A Downward Spiral: A Case Study in Homelessness

Learning Objectives: At the end of this case, you will be able to:

? Analyze at least three issues contributing to mental illness in the homeless.

? Describe barriers to mental health care for individuals who are homeless.  

? Reflect on your personal views and understanding of the mentally ill homeless population.

Description

Thirty-six-year-old John may not fit the stereotype of a homeless person. Not long ago, he was

living what many would consider a healthy life with his family. But when he lost his job, he

found himself in a downward spiral, and his situation dramatically changed.

John’s story is a fictional composite of real patients that are treated by Health Care for the

Homeless. It illustrates the challenges homeless people face in accessing health care and the

despair they often experience. 

Case:

Married with two young children, John and his wife rented a two-bedroom apartment in a safe

neighborhood with good schools. John liked his job as a delivery driver for a large food service

distributor, where he had worked for more than four years. His goal was to become a supervisor

in the next year. John’s wife was a stay-at-home mom.

John had always been healthy. Although he had health insurance through his job, he rarely

needed to use it. He smoked half a pack of cigarettes each day and drank socially a couple times

a month. In the past he had struggled with an addiction problem—mostly alcohol and

marijuana—but since having kids he had made some significant improvement in his drinking

behaviors. John grew up in a pretty tough neighborhood and both his parents were alcoholics. He

had endured some abusive behaviors from his father when he was younger and developed some

problems in school with acting out. He eventually saw a school counselor and things settled

down. He never followed up with any mental health counseling once he left school. Overall his

life appeared to be going well. 

One afternoon, John’s company notified him that it was laying him off along with more than a

hundred other employees. Though he was devastated about losing his job, John was grateful that

he and his wife had some savings that they could use for rent and other bills, in addition to the

unemployment checks he would receive for a few months.

John searched aggressively for jobs in the newspaper and online, but nothing worked out. He

began to have feelings of anger and worry that led to panic. His self-esteem fell, and he became

depressed. When John’s wife was hired to work part-time at the grocery store, the couple felt

better about finances. But demoralized by the loss of his job, John started to drink more often.

Two beers a night steadily increased to a six-pack. John and his wife started to argue more often.

Then, about six months after losing his job, John stopped receiving unemployment checks. That

week, he went on a drinking binge that ended in an argument with his wife. In the heat of the

fight, he shoved her. The next day, John’s wife took the children and moved in with her parents.

No longer able to pay the rent, John was evicted from the apartment.

John tried to reconcile with his wife, but she said she’d had enough. Over the next few months,

John “couch surfed” with various family members and friends. At one point, he developed a

cold, and when it worsened over a few weeks, he sought care at the emergency department.

Hospital staff told him that he would be billed because he didn’t have insurance. John agreed,

and a doctor diagnosed him with a sinus infection and prescribed antibiotics. With no money to

spare, John could not get the prescription filled.

John continued to live with family and friends, but his heavy drinking and anger only got worse,

and his hosts always asked him to leave. He went from place to place. Finally, when John ran out

of people to call, he found himself without a place to stay for the night and started sleeping at the

park.

He became more depressed with little hope that things would ever get better and often thought

about ending his life. John’s ability to cope with his homelessness led him to engage in

increasingly risky behaviors. He often found himself getting into fights, had begun to rummage

through trash for cans and bottles and now had an arrest record for loitering and petty theft. 

Winter arrived, and it was too cold for John to sleep outside, so he began staying at a shelter run

by the church. Each morning, he had to leave the shelter by 6 AM. He walked the streets during

the day and panhandled for money to buy alcohol.

One evening, some teenage boys jumped John in park, stealing his backpack and kicking him

repeatedly. An onlooker called 911, and John was taken to the emergency department. Later that

evening, the hospital discharged John. He returned many times to the emergency department for

his health care, seeking treatment for frequent colds, skin infections, and injuries. Providers

never screened him for homelessness or mental illness and always discharged him back to

“home.” 

Adapted from Terri LaCoursiere Zucchero, PhD, RN, FNP-BC, and Pooja Bhalla, MSN, RN

Discussion Questions:

1. What events in John’s life created a “downward spiral” into homelessness and hopelessness?

Which events are related to social needs, mental health needs, medical needs and which could

health care have addressed?

2. What were some of the barriers John faced in accessing medical care; mental health care?

3. How does homelessness and mental illness intersect? Do you believe homelessness may

develop because of a mental health issue or do you believe those who become homeless

eventually sink into psychological despair?

4. The tipping point for many people who live at the margins of society may be things that could

have been managed given the right supports. How can your role as an RN help to identify,

alleviate or support those who are in need like John? 

5. In your own experience, have you encountered a homeless individual? What was that like? Do

you recall what you were thinking?

Helpful resources to answer the questions

financial-disaster-2017-01-12

Also, check the attached files including class lectures.