live in such conditions and often are physically or mentally ill and suffering from more than one affliction. While the extent of homelessness by its nature is impossible to measure accurately, the National Coalition for the Homeless (NCH) cites the Urban Institute in 2000: 3.5 million people, 1.35 million of them children, are likely to experience homelessness in any year. But NCH points out that more important than precise numbers about prevalence is progress in ending the situation.

David E. Pollio, Associate Professor of Social Work, George Warren Brown School of Social Work

Ending homelessness, however, is as difficult as the phenomenon is complex. “Nobody completely understands it,” says David E. Pollio, associate professor of social work at the George Warren Brown School of Social Work who also holds an appointment in psychiatry at the School of Medicine. At the social work school’s Comorbidity and Addictions Center (CAC), of which Pollio is associate director, investigators probing for answers and evidence include CAC senior research collaborators Carol North, professor of psychiatry at the School of Medicine, and Edward L. Spitznagel, Jr., professor of mathematics in Arts & Sciences and of biostatistics at the medical school. The three are longtime research partners; their progress is considerable.

Designing research for service
The data about homelessness that North, Pollio, and Spitznagel have accumulated on the streets, in shelters, and through agencies in St. Louis City are massive. And while each piece of new knowledge serves the formidable goal of ending the situation someday, the central purpose of the research is service—a principle consonant with the researchers’ own history of helping others.  Studying homelessness in St. Louis since 1987, North, a psychiatrist who has training as an epidemiologist, has been a volunteer and a health-care provider to area homeless and indigent populations for many years; Pollio, also active in his community, ran a drop-in center and group program for street people before joining the School of Social Work in 1994; and statistician Spitznagel—who reins in the variables and designs social research that is unbiased and sound—works tirelessly with colleagues in psychiatry, anesthesiology, cancer epidemiology, otolaryngology, and infectious diseases—plus “a huge number” of people at the social work school, including 12 Ph.D. students a year.

Carol North, Professor of Psychiatry, School of Medicine

North, Pollio, and Spitznagel study the “literally homeless,” which they define as people currently without a stable residence and living in a public shelter or unsheltered location without a personal mailing address for 14 consecutive days. “They’re the folks who need social services immediately,” says Pollio.

With support from the National Institute on Drug Abuse, North, serving as principal investigator, and Pollio led research in the city of St. Louis—“Service Use, Needs, Costs, and Outcomes from Drug Abuse in St. Louis,” or SUNCODA—that will affect services and policy. In part by introducing an important longitudinal dimension, the study built on methods developed in earlier landmark studies by Lee Nelken Robins, now professor emerita of sociology in psychiatry, in 1980, and by North and the late Elizabeth Smith, associate professor of psychiatry, in 1990. SUNCODA followed the progress of 400 homeless adult men and women over two years to determine what services the homeless were using, how they used them over time, how needs matched available services, and what happened to the people as they used the services.

To obtain a representative sample, interviewers recruited participants randomly and year-round from night centers and day shelters in numbers based on total occupants and systematically searched streets and public areas. (“I also designed a way to ‘lock in’ the interviewers so they couldn’t say, ‘Oh, that person looks more interesting to me than the other,’” says Spitznagel.) Each SUNCODA participant was interviewed three times for two to three hours, a year apart, and briefly every three months.

Edward L. Spitznagel, Jr., Professor of Mathematics, Arts & Sciences

“We did all kinds of things to be sure they stayed in touch with us,” explains North. “We set up a drop-in center where they could get coffee; we handed out calendars; we had them call in. We even put up posters on buses and kiosks.

“The attention the people received as we gathered information likely wasn’t a significant factor in their lives,” she adds, “but it probably provided some kind of anchor—just to have someone to talk to and connect with once in a while.”

“We collected so much information,” says Pollio, “and it was so methodologically sophisticated that we’ll be working with this material for years!”

A sense of the homeless
The documented profile is grim, and necessarily qualified in part. Among the findings: • “The media-propagated notion that the homeless are primarily de-institutionalized mentally ill people is inaccurate,” says North. • Contrary to popular perception, only 10 percent of homeless people have schizophrenia—although that illness, which affects 1 to 2 percent of the general population, is overrepresented among the homeless. • Alcohol and drug-abuse problems and economic troubles are far more prevalent than schizophrenia, but to say simply that addiction causes homelessness is a mistake. (Addiction and illness, and particularly having two disorders at once, are likely risk factors for homelessness, but something else is likely going on, the researchers believe.) • “A form of depression is the most common psychiatric diagnosis excluding drug and alcohol abuse, and it seems in part related to the miseries of being homeless,” says North. • One-fourth of homeless men sampled met criteria for antisocial personality disorder. • As North, et al., reported in the American Journal of Public Health (January 2004, Vol. 94, No. 1), mood and substance-use disorders have dramatically increased since 1980, and the proportion of minorities among the homeless has risen as well.

Tilting at dragons
North and Pollio’s approach to research springs from their idealism and intellectual synergy. “There are just all sorts of important questions to pursue!” says Pollio.

Does the current trend to provide one-stop shopping for services miss any groups? (A paper to be published in 2005 reveals that persons aren’t necessarily missed by combined-care systems, but their multiple mental health conditions are.) What about the distance people travel to services? (Another research paper-in-progress shows that NIMBY, the “Not in my back yard” reaction, is not about actual homeless behavior but about “housed” prejudice.)

A future research path will be testing “the tenant-of-last-resort hypothesis.” Trying to understand causes of homelessness, North, Pollio, and Spitznagel sought a comparison group by returning to the last rental address homeless people used. They hoped to find renters much like the homeless; instead, they often found abandoned buildings, parking lots, or gentrification. They realized then that people who rent to individuals with poor work histories, mental illness, or addiction have only one other option—to let the building be abandoned. “So the people who became homeless had not been tenants of choice,” says Pollio, “but they occupied a niche in the housing market. The housing abandoned them.

“Truly preventing homelessness means intervening with people at high risk of becoming homeless in the future. So if we’re correct, we’ll identify properties containing people at high risk of homelessness and intervene for the first time, so they are never homeless.”

While such targeted prevention would be a tremendous achievement, identifying every risk category for homelessness seems lifetimes away. “The only way to really stop homelessness from happening is to make housing a civil right,” Pollio concedes, “and I don’t think this country is quite ready to do that.”

“Truly preventing homelessness means intervening with people at high risk of becoming homeless … So if we’re correct, we’ll identify properties containing people at high risk … and intervene for the first time, so they are never homeless,” says Professor Pollio.

North, Pollio, and Spitznagel do think, based on research, that the costs of cutting social services is higher in the long-term than the costs of providing them in the first place. “What’s more, data we have support this interpretation,” says Pollio. “Homelessness prevalence is a downstream product of not-well-thought-out public policy.” When the three researchers and their colleagues examined 20-year data they drew upon for a recent journal article, they realized that social policies implemented in conjunction with or before each sample predicted changes in the homeless population. “Basically, we believe that the influx of mentally ill in the 1980 data traces to the consequences of the Community Mental Health Centers Act,” Pollio says—and soaring drug addiction, especially crack cocaine, between 1990 and 2000 correlates to “this odd policy of zero tolerance for substance abuse—that people are kicked out of programs if they’re using.”

Pollio wonders, too—and emphasizes that this concern is not yet data-based—about a connection between women and children being the fastest-growing homeless constituency and TANF (Temporary Assistance for Needy Families), which removes the safety net for people whose welfare benefits expire after five years. That takes him to what he calls a “scary” possibility: “Missouri and other states are cutting Medicaid eligibility, which formerly was 100 percent of poverty level, by roughly 20 percent. Who will be dumped? The answer: A portion of the working poor,” he says. “This is an inference drawn from data, not from imagination.”

In the meantime, the SUNCODA study promises to yield information that will be critical to the lives of the roughly 5,000 people North estimates are homeless in St. Louis each year—and, in time, to the lives of millions of Americans nationwide. “I think we’ll find out how well the services agencies provide actually meet homeless individuals’ needs,” says North. “And we will learn what other factors affect whether people even get to the appropriate facility for treatment.”

With an eye to prevention as well as improved services, Pollio plans to continue his work on feeder populations such as runaway youth—and says his productive collaborations with North (Spitznagel calls the pair “very, very creative”) will continue after fall 2005, when she becomes the Ray and Nancy Hunt Professor of Psychiatry at the University of Texas Southwestern Medical Center at Dallas. These researchers now plan to expand their collaborative efforts to address the combined problems of homeless populations bridging both urban areas. “It is my hope that this work will enable us to help solve some of the serious social problems that have contributed to homelessness—and make a tangible difference,” says North. “We wouldn’t be doing this research if we didn’t believe that.”

“Carol and I see the world the same way,” says Pollio. (Both have won Mortimer Goodman service awards from the National Alliance for the Mentally Ill in different years for outstanding contributions to improving mental health through services.) “You have to act as if what you do will change things fundamentally. Whatever happens in my life, I’ll know I’ve left the world better for having tried.”

Judy H. Watts is a free-lance writer based in Santa Barbara, California, and a former editor of this magazine.

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