A Role for Families of the Unhoused Mentally Ill

By Howard Dichter, M.D., and Rajesh Mehta, M.D.

Mr. T is in his late 20s and is grappling with schizophrenia as well as abusing methamphetamine. He suffers from paranoid delusions that his family is seeking to control and harm him. He occasionally exhibits violent behavior towards his mother.

Mr. T’s mother immigrated legally from China when Mr. T was 6 years old. Recognizing her child’s emotional difficulties, she felt a cultural obligation to care for him within the home. She also faced language barriers that created additional challenges in accessing social resources for her son.

Because Mr. T was unable to work or support himself, the family allocated the garage to Mr. T, which provided him with some independence. However, he still had to use his mother’s bathroom and kitchen, forcing regular, close proximity between mother and son.

Unfortunately, unstable housing arrangements like these can often deteriorate, resulting in the family member with a serious mental illness (SMI) being unhoused.

Contrary to common assumptions, single, unhoused adults often do have family members. Unfortunately, relationships with families are often fraught with difficulties, especially when the unhoused individual has an SMI. In such situations, usually, all family members suffer.

It is extremely challenging to maintain family connections when one member of the family is an unhoused individual with an SMI. When this problem was studied in one community treatment center, 73% of those unhoused single individuals who were being treated for an SMI had significant contact with their families.

In light of the findings, it is important to recognize that unhoused individuals can have families in their lives. Understanding the dynamics and difficulties faced by families dealing with a mentally ill, chronically unhoused individual will facilitate developing strategies to support both the unhoused individuals and their family members. This is important in order to attain better treatment outcomes for all concerned.

Early Family Dynamics That May Contribute to Unhousing

Unhoused adults often come from turbulent families that are dealing with severe social and financial stresses. Childhood traumas, like abandonment or maternal loss, may increase the risk of mental illness. Research has shown that 30% of formerly unhoused adults who also had an SMI were abandoned by their parents, and 32% experienced the death of their mother. Such experiences hinder the ability to form lasting bonds.

In addition, children benefit greatly from family support when they make the transition to being a teen and then an adult. In chaotic family situations, transitional psychological back-up may be unavailable, making it more likely an individual with SMI will become unhoused as an adult. Such individuals face complex challenges, especially if they also have comorbid problems with substance misuse.

The Role of Family Dynamics in Treatment

Despite the challenges that individuals with SMI and their families face, families find inventive ways to stay involved with the chronically unhoused individual. In efforts to manage their conflicts, families sometimes reach a compromise, as they did initially in the case of Mr. T.

Ongoing family connections can enhance the stability of unhoused individuals, supporting them to function at their best capacity. Enduring relationships, with intermittent financial, food, clothing, and even temporary housing, may come from siblings, cousins, children, or other family members. Here is an example:

Mr. L was chronically unhoused, often taking refuge behind a dumpster in his childhood neighborhood. Once a promising engineering student, his life took a negative turn when he developed schizophrenia in early adulthood and began abusing alcohol later in life. Complicating matters further, he had a stroke that was believed to have been caused by hypothermia from living on the street during the winter. The stroke affected his ability to produce language (aphasia), leaving him with communication difficulties and increased isolation.

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Yet, despite his circumstances, Mr. L maintained a cheerful demeanor and received support from local businesses that had known him before he became ill. The businesses did their best to assist him. In addition, his sister visited regularly, providing him with necessities such as clothing and food.

The Role of Mental Health Providers in Engaging Families

Reconnecting with a family member can trigger feelings of loss and trauma, particularly for children, with the potential for reawakening past painful experiences. For mental health professionals treating an unhoused individual in contact with their family, the whole family needs to be considered. A family-oriented perspective is crucial. For example, family strengths are highlighted while past trauma is given careful consideration. Families also benefit from education about SMI and skills to manage behavioral challenges.

If the focus of treatment is solely on the individual experiencing homelessness and their relationships are overlooked, it can lead to unintended harm and the severing of family support, as illustrated in the next case.

Ms. P is in her 60s with longstanding schizophrenia. She experienced a significant cognitive decline that required care in a nursing home. Her long history of paranoia and openly expressed animosity towards family members had estranged her from her relatives. Her 25-year-old daughter, recognizing the nature of schizophrenia, wanted to reconnect and support her mother.

Despite her desire to maintain contact with Ms. P, the daughter grappled with symptoms of post-traumatic stress caused by early experiences with her mother’s behaviors that grew out of her paranoia. Ms. P had a pension from employment before she developed schizophrenia. However, when the nursing home proposed that the daughter assume guardianship of her mother’s finances, the daughter declined the responsibility, due to the overwhelming psychological stress it might place on her.

It is important to strengthen available family connections for unhoused individuals to maintain housing stability, find purpose, and improve their overall mental health outcomes. Mental health providers should be trained to value family relationships, understand their complex dynamics, and assist in re-engaging estranged family members. Understanding family relationships is crucial to helping unhoused individuals maintain various types of family connections, especially when the unhoused individual has an SMI.

A relationship, educational, trauma-based, and family-strengthening approach is recommended to navigate the hazards associated with reconnecting unhoused individuals with their families. Such an approach can help strengthen family connections and mitigate the challenges of maintaining family connections when one member of the family is an unhoused individual with a serious mental illness.

Resources for families and clinicians

• Projects for Assistance in Transition from Homelessness (PATH): This program funds services for people with serious mental illness (SMI) experiencing homelessness.
• Treatment for Individuals Experiencing Homelessness (TIEH): This program expands access to mental and substance use disorders treatment for people experiencing homelessness along with a serious mental illness, serious emotional disturbance, or co-occurring disorders.
• Healthy Transitions: Improving Life Trajectories for Youth and Young Adults with Serious Mental Disorders Program: This program improves and expands access to developmentally, culturally, and linguistically appropriate services and supports for transition-aged youth and young adults.

• Minority HIV/AIDS Fund: Integrated Behavioral Health and HIV Care for Unsheltered Populations Pilot Project: This pilot program provides comprehensive healthcare for racial and ethnic medically underserved people experiencing homelessness, through the delivery of portable clinical care integrating behavioral health, HIV treatment, and prevention services.

Howard Dichter, M.D., and Rajesh Mehta, M.D., are members of the GAP Committee on Family.