Creating a Science of Homelessness During the Reagan Era

Abstract

Policy Points:

• A retrospective analysis of federally funded homeless research in the 1980s serves as a case study of how politics can influence social and behavioral science research agendas today in the United States.

• These studies of homeless populations, the first funded by the National Institute of Mental Health, demonstrated that only about a third of the homeless population was mentally ill and that a diverse group of people experienced homelessness.

• This groundbreaking research program set the mold for a generation of research and policy characterizing homelessness as primarily an individual-level problem rather than a problem with the social safety net.

Context

A decade after the nation's Skid Rows were razed, homelessness reemerged in the early 1980s as a health policy issue in the United States. While activists advocated for government-funded programs to address homelessness, officials of the Reagan administration questioned the need for a federal response to the problem. In this climate, the National Institute of Mental Health (NIMH) launched a seminal program to investigate mental illness and substance abuse among homeless individuals. This program serves as a key case study of the social and behavioral sciences’ role in the policy response to homelessness and how politics has shaped the federal research agenda.

Methods

Drawing on interviews with former government officials, researchers, social activists, and others, along with archival material, news reports, scientific literature, and government publications, this article examines the emergence and impact of social and behavioral science research on homelessness.

Findings

Research sponsored by the NIMH and other federal research bodies during the 1980s produced a rough picture of mental illness and substance abuse prevalence among the US homeless population, and private foundations supported projects that looked at this group's health care needs. The Reagan administration's opposition to funding “social research,” together with the lack of private-sector support for such research, meant that few studies examined the relationship between homelessness and structural factors such as housing, employment, and social services.

Conclusions

The NIMH's homelessness research program led to improved understanding of substance abuse and mental illness in homeless populations. Its primary research focus on behavioral disorders nevertheless unwittingly reinforced the erroneous notion that homelessness was rooted solely in individual pathology. These distortions, shaped by the Reagan administration's policies and reflecting social and behavioral scientists’ long-standing tendencies to emphasize individual and cultural rather than structural aspects of poverty, fragmented homelessness research and policy in enduring ways.

On october 30, 1981, audrey j. ward of west milford, New Jersey, wrote a letter to President Ronald Reagan, enclosing a local newspaper article about Richard and Evelyn Miklas, a white couple in their 50s who had been living for 5 months in “a run-down doorway” in the nearby city of Paterson. Richard had been injured at his job, and Evelyn had become disabled from arthritis, the article said.1^(pp1,24) “I really know what cutbacks you are making, but considering this case, any cutbacks should definitely not be made with people in situations like this couple,” Ward pleaded with the president.2 On February 5, 1982, John A. Svahn, President Reagan's new commissioner of Social Security, sent a typed reply to Ward informing her that there was nothing he could do: “It is indeed regrettable when people who need help find that they cannot qualify for any federally aided programs,” Svahn stated. “People in such situations must rely on State or local assistance programs or voluntary organizations to provide temporary help.”3 Svahn's letter, the first written comment by a Reagan administration official on homelessness, reflected the administration's policy of cutting federal welfare benefits and “devolving” responsibility for meeting citizens’ needs from the federal government to states and localities.4^(p40)

In the period between Ward's letter and Svahn's reply, a woman named Rebecca Smith froze to death in her cardboard hut on New York City's blustery Tenth Avenue. The 61-year-old African American woman had died even though numerous city social workers and a mobile outreach team from the State Department of Mental Health had tried to persuade her to go to a shelter, and the city had sought a court order to have her forcibly removed from the streets to save her life. But the order had arrived a day too late.5^(pA1),6^(pA2) Smith's death became a front-page New York Times story and even was covered in the national media.7^(pB1) When Smith's daughter revealed in news interviews that her mother had been a college valedictorian and talented pianist before a 10-year hospitalization for schizophrenia, the story attracted even more attention, as it confirmed other reports suggesting sharp demographic shifts in the urban street population.8^(p34),9 The dwindling clusters of grizzled, single, white, older alcoholic men who had historically circulated between flophouses and missions in the nation's Skid Rows had seemingly been replaced by a more diverse population that included more women, more African Americans, more young people, and a substantial number of people suffering from serious mental illness.9 In addition, unlike most Skid Row denizens, many in this new homeless population were sleeping out on the streets.

While the Reagan administration maintained silence on the issue until 1984,10 grassroots social activists, mayors of major cities, and some members of Congress began in early 1982 to insist that homelessness was a national crisis.11^(p1),12,13^(pxvii) This emerging public discourse, however, involved little agreement on the causes of homelessness, how many Americans were homeless, their characteristics, and what should be done to remedy the problem. If seriously mentally ill people like Smith typified the new homeless population, then the mass deinstitutionalization of mental patients from state hospitals that had begun in the 1960s was likely the cause, and any solution would have to focus on long-term, systemic improvements in the treatment of mental illness.14^(p4) But if poor, physically disabled people like the Miklases represented the true face of the new street population, then homelessness likely stemmed from economic causes such as the recession and cutbacks in spending on social programs for the poor and disabled, not primarily from flawed mental health policies. While grassroots activists were urging political leaders to address this crisis, a few people and organizations also recognized the need for scientific studies to determine the causes and character of the new homelessness.

This article analyzes the initial research effort to address the 1980s homelessness crisis in its historical and policy contexts. After reviewing the longer history of American homelessness and homelessness research in connection with broader social discourses concerning poverty, I explore how homelessness reemerged in the 1980s as a social problem, look at the role of research in defining this problem, and examine how politics shaped the research agenda. The article focuses on pioneering ethnographic efforts by researcher-activists in New York, as well as a small but seminal research program on mental illness and homelessness begun in 1982 by the National Institute of Mental Health (NIMH) that was later expanded to include research on substance abuse in homeless populations funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA). My analysis of this program illuminates how the political context of the 1980s shaped the larger trajectory of US homelessness research, and how the social and behavioral sciences responded to homelessness.15^(p1)

I show that the NIMH-initiated program, launched with little fanfare in a contentious political environment, began to answer important questions about the service needs of homeless subgroups and to demonstrate that the majority of homeless persons were not mentally ill.16 My article also highlights the lack of federal or private support for an inquiry into why so many people without serious mental illness or substance abuse disorders were homeless, and why this lopsided research agenda led to a disproportionate focus by researchers and policymakers on the individual pathology of homeless populations. I distinguish substance abuse—even though it is categorized as a mental disorder or disorders in recent editions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM)—from mental illness because the researchers during the period under analysis initially regarded it as distinct from mental illness, and the federal research institutional structures reflected this distinction.17 This distortion of the homelessness problem, I argue, reflected long-standing trends in sociology and behavioral science to view poverty as “a problem of persons” rather than “a problem of place, resources, political economy, power, and market failure,” as Michael Katz has noted.18^(pxii) This problem was further influenced by a political climate that favored individual-level explanations of homelessness and discouraged research into possible structural factors underlying the problem, such as the housing market, social services, and changes in the economy. This individualization of homelessness research during the 1980s, I conclude, defined the parameters of the issue in a narrow and fragmented way that has had an enduring influence on homelessness research and policy.

Methods

This article is based on my analysis of archival and published material, along with a series of interviews conducted between 2006 and 2013. This analysis began with a broad review of the scientific and historical literature on homelessness and poverty published from the 1870s to the present. This review was augmented by a careful reading of published government reports, historical news reports, and relevant published material available online. To look at the archival material related to this topic, I visited university libraries and the Ronald Reagan Presidential Library, and I collected additional reports and materials produced in the 1980s and 1990s by the NIMH, NIAAA, NIDA, and the Substance Abuse and Mental Health Services Administration (SAMHSA).

I identified my initial interview subjects based on a review of the literature and referrals from researchers well known as experts in the field. After obtaining the prospective interviewees’ consent, I conducted, and recorded, unstructured interviews both in person and over the phone. At the start, I conducted several interviews with another researcher who was initially involved in the project. Using the snowball sampling method, I identified additional interviewees through referrals from the first round of interviewees, and these second-round interviewees then identified others. The interviewees included government officials, researchers, social activists, and others who had been involved in homelessness research and policy during the 1980s and 1990s. Although the interview questions were open-ended, they concentrated on the interviewees’ professional backgrounds; how and when they became involved in homelessness research, policy, or activism; their specific activities in relation to homelessness; their general recollections of this period and of key figures involved in homelessness; and their views of homelessness and homelessness research. Individualized follow-up questions further probed the interviewees’ experiences and recollections.

In the analysis stage, I made transcriptions of the interviews, which I then gave to the interviewees to edit, correct, and annotate. I next reread more closely the corrected interviews and loosely coded them. For this stage I used a grounded-theory approach, an inductive approach in which particular phenomena, such as ideas, experiences, and places, are labeled with a series of codes, or words with specific meanings, and then the codes in different interview transcripts are related to one another. Recurring codes were combined into loose thematic categories.19,20^(pxxxi) After deciding on these categories, I reviewed the interviews along with notes from analyses of published and archival sources to validate the thematic content and to produce the findings and conclusions presented here.

Tracking Transients

The historical record demonstrates that homelessness is not a new problem in the United States. Poor wanderers and beggars are mentioned in colonial-period records, and by the early 19th century, cities like New York and Philadelphia had established almshouses for their local poor.21^(p3) A new population of unattached, poor, and seasonally unemployed men appeared during the mid-19th-century industrialization of the North and the conversion from farm to industrial wage labor.22^(p90),23 These men, most of them native-born whites or European immigrants, congregated in neighborhoods that eventually became known as Skid Rows. This population grew after the Civil War, especially with the onset of an economic depression in 1873. The transcontinental expansion of rail lines enabled these men to also become nomadic, “riding the rails” from town to town, finding temporary work in the expanding Western economy, begging, and sometimes stealing.21^(pp35-40),24^(pp7-8) Commonly known as “tramps,” they became objects of widespread social derision as well as targets of law enforcement. Although a few women joined this “tramp army,” it was generally unsafe for them. Also, whereas charities took a special interest in aiding white, native-born women and their children to keep them off the streets, able-bodied poor men who were not working were often arrested for vagrancy and forced to perform heavy labor or expelled from town.21^(pp10-11) Toward the end of the 19th century, in addition to the tramps, the more industrious “hobos” and the less transient “Skid Row bums” became commonly recognized social types.24

The first surveys of this population were begun in the 1890s by social and moral reformers, who concluded that individual character flaws—especially idleness, intemperance, or criminal “mendicancy”—were responsible for the plight of most tramps and hobos. Such findings justified policies in which these men were forced to work for any food or shelter they received from city or town governments.25,26 By 1920, the Chicago School of Sociology had applied its supposedly objective, but still value-laden methods of social science to the study of the hobo. Chicago sociologist Nels Anderson, who had lived as a self-identified hobo before attending graduate school, published a series of studies on hobo culture, in which he characterized it as a “floating fraternity” and an adventure-filled if rough alternative to the comforts and constraints of post-Victorian domesticity.27,28^(p39) Anderson's work somewhat de-stigmatized the “homeless man” (a term he used interchangeably with “hobo”) by portraying him as a hard-working and resourceful, if hard-drinking, social type. He also described the interdependent relationship between the hobo culture and the seasonal and casual labor markets. But in Anderson's studies, as in much of Chicago School sociology, the economic and other structural factors that shaped the world of homeless men took a back seat to analyses of culture and individual character.29

The association between homelessness and a distinct hobo subculture became tenuous during the Great Depression, which thrust farm families and other settled workers into the ranks of the migratory unemployed while also temporarily swelling the population of unemployed unattached men.28,21 Then World War II changed the picture of homelessness even more dramatically. An entire generation of would-be candidates for the hobo life was swept into the military or into stationary war-related employment. In the booming postwar economy, most remained in the skilled working class or entered the middle class with help from the GI Bill and other veterans’ benefits.21^(pp224-225)

Ironically, the most intensive and methodologically rigorous studies of this homeless population were conducted during the postwar era, when only a graying remnant remained in decaying Skid Row neighborhoods.30 Many buildings in these neighborhoods were targeted for demolition in federally financed urban renewal and redevelopment projects. Social research promised to provide policymakers with insights on what to do with the residents of these areas when the wrecking ball hit. Redevelopment authorities in Philadelphia, Chicago, Minneapolis, and Sacramento funded major residential surveys of their Skid Row districts, conducted by sociologists between 1957 and 1960, in connection with plans for urban renewal.31^(pp13-15) By the early 1970s, sociologists could credibly assert that there was “no other type of problem area in the United States about which we are as well informed as Skid Row.”31^(p11) These sociologists tended to view Skid Row residents through the lens of individual pathology, characterizing these men as alcoholics plagued by “disaffiliation”—a failure to develop bonds to family, school, work, religion, politics, or recreation that would have tied them to the culture of Cold War domesticity.31^,33,34 Such an emphasis on the men's behaviors and social roles reflected the increasing influence of behavioral science in the postwar decades.29 Most of these men belonged to a generation that had been deeply affected by the economic and psychosocial dislocations of the Great Depression but was too old to benefit much from the World War II economic boom.32 Yet these sociologists, rather than analyze the Skid Row men in socioeconomic and generational contexts, applied perspectives similar to those emphasized by midcentury developmental psychologists characterizing them as failures at the essential tasks of adulthood.35 These behaviorally focused Skid Row sociologists also generally ignored sections of African American neighborhoods that were similar to the largely white Skid Rows. Consequently, as Kenneth Kusmer noted, they overlooked many black, marginally housed men.21^(p233)

By the early 1970s the residual Skid Row population (along with tens of thousands of poor African American, Puerto Rican, and white ethnic urban residents) had been displaced by urban renewal's large-scale “slum clearance” projects.36,37 In New York City, new social welfare policies placed “unattached men” in rooming houses outside the Bowery or in single-room occupancy (SRO) hotels. In other cities, similar dispersal resulted from the redevelopment of Skid Rows. “The situation hasn't been alleviated, it's merely been displaced,” an informant in St. Louis told sociologists Howard Bahr and Theodore Caplow in the early 1970s. “Instead of one big Skid Row we now have a lot of little ones around the city.”31^(p50) Nevertheless, unsheltered homelessness was virtually absent from the US social landscape during the mid-1970s. In a 1976 history of low-cost housing in Manhattan, scholar Anthony Jackson could credibly state, “The housing industry trades on the knowledge that no Western country can politically afford to permit its citizens to sleep in the streets.”38^(p305) When President Jimmy Carter used the word “homeless” or “homelessness” in public speeches or remarks, these terms almost always referred to people displaced by natural disasters or armed conflicts.39 By the decade's end, however, it became difficult for residents of New York, Los Angeles, and Washington, DC, to ignore the proliferation of “shopping bag ladies” and the ragged, often disoriented, men living in public spaces (interviews with Susan Barrow, April 8, 2011, and Rodger Farr, March 4, 2011).40^(p21),41^(pC1),13

Research and “Reaganville”

The growing presence of people living on the streets of New York and other cities provoked questions among social service providers. Where did the “street people” come from? Why were they living on the streets? How many were there? In 1979, a program called Project Reach Out was initiated on Manhattan's Upper West Side under the assumption that most of this new group consisted of people with serious mental illness who were camping out on park benches and sidewalks because they did not know how to access housing services. The program sent trained outreach workers to find these people and help them with service referrals.40^(p21) “They quickly realized there were other kinds of issues going on … that there wasn't any housing, that there wasn't any place at this point where they could refer people who were on the streets and had lost their housing,” remembered anthropologist Susan Barrow, who shadowed Project Reach Out personnel during her ethnographic research on residents of SRO hotels (interview with Barrow).

In 1979 the Community Service Society, one of New York City's oldest charities, hired Kim Hopper and Ellen Baxter, Columbia University anthropology graduate students, to complete an ethnographic portrait of “mentally disabled adults” living in the city's public spaces. The two conducted fieldwork using a mixture of participant observation, interviews, and direct observation while at the same time offering their subjects assistance with obtaining shelter and/or emergency medical aid and with navigating the social service bureaucracy. They sought to uncover “the commonalities of this population; how they became homeless; and why they remained on the streets, especially when the city allegedly was offering shelter to everyone who sought it,” according to a summary of the research.42^(pp2-6) Baxter and Hopper, the first researchers to study this new population, soon realized that few of their subjects fit the profile of the old, white, alcoholic men that had dominated the sociological literature on Skid Row. Instead, this new street population appeared to be younger and to include people struggling with numerous problems unrelated to alcohol abuse, as well as a large proportion of women and people of color. Many slept in public places far from the Bowery and did not frequent bars. “There was a concentration of women, and men too, in Grand Central Station, Penn Station, [the] Port Authority [bus terminal], and throughout the public subway system and the well-lit streets of the East Side,” Baxter recollected in an interview (interview with Ellen Baxter, September 12, 2006).

In March 1981, the New York Times publicized Baxter and Hopper's research. The page-1 article, headlined “Help Is Urged for 36,000 Homeless in City's Streets,” highlighted the researchers’ quantitative estimate of the problem's dimensions.43^(pA1) This number, which they cautioned was a rough estimate derived solely from combining a state agency's estimate of the city's homeless men with a voluntary agency's estimate of the city's homeless women, soon came under fire by city officials as an inflated figure. This criticism then became the opening salvo in a decade-long “numbers controversy” among government officials, researchers, and activists over how many people actually were homeless.44^(p355) The Times article and the attention it received nevertheless increased pressure on the city government to do something about the “homeless” problem (interview with Baxter; interview with James A. Krauskopf, August 2006).45^(p102)

In addition to calling attention to this new social problem and its dimensions, the report played an important role in framing it. Baxter and Hopper deliberately chose to use the label “homeless” to characterize the new street population, selecting this word because it “did not have a negative connotation like ‘bum’ and ‘vagrant,’” Baxter remembered (interview with Baxter). In doing so, they resumed a practice of deliberate renaming and reframing begun in the early 20th century, when Anderson and other Chicago sociologists introduced the term “homeless man” as an allegedly more scientific alternative to “hobo.”28,24^(pp129-130) Baxter and Hopper's emphasis on making “homeless” the defining descriptor for this new population reflected, moreover, a more overtly political agenda than Anderson's; they sought to reframe the core problem as one centered on the lack of housing more than one of mental illness, personal choice, or individual social failure. “We redefined it,” Hopper explained in an interview:

We said that mental illness is only part of what we're seeing and hearing from other people working in the field. And so if we want to understand the particular problem of mental illness, we need to understand the larger issue of homelessness within which this is just one small part. (interview with Kim Hopper, August 25, 2006)

Their semantic move, indicative of a stance that blended research with advocacy, resulted in the widespread adoption by journalists, politicians, and researchers of the term “homeless,” in place of other terms such as “shopping bag lady,” “helpless alcoholic,” “street person,” or “vagrant.”40^(p21),46^(p1) Meanwhile in 1982, Baxter and Hopper, together with a young lawyer named Robert Hayes who had successfully sued New York City to force it to provide emergency shelter to all who demanded it, formed the National Coalition for the Homeless (interview with Robert Hayes, August 8, 2006).47^(p14)

These activists found ample evidence to link New York City's homeless problem to a lack of affordable housing (interview with Hayes). In the late 1970s, the city had sought to attract back higher-income residents, who had been fleeing to the suburbs since the late 1940s, and thus eventually rebuild a residential tax base depleted by this flight. It did so by creating short-term tax incentives that encouraged owners of cheap rooming houses and SRO hotels to renovate and convert them into condominiums and rental apartments for middle- and upper-income New Yorkers. SROs had long housed those at the margins of the economic system, including people with serious mental illness or physical disabilities, and anthropologists studying SRO residents in the late 1970s documented that some residents were being evicted from these buildings and then, having nowhere to go, were setting up camp on adjoining sidewalks (interview with Barrow; interview with Anne Lovell, July 21, 2011). While Mayor Ed Koch publicly blamed the surge in the street population on the state's shuttering of mental hospitals, New York Governor Hugh Carey pointed to the tax abatements for SRO conversion, deflecting the blame for homelessness back to the mayor.48^(pB1)

Such a quick and dramatic reduction in low-cost rental housing, however, had not occurred elsewhere in the country. A 1979 study by the US General Accounting Office had called lack of affordable rental housing a “nationwide crisis,” affecting “millions of Americans,” and housing officials in Boston and other cities reported such shortages during the early 1980s.49^(p1) But a January 1982 Rand Corporation study, commissioned by Secretary of the US Department of Housing and Urban Development (HUD) Samuel Pierce, found no “persuasive evidence of a shortage in rental housing.”49^(p51) The study's author acknowledged that a “prospective crisis” loomed, owing to investors’ “general loss of interest in building or owning rental property,” a detail not noted by Reagan administration officials or the news media.49^(p51),50^(pA2) Instead, the administration used the report to justify its action to simultaneously halt construction of new federally subsidized low-income housing while raising the rents on such housing and introducing a much less costly program of housing vouchers.50^(pA2),51^(pA13) These changes comprised part of the president's effort to fulfill his campaign promise to “get government off our backs and out of our pockets,” which he began in March 1981 with a proposal to slash $47 billion from the federal budget, largely by cutting domestic social spending.52 After the president survived an assassination attempt on March 30 of that year by John Hinckley Jr., his popularity surged, and $35 billion of his proposed cuts passed Congress.53^(pp141-143)

These budget cuts, occurring amid an unemployment figure that averaged 9.7% in 1982, sparked protests from another group of social activists dealing with homelessness and poverty.53^(p147) On Thanksgiving 1981, a Washington, DC–based group called the Community for Creative Nonviolence (CCNV) erected a tent encampment in Lafayette Park, across from the White House, to demonstrate solidarity with people thrust into homelessness. They called it “Reaganville,” a reference to the “Hoovervilles” that sprang up during the Great Depression.54 The group also planted a field of white wooden crosses in the park, each representing a person who had died “homeless and alone” in the United States over the previous 6 years.13^(p62) The CCNV, whose members drew inspiration from the Catholic Liberation Theology movement and other strains of Catholicism that emphasized a Christian duty to address poverty and social injustice, had for years been distributing food to the local poor in Washington, but now, through public demonstrations and hunger strikes, they sought to bring national attention to the plight of the thousands of people sleeping outdoors. Smith's death in New York and the increasing attention being paid to homelessness nationwide gave the organization's leader, Mitch Snyder, a national platform to wage a campaign against the Reagan administration's social spending cutbacks and for increased government spending to address homelessness.13

Meanwhile, in mid-1982, national charities found they were facing unprecedented need at their food pantries and shelters. The United Way and other voluntary groups successfully lobbied Congress to pass a $50 million appropriation for an Emergency Food and Shelter (EFS) program that they would jointly administer. Congressional Democrats then tacked this measure on to a December 1982 jobs bill as part of their ideological battle against the Reagan administration's spending cuts.55^(pA3),56^(p2)

Enter NIMH

Given this politically polarized climate, 1982 seemed a particularly difficult year for a federal agency to begin a research initiative on homelessness. The ax of Reagan's budget director, David Stockman, fell not just on social programs like low-income housing and education but also on federally funded social research, which the administration likely viewed as tied to allegedly failed social programs.57 This new mandate delivered a strong punch in the gut to the NIMH as well as to the NIAAA and NIDA. In the late 1970s, these institutes had weathered scandals over peer review policies and were regarded by some scientists as less reputable than the NIH, from which they had been spun off in 1974 and then brought together under an administrative umbrella agency, the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA).58–60 The Reagan administration's Office of Management and Budget (OMB) had originally “contemplated cutting” the research budget for the institutes under the ADAMHA umbrella by as much as 40%, an NIMH official told Science in March 1981: administration officials initially believed that all the studies they funded fell into the suspect category of social research.57^(p1397) The administration's proposed cuts reduced the overall budget for these institutes by nearly half, eliminating 376 positions within them and redirecting most of their “services” funding, originally allocated for federal programs, including community mental health centers, to block grants to the states that could be used for any health care–related expenditure, and eliminating training programs for social research.61^(pp6-9) “It was a disastrous time for mental health,” remembered Larry B. Silver, a community-trained psychiatrist who served as deputy director and then acting director of the NIMH during the early 1980s. “I don't know if we've ever recovered from it” (personal communication with Larry B. Silver, September 30, 2010).

During this period, officials at these institutes operated under both directives from the OMB defining what types of research was acceptable and statements from the Department of Health and Human Services (HHS), the parent of the ADAMHA and NIH, that it would not support “studies of large scale social conditions or problems.”62^(p1054) Such directives meant that federal funding for research on homelessness in connection with the larger landscapes of poverty, urban renewal, and deindustrialization was almost certainly off the table. Nonetheless, 1982 was the year that the NIMH began awarding grants to extramural research groups to study homelessness and mental illness.

Much of the impetus for the NIMH program came not from the institute's leadership but from a mid-level official, Irene Shifren Levine (interviews with Pamela Fischer, July 21, 2011; Barbara Lubran, October 25, 2010; and Fred Osher, December 2, 2010). Levine, a clinical psychologist, had worked at the NIMH's Community Support Program (CSP) since its inception in 1978. The CSP, which had begun as a response to the wide-scale deinstitutionalization in the 1960s and 1970s of mental patients to be treated in the community, funded demonstration programs and other short-term contracts with state mental health agencies to foster the development of community support services for seriously mentally ill adults.63 It was in connection with this work that Levine first encountered the homelessness issue. “It became apparent that there was this large population of [mentally ill] people that was growing in the streets as the result of deinstitutionalization policies,” she remembered (interview with Irene S. Levine, November 22, 2010). In 1982, Levine began by inviting 12 homelessness research pioneers from around the country to a “roundtable” discussion on homelessness. While advocates and politicians in New York City and Washington had begun to wrestle with the issue, “in many places in the country it still hadn't been recognized and named as a problem,” according to Levine (interview with Levine). The roundtable participants indicated that NIMH could play a role in helping promote research in this new area.

In the cost-cutting environment of the early 1980s, Levine had to find funding for studies within existing NIMH programs. Following a competitive proposal review process, the first study to be completed was a cross-sectional survey that polled the clients of a Baltimore mission.15^(p7) Conducted by Johns Hopkins University researcher Pamela Fischer in 1983, this study received $125,000 under the existing NIMH Epidemiological Catchment Area (ECA) program.15^(p8) In the ECA program between 1980 and 1985, teams at 5 universities around the country conducted diagnostic interviews of more than 20,000 respondents from local “catchment areas” to determine the baseline incidence and prevalence levels of mental disorders, which were then largely unknown, as well as to investigate service usage and need for persons with mental illness. They used the NIMH's standard Diagnostic Interview Schedule (DIS) and categorized their diagnoses according to the DSM-III, which was then the standard diagnostic manual for mental health clinicians.64 The ECA data provided the homelessness researchers with communitywide samples that they could use to compare with samples of homeless individuals when measuring rates of mental illness, thus enabling them to determine how far the rates in mental illness among this group diverged from local baselines. Fischer conducted interviews of 51 mission users, using the DIS as well as a 20-item version of the General Health Questionnaire (GHQ) that measured current distress, and compared them with a community sample (n = 1,338) from the Baltimore ECA study.65 She recalled that it was difficult to justify to the proposal's reviewers the sampling methods and sample size: Because the size and the demographic profile of the larger homeless population were unknown at the time, there was “no way to design any kind of sampling plan that [was] representative in any way” of this population (interview with Fischer).

The Baltimore survey became the first of 10 studies funded by the NIMH between September 1983 and July 1986 to investigate the prevalence of mental illness in homeless populations. Five single-city studies were funded as supplements to state CSP grants in California (Los Angeles), Massachusetts (Boston), Michigan (Detroit), Missouri (St. Louis), and Wisconsin (Milwaukee). The Los Angeles study also used ECA samples. Two additional studies in New York City and 1 in Baltimore, along with a statewide Ohio study, received direct research grant money.15^(pp8-9) These studies “became the primary scholarly work in this area,” homelessness researchers later wrote in a review article.66^(p47) Along with Baxter and Hopper's studies and studies funded by the Robert Wood Johnson Foundation to investigate the health care needs of homeless populations, they comprised the “first generation” of homelessness research.67^(p40),68,69,16

By funding these homelessness studies with $1.5 million from other areas, Levine and a small cadre of staffers at the CSP had managed to squeeze out a meaningful research program from a few collected budgetary pebbles.15 Considering that the Reagan administration repeatedly proposed phasing out the entire CSP between 1981 and 1985, only to see it saved through the objections of congressional oversight committees, the creation of a new research program on homelessness during this time can be regarded as a singular accomplishment.70^(p83),71^(p5),72^(p43) In addition, Levine and her colleagues at the CSP created “CHAMP,” a clearinghouse on homelessness among mentally ill people, and sponsored 20 small-scale service demonstration projects to provide community-based treatment for homeless mentally ill populations primarily through “outreach and intensive case management.”73^(p3),16^(p1132) Given Levine's crucial role in initiating these efforts, her colleagues at the NIMH, NIAAA, and NIDA admiringly called her the “godmother” of homelessness research (interview with Lubran).

When the first results of the NIMH-sponsored research appeared, they sparked controversy within the agency. In a 1985 Public Health Reports article based on a grand rounds presentation, NIMH Director Shervert H. Frazier discussed the results of the 1983 to 1985 statewide Ohio study. The 16-month survey of 979 shelter, mission, and street dwellers in 19 counties, conducted by Dee Roth and Gerald Bean at the Ohio State Department of Mental Health, had “come under fire” for its “expansive definition of ‘homeless,’” Frazier noted in his article. The researchers included in their definition people who were living on the streets or in shelters—the group that other researchers were beginning to call “the literal homeless” (interview with Fischer)74^(p1336)—as well as those staying temporarily with family and friends, and those who had been staying in “cheap hotels or motels” for 45 days or less. Roth and Bean wrote in an article presenting their study's findings that they developed this broad definition of homelessness “in line with the thinking of Baxter and Hopper.”75^(p713) Even more provocative were their results: less than one-third of the respondents exhibited “behavioral symptoms sufficiently severe to require specialized mental health care and fewer than five percent required psychiatric hospitalization.” These results “are contrary to the experience of some front-line health and human service personnel who are working with the homeless,” Frazier stated.76^(p467) Frazier, who, as a psychiatrist at Baylor University and while serving as the Texas commissioner of mental health and mental retardation, had embraced deinstitutionalization during the 1960s, later came to believe that this policy was largely responsible for homelessness (interview with Shervert H. Frazier, May 25, 2011). In light of the Ohio researchers’ findings casting doubt on deinstitutionalization as the main cause of homelessness, Frazier called for increased methodological rigor in future studies of homelessness.76^(p467)

Around this time, debates around the relationship between homelessness and mental illness were becoming heated. Just 2 months before the release of the Ohio study's initial findings, a study published in the American Journal of Psychiatry titled “Is Homelessness a Mental Health Problem?” had led to a media frenzy, according to Harvard psychiatrist Ellen Bassuk, the lead author. Bassuk and 8 other “experienced mental health professionals” had interviewed 78 homeless men and women at a Boston homeless shelter, using a previous 1-day citywide shelter census to determine that the respondents constituted a representative sample of the local shelter population. Following each interview, each team member completed a questionnaire that used diagnostic criteria from the DSM-III. They diagnosed psychosis in 46% of respondents and chronic alcoholism in 29% (with more than 6% having both psychosis and chronic alcoholism). They reported personality disorders in an additional 21% of respondents who did not have psychosis. On average, the respondents were in their 30s, much younger than the typical deinstitutionalized mental patient. “The shelters have become ‘open asylums’ to replace the institutions of several decades ago,” Bassuk and colleagues wrote in the article.77^(p1549) The Associated Press ran a story about the report under the headline “Survey Finds Most Homeless People in Shelter Are Mentally Disturbed.”78 Bassuk later remembered that media reports characterized her article as a criticism of the state's shelter system or an attempt to “blame the victim” for homelessness. Homeless advocates reacted, too. Hayes of the National Coalition for the Homeless came to Boston to meet with her and to warn her that her research would be used by politicians and city housing authorities to deny housing funds for homeless people by shifting responsibility to state mental health authorities (interview with Ellen Bassuk, July 27, 2006; personal communication with Bassuk, October 22, 2008).

In Los Angeles, researchers encountered a more collegial environment. Rodger Farr, a psychiatrist working for Los Angeles County's mental health department, had set up a mental health clinic in the city's Skid Row in 1979 to address the influx of seriously mentally ill people to the area. (Los Angeles's Skid Row has remained one of the few such neighborhoods whose cheap “flophouse” hotels were not razed during urban renewal, largely because of the city's tendency to grow outward rather than to rebuild existing neighborhoods.79) Farr, as a recognized pioneer in providing services for Los Angeles's homeless population, had participated in Levine's early roundtables. When Farr received funding from the NIMH to study homelessness on Skid Row, he hired Paul Koegel and Audrey Burnham from the University of California, Los Angeles, to design and execute the study. Building on Farr's contacts with local missions and shelters, the researchers conducted interviews with more than 300 people at numerous places where people sought beds and meals and at indoor and outdoor congregating areas, and they designed sampling mechanisms to ensure that they were not interviewing the same person in 2 different locations. Using the ECA sample for comparison, the Los Angeles researchers became the first of the NIMH-funded group to use both sophisticated sampling methods and a robust comparison group for rates of mental illness (interview with Paul Koegel, January 18, 2011).

The results of the Los Angeles study, released in March 1986, created nearly as much surprise as did those of the Ohio study. Farr, the lead author and a long-time clinician, had believed that homelessness was a problem resulting primarily from mental illness and deinstitutionalization. He had observed many cases of what he called “Greyhound therapy,” in which mental hospitals in various states discharged patients with a ticket for a Greyhound bus trip to California. Farr would often see these former patients after they had run out of medication, several days or weeks after they had disembarked at the bus depot, which was located near Skid Row (interview with Farr). The researchers, however, found that only 28% to 33% of their sample suffered from chronic and severe (serious) mental illness, depending on the specific diagnostic criteria used, and only 26.7% had ever been in a mental hospital. The prevalence of serious mental illness in the sample was still extremely high, with schizophrenia 35 times as prevalent as in the comparable ECA community sample, and bipolar disorder 18 times that of the ECA sample. The researchers also acknowledged that they had likely undercounted the number of seriously mentally ill people in the homeless population, as some people with schizophrenia were likely too distrustful of researchers to answer interview questions. Moreover, their definition of severe mental illness did not include antisocial personality disorders or anxiety disorders, both of which can be disabling. Nevertheless, they concluded that the data “do not support the simplistic notion that the homeless are largely comprised of ex-state hospital residents.”80^{(ppix,xi,xiv)}

The high rate of substance abuse among respondents (46%) constituted the most delicate finding, Burnham remembered (interview with Audrey Burnham, March 1, 2011). Implicitly acknowledging a tendency in American social policy to blame individuals for their poverty, the researchers did not want to “fuel the fires of those who would dismiss the homeless in the downtown area of Los Angeles as alcoholic bums who are themselves responsible for their misery.”80^(pxiv),18 Los Angeles's Skid Row shouldered a century-long reputation for sheltering socially undesirable alcoholic men in its missions and flophouses.79,81^(pA9),82^(p2) It would be easy, therefore, to explain homelessness in this area by dusting off the stereotype of the disaffiliated, alcoholic Skid Row “bum.” Instead, Farr and his colleagues wanted to draw attention to the need for publicly funded alcohol and drug rehabilitation efforts in this area.

The Los Angeles study's findings were similar to those of the other NIMH-funded, first-generation studies. Most reported mental illness in about a third of the homeless population they surveyed, as well as finding elevated rates of substance abuse.15^(p15) Taken together, these studies undermined both the contentions of some activists that the new homelessness was simply a problem of affordable housing and the claims by community psychiatrists that homelessness was simply a problem of mental illness resulting from deinstitutionalization.13,83 In contrast, these findings suggested that homelessness was a complex issue, directly related to untreated mental illness and substance abuse in many but not the majority of cases, and that policies and programs addressing homelessness needed to consider people's needs for housing as well as services. As the Ohio researchers noted in discussing their study's implications for homelessness policy,

Systems which develop or provide housing, income, job training, employment, health care, and psychiatric services must come together to provide the array of services necessary for each individual. Providing psychiatric services to a mentally ill homeless person leaves the person still homeless, just as providing food to a hungry homeless person leaves the person still homeless.84^(p213)

But these studies had serious methodological limitations. They varied widely not only in their definition of homelessness and in their sampling methods but also in the criteria and instruments they used to measure mental illness. Two studies used the DIS, one an abbreviated version of the Psychiatric Status Schedule (PSS), and another the Brief Symptom Inventory, a quick measure of current symptoms from anxiety and poor morale to paranoia and psychosis. The largest study, a survey of 8,061 shelter users in New York City's municipal shelters, employed the prior use of mental health services and self-reported mental health problems as the criteria for determining that a shelter user was mentally ill.75,15,85,86^(p601) Furthermore, all the studies used a cross-sectional survey design that made it impossible to determine the causal etiology of participants’ mental illness. “None of the studies had a design which allowed for reliably separating homeless mentally ill persons into those who were mentally ill prior to becoming homeless and those who became mentally ill following an episode of homelessness,” a 1986 NIMH conference report on the research noted.15^{(p13,italics in original)} A further limitation of this research was the fact that few of the studies included homeless women and none included homeless families, the latter of which were being recognized by the mid- to late 1980s as “the fastest growing segment of the homeless population.”67^(p10)

While the NIMH studies were still under way, the NIAAA began sponsoring extramural research on homelessness. Like the NIMH program, the NIAAA initiative bubbled up from the middle of the institutional structure. Barbara Lubran, who had a master's degree in public health and, at the time, was working in the NIAAA budget office, was motivated by the urgency of the problem and was encouraged by Levine to organize a conference on homelessness research (interview with Lubran). The NIAAA program, unlike its NIMH counterpart, initially looked to the older sociological literature on Skid Row for background and context. The NIAAA officials and extramural researchers at first assumed continuities between homeless persons with alcohol abuse disorders in the 1980s and earlier generations of Skid Row alcoholics.87 But the new NIAAA-sponsored research increasingly indicated that the population of homeless alcohol abusers overlapped significantly with populations abusing drugs and experiencing serious mental illness. Fred Osher, a psychiatrist and consultant to the NIMH and NIAAA programs, proposed the term “co-occurring disorder” to refer to this common overlapping condition (interview with Osher).

Overall, the NIMH and NIAAA studies represented what one researcher called “a turning point” in researchers’ understanding of homelessness (interview with Koegel). Whereas the initial group of experts to examine the issue of homelessness was composed largely of mental health clinicians who had viewed it “through a clinical lens,” the NIMH and NIAAA-funded studies “started bringing some level of empirical understanding to the problem,” noted Koegel of the Los Angeles study. “The question started becoming ‘how can we best understand who these people are and where they are coming from; how can we meet their needs effectively?’” The program also created a network of homelessness researchers, he remembered, and “gave birth to the field of contemporary homelessness research” (interview with Koegel).

The 1984 Campaign

In 1984, homelessness became a presidential campaign issue. In a televised interview aired in January of that year, a reporter asked President Reagan about criticism that his policies favored the rich. He responded by referring to “the people who are sleeping on the grates, the homeless who are homeless, you might say, by choice.”10^{(italics added)} Meanwhile, mayors and governors reported that homelessness was surging around the country even as economic indicators pointed to a strong recovery from the 1981 recession.88^(pA3) This situation provided an opportunity for the Democrats to strike the president at a vulnerable spot. In January 1984, the Democratic-led House Committee on Government Operations began a series of hearings on the federal response to homelessness, some of which were held at Washington, DC, homeless shelters. Many Democrats seized the opportunity to highlight the administration's inattention to the issue.14

In reaction to these moves, the Reagan administration publicly questioned the need for any federal response to homelessness, even the one that had already been launched. In October 1983, HHS had established the Federal Interagency Task Force on Food and Shelter for the Homeless to coordinate its efforts in this area with those of 14 other agencies. The Federal Emergency Management Agency (FEMA), which had been assigned to coordinate the emergency food and shelter program with the United Way and other voluntary groups, along with the Department of Defense, ADAMHA, and other agencies, participated actively in the project.14^(pp1-2) Although the HHS task force programs used existing budgetary resources and relied on private organizations to distribute surplus government material, John A. Svahn, the commissioner of Social Security who had earlier defended the administration's inaction on homelessness in his reply to a constituent, reportedly expressed concern that HHS was “hyping” the homelessness issue in organizing the task force.89 In a February 23 memo echoing Svahn's concerns, presidential aide Donald Clarey underlined the administration's view that homelessness was the fault of negligent states and individuals:

The whole question of the homeless, in my opinion, should be addressed from a different angle, namely, that well over 50 percent of these people are released mental patients and victims of terrible neglect by states (New York is by far the worst). Most of the others are alcoholics and drug abusers. Very few are there as a result of unemployment alone. These states have found it expedient to let them roam the streets with no supervision or support mechanisms because it is cheaper to put them on SSI (federal disability benefits). Most of the people who sleep on grates are eligible for SSI but probably don't want to participate.90,91

This memo, along with President Reagan's comment about homelessness “by choice,” reflected the long-standing tendency to blame individuals for homelessness that had permeated social science and popular opinion from the days of tramps and hobos through the era of urban renewal. This deep-rooted belief, together with the assumption that closing the state hospitals had caused contemporary homelessness among people with mental illness, served to justify the administration's inaction on the issue.

In April 1984, President Reagan seemed to depart from this stance by holding a meeting with an administration official to discuss homelessness.92,93^(p23),94^(pA23) In this meeting, with HHS Secretary Margaret Heckler, he requested that she prepare a report for him on the subject.92 In mid-August, Heckler delivered the report, which suggested addressing homelessness through public and private partnerships and better coordination among existing agencies.95 But presidential aides explicitly ordered that her report not be transmitted to Congress.96 Perhaps this was because it indicated that “the Federal government can do more to make sure the homeless receive the benefits to which they are entitled and to provide technical and other assistance to local groups which provide direct services.”92^{(italics added)}

HHS officials, however, either did not receive or simply did not obey the directive from the president's aides to keep the report away from Congress, suggesting a possible split within the administration on the issue. When Ted Weiss, the liberal New York City congressman leading the House hearings, requested the report in September, the assistant HHS secretary for legislation sent it to him.97 Weiss's committee quickly released it to the public on October 3.14^(p19) The HHS officials subsequently backpedaled, sending the committee a second document, which committee reports described as “a quickly written analysis which refutes and rebuts every major recommendation contained in the document.” When HHS official Harvey Vieth, who chaired the task force that drafted the original HHS report to the president recommending more action on homelessness, later testified during the hearings, he denied ever having read it.14^(p17)

During the hearings, Democratic congressmen lambasted HHS for this mixed message and for failing to direct sufficient resources toward homelessness. But they reserved their worst criticism for HUD.14^(p22) The agency, which had sharply curtailed its budget requests for and expenditures on low-income housing during the first years of the Reagan administration, had not explicitly addressed homelessness until releasing its first report on the issue in May 1984.98^(pG1),99 This report estimated the homeless population of the United States at between 250,000 and 350,000. After its release, the acting assistant housing secretary, Benjamin F. Bobo, was publicly quoted as saying that the report indicated homelessness “is not as widespread a problem as previously had been thought.”100^(pC6) These comments and the report's findings sparked outraged responses by Mitch Snyder's CCNV and other activist groups.101^(p12) The CCNV's leaders, who were not trained researchers, had conducted a telephone survey of homeless shelter providers in 1980 and estimated based on this survey that the United States had a homeless population of 2.2 million to 3 million.13 Snyder repeatedly cited this figure in interviews with the news media, and after HUD released its report, he filed a lawsuit against the agency demanding a retraction of the report.100^(pC6) Meanwhile, congressional Democrats held a hearing at which they alleged that the HUD report represented the Reagan administration's attempt to evade responsibility for addressing homelessness.102^(pA15) News reporters meanwhile continued to report CCNV rather than HUD estimates or reported both estimates as the upper and lower boundaries of the US homeless population.45^(p107)

A Changed Climate

After President Reagan's 1984 landslide reelection victory, partisan battles over homelessness cooled somewhat. Some Republicans began to publicly acknowledge that homelessness, especially among people with severe mental illness, was a national problem.103^(pC6) But after the 1986 midterm elections, the Reagan administration was seriously weakened: Democrats now controlled the House and Senate, and an embarrassing scandal surfaced over the administration's secret arms dealings with Iran and payments to the Nicaraguan Contra rebels (Iran-Contra), thereby undermining the administration's credibility even with some Republicans.104^(pA9) In this changed climate, a comprehensive bipartisan proposal to address homelessness began to take shape, despite the administration's lack of support for it.105,106^(pA6) The substance abuse treatment and prevention sector also worked to secure funding in the bill for new NIAAA- and NIDA-sponsored research on substance abuse among homeless populations (interview with Lubran). The NIMH found allies from both parties to support the expansion of its research on homelessness and mental illness. Republican Senator Pete Domenici of New Mexico, whose daughter had been diagnosed with schizophrenia at age 17, and Senator Al Gore's wife, Tipper, who was becoming an outspoken advocate on homelessness and for the humane treatment of mental illness, became key allies of the NIMH program.107,108^(pA10) Levine met with Domenici's wife, Nancy, at teas hosted by Mrs. Gore in downtown Washington, and they began collaborating with an active network of congressional wives to ensure that the seedling programs Mrs. Domenici had nurtured could receive enough funding to grow into larger research efforts (interview with Levine; interview with Loretta Haggard, November 23, 2010).

Others involved in early efforts to develop health care programs for homeless populations also strongly influenced this legislation. The Health Care for the Homeless Program (HCHP), funded with $25 million by the Robert Wood Johnson Foundation and the Pew Charitable Trusts, had begun establishing clinics in 1984 as demonstration programs in 19 cities.69 Run by Philip Brickner, a New York City community physician who had been serving SRO and shelter populations since the late 1960s, the HCHP was collecting data on 100,000 people who attended the program's clinics.109 Even though the program evaluation and data collection were not complete in 1987, HCHP advocates were able to convince congressional leaders to include in the legislation a federally funded expansion of the program.110^(p173)

In July 1987, a lame-duck President Reagan reluctantly signed the Stewart B. McKinney Homeless Assistance Act (McKinney Act), the first landmark piece of federal homelessness legislation. Although pushed through by a Democratic Congress, it was named for its chief Republican sponsor, Representative Stewart B. McKinney of Connecticut, who had died of AIDS that May.111,112^(pB4),113 This legislation included more than $1 billion in funds to dramatically expand an emergency shelter grant program administered by HUD; to create housing demonstration programs; and to fund health care, education, and job training for people experiencing homelessness.114^(pA1) The HCHP, administered by the Health Resources and Services Administration (HRSA), was awarded $44.5 million for 109 projects in 43 states to fund mental health, substance abuse, and physical health care services, and served more than 230,000 people in 1988 alone.115 The NIMH, NIAAA, and NIDA also were awarded funds for research demonstration projects on programs addressing mental illness, alcoholism, and drug abuse among homeless populations (interviews with Levine and Lubran). Subsequently, the NIAAA and NIDA demonstration projects implemented and evaluated alcohol and drug treatment programs for these populations.116^(p1) The NIMH demonstration programs included 9 local efforts to administer mental health services to adults experiencing homelessness and 3 to serve the needs of homeless children with “emotional disturbance.”67^(p45) The McKinney Act also tasked NIMH with administering block grants to states for homeless mentally ill populations. For this legislation, the total funding for NIMH, NIAAA, and NIDA programs related to homelessness grew to $74 million by 1990.117^(p39)

Immediately after the McKinney Act was passed, the NIMH held a joint meeting with NIAAA, NIDA, and HCHP researchers to review research methodologies and discuss needed improvements in the coming generation of federally funded research. The major discussion topics were the lack of uniformity in definitions of homelessness, substance abuse, and mental illness; the need to expand research on homelessness among women, families, and ethnic minority groups; and the need for more rigorous sampling methods.73 William Breakey of Johns Hopkins University pointed out a serious flaw in the studies’ cross-sectional survey designs: they tended to oversample the “regulars” in homeless shelters or on the street, whom other researchers were beginning to identify as a distinct subpopulation disproportionately plagued by mental illness, substance abuse, and physical disability.^{65,73(p27),118} Such oversampling also led to an overestimation of mental and physical illness prevalence among homeless populations.73^(pp27-28) In just a single-night survey of a shelter hosting 10 people, for example, researchers might classify 6 persons, or 60%, as mentally ill. But if the study were to be conducted over 6 months, the researchers might find that these same 6 mentally ill people remained in the shelter, while another 12 people who were not mentally ill stayed at the shelter for shorter periods, “cycling through” the remaining 4 spots. The 6-month prevalence of mental illness in the shelter would then be six-eighteenths, or about 33%, rather than 60%. Such longitudinal analyses promised to resolve the controversy that had raged over the prevalence of mental illness in homeless populations.

By the early 1990s, researchers had begun to address these methodological issues. While second- and third-generation studies helped characterize numerous homeless subgroups, including families, children, and people in rural areas, most influential among this new wave of research were the longitudinal studies of shelter use conducted by Dennis Culhane and his colleagues.69,119–121 Using data obtained from public shelters in New York and Philadelphia to track patterns of shelter use, some of Culhane's studies showed that the majority of shelter users remained homeless for short periods but that 10% of them stayed for more than 6 months and used more than half the shelter's resources.121 Other studies subsequently demonstrated that this chronically homeless group consumed disproportionate amounts of emergency room services, policing, and other public resources and that such use could be curbed through a “housing first” approach.122,123 This approach, also known as “permanent supportive housing,” provides permanent housing to individuals who are both homeless and disabled because of mental illness and/or chronic substance abuse. It also includes support from human service workers to prevent crises and manage disability payments but does not require that participants abstain from alcohol and drugs or adhere to a treatment regimen in order to receive housing.124,125

Over the past decade, advocates for the “housing first” approach have convinced increasing numbers of public officials to embrace this model, using the argument that it is less costly for governments to move chronically homeless individuals to permanent supportive housing than to let them stay on the streets and pay for the services they consume.126,127 This approach has continued to gain ground as research findings have validated the cost argument and have demonstrated high levels of housing stability among participants, regardless of their success in substance abuse or mental illness treatment.128,124 Indeed, its growing adoption has been credited with an overall nationwide reduction in the chronically homeless population.129

Far less attention has been paid to homelessness among people without serious mental illness or other disabling conditions. This pattern is consistent with trends begun during the first generation of homelessness research. In a 1990 article, 2 leading investigators of family homelessness alleged that “researchers seeking federal dollars to study homelessness are steered away from concerns about housing or poverty or racism, and toward the differential diagnosis of mental disorders among homeless people.”130^(p3) Others later noted that a mental health–focused approach to homelessness had particularly negative consequences for homeless families, as most were forced to undergo counseling as a condition of receiving shelter or housing, despite findings that rates of serious mental illness in these families were no higher than those of the housed poor.131,66^(p47) While foundation-funded studies of family homelessness began to bring greater understanding to the issue in the 1990s, the early research priority given to studying homeless individuals with mental illness and substance abuse set the mold for the direction of homelessness policies: up until the past few years, federal, state, and local efforts to address homelessness have continued to prioritize chronic homelessness among individuals over family homelessness and short-term individual homelessness (interview with Bassuk; interview with Philip Mangano, August 17, 2006). This narrow focus is consistent as well with an overall lack of attention by policymakers to families in poverty (interview with Bassuk).

This policy focus, however, has begun to shift over the past 5 years. Opening Doors, the Obama administration's strategic plan for ending homelessness, addressed a wide swath of homeless individuals and families.132 In addition, the Homelessness Prevention and Rapid Re-Housing Program (HPRP), targeted at people who were losing their homes during the Great Recession, was funded with $1.5 billion as part of the American Recovery and Reinvestment Act of 2009, legislation commonly known as the “stimulus package.” Unlike most “housing-first” programs, for which most transitionally homeless individuals and families are not disabled enough to qualify, this program targeted people who needed temporary financial and housing assistance during a crisis period to keep them from living on the streets or in shelters.133 Although this program has been cited as a cause of an overall drop in homelessness between 2007 and 2013—a reduction that notably occurred during the worst economic downturn since the Great Depression—the HPRP's funding ran out in 2012.^134-136 Meanwhile, hundreds of thousands of families and poor, nondisabled individuals in the United States continue to experience bouts of homelessness every year.133

Conclusion

The first generation of homelessness research can be regarded as simultaneously groundbreaking and crippled by its political and sociohistorical context. Baxter and Hopper's pioneering ethnography brought homelessness into the national consciousness, and the NIMH- and NIAAA- funded studies established a foundation for an empirically based approach to investigating the scope and dimensions of the problem. In particular, these early studies can be credited both with disproving the widely held assumption that homeless populations consist solely of deinstitutionalized or untreated mental patients, and with identifying a distinct subpopulation of chronically homeless individuals who were disabled by combinations of mental illness, substance abuse, and physical illness. Subsequent research that built on this foundation has fostered an empirically grounded approach to addressing homelessness among people with serious mental and physical disorders. The lack of early federal support to address the structural causes of homelessness, however, unwittingly led to a disproportionate policy focus on the most physically and mentally disabled minority of the homeless population. The blame for this fragmented approach to homelessness belongs not primarily on the NIMH or the NIAAA but on the larger political context in which they operated. The parameters of acceptable research were highly circumscribed by Reagan administration officials, who clung to a historically rooted ideological belief that homelessness resulted mainly from individual character flaws. The administration's 1981 attack on the federal government's social research programs, its aggressive denial of federal responsibility for responding to homelessness, and its move to cut HUD funds by 70% between 1980 and 1987 together forestalled the development of a coordinated homelessness research program that examined housing, employment, and social services along with mental and behavioral health aspects.137^(pE1) The unwavering belief of many mental health experts that deinstitutionalization was the sole cause of homelessness, along with the long legacy of sociological research that focused on the individual and cultural pathology of the poor rather than on the economic and political causes of poverty, formed the ideological bedrock for this individualization of a structural problem. Moreover, the impact of this distortion continues to be felt today, as the homeless crisis of the 1980s lingers into the second decade of the 21st century.

Funding/Support

The National Institutes of Health Office of History, the National Library of Medicine, the National Institute on Drug Abuse, and Columbia University's Mailman School of Public Health funded the research that led to this publication.

Conflict of Interest Disclosures

Jones has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. No disclosures were reported.