Journal of Gerontological Nursing


Jennifer Boondas, MPH, RN


Millions of homeless people walking our city streets has provoked a public outcry. Where does the responsibility lie?


Millions of homeless people walking our city streets has provoked a public outcry. Where does the responsibility lie?

The homeless elderly are in desperate circumstances. They suffer from the effects of poor health, extreme poverty, and social isolation. The human condition of homelessness has existed in society for as long as other major social maladies. The victims have fallen into the lower depths of the social structure. They are rootless, homeless, labeled, and stereotyped. We hear of the "derelict" who suffers from the ravages of alcohol, the "hobo" who is lured to the open road, and the "bag-lady" who adds to her collection rummaging through trash. In one extreme they have been romanticized in literature and music, while in the other extreme, they have been ridiculed, harassed, and exploited in conventional society. Very few understand them. Today, the number of homeless men and women is increasing at an alarming rate. What was once perceived as a problem solely of the elderly is now seen as a problem of the young as well. The literature clearly reveals the full magnitude and complexity of the problems are yet to be grasped. By its very nature, the condition of homelessness does not lend itself to accurate census count; there are only approximations. Testimony presented in 1980 by various organizations and groups to the Congressional committee investigating the problem indicated that at least 1% of the nation's population, or 2.2 million, were without shelter.1

An ongoing infiltration of homeless into the city streets and public places has continued to provoke public outcry. With increased public awareness of this as a social problem which affects all citizens, the homeless are now viewed as symbols of alienation and dispossession. What was initially public apathy, abhorrence, and curiosity is gradually being replaced by concern, empathy and advocacy. How society should deal with this complex socially rooted problem is unclear. Social scientists in the United States and in Europe are raising questions and seeking answers through research.

B.I. Larew, in her study of the homeless, reported that their life style is most accurately characterized by deprivation, of being victimized plus the need to remain distant and unknown to police as well as the "helping" institutions.2 For them, to survive is to adapt to a life style outside, exposed to the elements. They seek abandoned buildings, dilapidated trucks and automobiles, sidewalk heating vents, bus and train terminals or other public places to rest. They sift through garbage and rely on handouts for sustenance. Personal cleanliness is almost impossible because public bathrooms are scarce. Over time some develop street wisdom and exhibit resiliency and durability. Others are more unfortunate and have increasing difficulty coping day to day.

To gain deeper insights into the phenomenon of homelessness, the theoretical framework in the theory of disengagement, one of the major theories in social gerontology, can be used. By definition, disengagement is a universal process whereby society and the aging individual withdraw from one another. The process is gradual, inevitable, mutually satisfying, and normal. The theory's underpinnings are:

1) The universal mortality of man; and

2) The need for society to outlive the individuals who make it up.

A corresponding concept is that as individuals grow old, there is a reduction in the number and variety of social interactions. This reduction in the number of interactions leads to increased freedom from the norms governing everyday behavior. The less individuals are controlled, the more those individuals become desocialized. The more individuals are desocialized, the more their behavior becomes eccentric or egocentric.3

Robert C. Atchley, a leading social gerontologist, indicates that both society and the aging individual create the conditions for disengagement to take place, and the individual's attitude toward disengagement determines the form the process takes. For the older individual, particularly the one in poor health, the sum total of his or her available energy may be wrapped up in mere physical survival with little left over for social engagement.4 While this theory is too simplistic from a psycho-social perspective, it nevertheless serves as a basis in analyzing the problem of homelessness.

For the average old person, disengagement is an individual process, which takes place on several psychosocial levels. It occurs without interference from meeting the basic human needs for food, shelter, and clothing.

The homeless face an extreme threat to meeting these basic needs. Disengagement ceases to be a successful survival mechanism for the older individual under such adverse conditions. Effective social disengagement requires protection from the raw elements and hunger. When society no longer provides this protection or when the individual rejects this protection, a pathological condition of homelessness mutually deleterious to society and the individual exists. The factors leading to this aberration are complex and require a broader theoretical framework in the areas of economics, sociology, and individual psychodynamics.

Causative Factors

Deinstitutionalization - Deinstitutionalization of the mentally ill, together with the massive depopulation of the mental hospitals in the past two decades, is regarded as a most significant factor. Estimates suggest that between one-third and one-half of the homeless people in America are exmental patients.1

The use of the newly discovered drugs in the late 50s, and the availability of federal support for a nationwide system of community treatment centers, made it possible to move patients out of the socially isolated mental institutions and into the community for after-care. The social reformers viewed this development as humane and progressive. Government bureaucracy viewed it as an economic measure to save public funds.

The projected impact of this move on the community with its prejudices, intolerances, and fears, was underestimated or seldom considered. Increasingly stringent commitment procedures accelerated the trend toward treating new patients in the community and releasing chronically hospitalized patients into the bewildering world outside.5 In 1976 the National Institutes of Mental Health (NIMH) reported its assessment of the effectiveness of deinstitutionalization, following an extensive review of the literature.

The essential components of deinstitutionalization were defined as follows:

1. The prevention of inappropriate mental hospital admissions through the provision of community alternatives for treatment;

2. Release to the community of all patients that have been given adequate preparation for such change;

3. The establishment and maintenance of community support systems for non-institutionalized persons receiving mental health services in the community.

With the emphasis on treatment alternatives, adequate preparation and support system, NIMH concluded that the problems of the chronically mentally ill were not being successfully addressed in the community in several crucial aspects. Discharged patients were not adequately prepared to function in the community. Inadequate treatment services, except for psychotropic drugs, added to the dilemma. Attention to and provision of community support systems were inadequate. Residential facilities and living arrangements were often below acceptable standards associated with a humane environment.6

Baxter & Hopper reported that many ex-mental patients lead inconsequential lives, shutaway in cheap hotels, boarding homes or "family care" facilities.

Given the deplorable conditions in which many former patients live, and the ways in which a poor environment can afflict a disordered mind, it is not surprising that they are particularly sensitive to disruption in their daily routines.7

Shortage of Affordable Housing - Today's shortage of affordable housing has reached critical proportions. At the same time, a revitalization of residential neighborhoods is taking place in our cities. This relatively recent phenomenon is viewed as desirable because it improves the image of the city, puts money into the economy, and generates tax revenue. However, these benefits, important as they may be, must be weighed against the social and economic hardships this phenomenon imposes upon many of the elderly who are being displaced.

Ironically, the awareness of the importance of aging in place (aging in the place where younger years were spent) to the well being of the elderly is increasing at a time when a number of city neighborhoods with high concentrations of elderly are being resettled by younger middle-class residents.8 Areas prime for revitalization are old neighborhoods with a high proportion of dilapidated and abandoned housing, many of which reflect an historic past. The residents who rent in these areas are usually elderly and financially constrained. Housing for many elderly is in rooming houses, residential hotels, and missions.

Living arrangements known as the single room occupancy (SRO) hotels have been referred to in the literature as the privately owned equivalent of the poor houses of the 1 9th century. Residual dependent people in the persons of alcoholics, narcotic addicts, the mentally ill, the crippled and chronically disabled, and the lonely aged live there.

These substandard housing units are a market for reinvestment to commercial hotels, condominiums, office and retail centers. Incentives such as property tax abatements and exemptions have fostered the renovation of old buildings and the razing of SRO housing. In New York City, between 1 970 to 1 982, 110,000 such units were lost, representing 87% of the total stock. Only 17,200 units remained. Nationwide in the same decade, 47 percent of the total supply disappeared.9

In human terms, the consequence of urban redevelopment is the involuntary removal, uprooting, and dislocating of a neighborhood's original residents, now grown old. Where do the displaced go? For the poor elderly, there are only a few options. To secure affordable housing in the neighborhoods where they have aged in place means they must double or triple-up, or shift from one kind of cubicle hotel to another. Failing that, they may seek shelter in missions or resign themselves to the streets.2 These are chaotic factors in the lives of the individuals involved and burdensome problems to society at large.

Poverty - Poverty among the elderly is widespread. In 1980, 56% of those over 65 years had annual incomes of less than $10,000; 26% received under $5,000. Poverty among the elderly rose from 13.9% in 1978, 15.1% in 1979, to 15.7% in 1980.1

The effects of income reduction in old age are compounded by rising inflation. Families of the aged, who also become impoverished or who have no surplus income to offer their aged relatives, cease to be a reliable support system. If government-supported services are also reduced because of budget strains, the net effect on the marginally poor elderly can be devastating. The individual must often choose between purchasing food or paying the rent. Anxieties develop over possible rent increases, threat of eviction, loss of one's money or vulnerability to robbery, and loss of control over one's own life.

For many elderly individuals, such a series of events, losses, and pressures can be so overwhelming that their life patterns are disrupted and they are catapulted into a life on the streets.


The rapid growth of homelessness is expected to continue. The problem has become a defineable social issue of unknown costs and consequences to the taxpayer. Social scientists and policy makers recognize that the plight of the homeless involves more than the provision of food and shelter.

The secondary complexities of the problem are yet to be understood. The paucity of information has made problem analysis difficult, but it is stimulating research to generate data which will accurately depict this population group.

Recent findings cited indicate that "homeless" is not a uniformly defined category, nor can the characteristics of homeless individuals be easily distinguished from those of the general population. The one factor cited most frequently as overwhelmingly significant in contributing to homelessness is economic hardship.10

The apparent truth is that the homeless represent a diverse group with diverse problems, and diverse life styles, rather than having a single psychosocial profile. This suggests that services to this group must be diverse, comprehensive, and flexible. Although the present economic recovery may lessen some of the economic pressures on the homeless, and their numbers may conceivably diminish, the need to provide services, food and shelter appears to be permanently impressed upon the consciousness of the community at large.

Recommendations for the amelioration of the problem have been presented to the House Sub Committee on Housing and Community Development (1982) by witnesses who have done pioneering outreach work with the homeless.

The issue for provision of shelter was addressed with the introduction of a three-tiered approach. The primary approach would attempt to meet basic emergency shelter needs through congregate facilities. The second approach would involve transitional accommodations, a step up from emergency shelter, designed to respond more to the differentiated needs of the homeless, to establish the necessary clinical linkages for health and social services, and to plan for permanent housing. The third approach, that of long-term supportive housing, completes the range of sheltering arrangements and includes keeping rents affordable and assuring ongoing services.

Financial support is needed for new housing construction and rehabilitation of existing housing facilities. Subsidies to meet the cost of rent, as well as the costs of health and human services are necessary. The primary responsibility for such support is that of government, at all levels. The private sector can play a role in augmenting the efforts of government as seen in current efforts of some major cities, and in formulating policies and models which combine the efforts of the total community.

To deal with the negative consequences of deinstitutionalization community mental health systems must be designed to provide a balanced system of care that assures least restrictive care and least obtrusive treatment along a spectrum ranging from community-based programs to quality institutions.6

Concern for human needs and human dignity is prompting society to pressure for a more responsive service system that addresses the specific needs of the mentally disabled clients and minimizes dependency and loss of personal identity. Outreach efforts provide the opportunity for the system to enter the world of the homeless clients and assist them in making use of the services that could improve the quality of their lives.


  • 1 . Hombs ME, Snyder M: Homelessness in America: A Forced March to Nowhere. Washington. DC. The Community for Creative Non-Violence. 1982.
  • 2. Larew BI: Strange strangers: serving transients. Social Casework 1980: 61(2): 107-111.
  • 3. Hochschild AR: Disengagement theory: a logical, empirical, and phenomenological critique. In JF Gubrium (ed). Time, Roles, and Self in Old Age New York. Human Sciences Press, 1976.
  • 4. Atchley RC: The Social Forces in Later Life: An Introduction to Social Gerontology. Belmont. CA, Wadsworth Publishing Company, 1972.
  • 5. Clausen J: The mentally ill at home: a family matter. Families Today (DHEW Publication No. (ADM) 79-898 pp. 653-695). Rockville. MD: National Institutes of Mental Health, 1979.
  • 6. Lerman P: Deinstitutionalization: A Cross Problem Analysis. (DHHS Publication No. (ADM) 81-987 pp. 14-24). Rockville. MD. National Institute of Mental Health. 1981.
  • 7. Baxter E, Hopper K: Private Lives/Public Places. New York, Community Service Society, 1981.
  • 8. Myers P: Aging in Place. Washington, DC, The Conservation Foundation. 1982.
  • 9. Committee on Banking, Finance and Urban Affairs, House of Representatives: Homeless in America (Serial No. 97- 100). Washington, DC, US Government Printing Office, 1983.
  • 10. Cohen Ci. Sokolovsky J: Toward a concept of homeless among aged men. J Gerontol 1983: 38(1): 81-89.
  • Bibliography
  • Ferraro KF: The health consequences of relocation among the aged in the community. J Gerontol 1983; 38(1): 90-96.
  • Rousseau AM: Shopping Bag Ladies. New York. The Pilgrim Press, 1981 . Shapiro J: Reciprocal dependence between single room occupancy managers and tenants. Social Work 1970; I5(3):67-73.


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