Victimization of Homeless Women with Serious Mental Illness

1. Victimization of Homeless Women with Serious Mental Illness Rebecca Bonugli Ph.D., APRN, PMHCNS Assistant Professor University of Texas Health Science Center at San Antonio School of Nursing With support from The Committee on Scholarship The Dean’s Scholarship Award The Center for Community-Based Health Promotion with Women and Children

2. Statement of the Problem • Victimization is a major public health problem among homeless women living with a serious mental illness (Kushel et al., 2003). • As one of the fastest growing segments of the homeless population, homeless women living with SMI appear to be particularly vulnerable to victimization (Cheung & Hwang, 2004; Lee, 2005). • Evidence verifies that these women are victimized at higher rates than their homeless male counterparts (Jainchill, Hawke, & Yagelka, 2005).

3. Statement of the Problem • The accumulation of traumas experienced by homeless women including physical assault, rape, incarceration, and lack of housing are associated with increased psychiatric disability, substance abuse, and medical comorbidities (Schanzer et al., 2007; Nyamathi, Stein, & Bayley, 2000). • Although there is a growing body of research in the area of homelessness, mental illness and trauma, little is known about the personal experiences of homeless women with SMI.

4. Purpose • Increase our understanding of victimization among homeless women with SMI as perceived by those who have lived the experience. • To provide the initial data that will serve as the basis for the development of a trauma informed intervention for homeless women with SMI.

5. Specific Aims • to describe the perceptions of homeless women with SMI of the risks for victimization. • to describe the resources homeless women with SMI use to avoid victimization. • to describe the relationship of resources, risks and victimization to the health status as perceived by homeless women with SMI. • to identify prevention strategies that these women believe may help women like themselves avoid further victimization.

6. Sensitizing Framework Conceptual Model for Vulnerable Populations Research (Flaskerud & Winslow,1998) • Resource availability • Relative risks • Health status

7. Eligibility Criteria • Homeless adult woman over the age of 18 • Diagnosed with SMI (schizophrenia, bipolar disorder, schizoaffective disorder, major depressive disorder) • Global Assessment Scale score > 50 • Brief Psychiatric Rating Scale score < 54 • Competent to sign informed consent as determined by the MacArthur Competence Assessment Tool for Clinical Research (Appelbaum & Grisso, 2001)

8. Design / Setting • Qualitative descriptive design • Convenience sample recruited from a transitional living shelter for homeless women with SMI • N = 15

9. Methods / Procedure • Fliers posted at transitional living shelter • Participants interested contacted the PI • Screened for eligibility • Consent obtained • Received a $20.00 gift card

10. Methods / Data Collection • Sociodemographic questionnaire • Individual interviews were audio-taped and ranged from 1 hour to 2.5 hours • Field notes completed after each interview

11. Methods / Data Analysis • Interviews were transcribed verbatim and then compared to original audio files to ensure accuracy and completeness. • Qualitative content analysis used to include line by line coding of data, recorded insights and reflections, identified similar phrases, patterns and themes, examined the commonalities and differences and examined the findings in light of current knowledge (Sullivan-Bolya & Harper, 2005).

12. ResultsSample DemographicsN = 15

13. Findings: Theme 1 1)Traumatic victimization occurred within the context and intersection of multiple losses for the women in this study. • Loss of job and economic resources • Physical displacement • Loss of spouse/partner • Loss of social support systems • Loss of self esteem • Loss of self esteem secondary to stigma

14. “I moved here from Michigan. She (my sister) told me that she didn’t want me there no more so she took me over to the shelter and left me there. Yeah…my oldest sister. I was terrified because when you go there all these people are sitting out on the street. I was terrified. It’s like anything can happen to you. It’s demeaning.”

15. Findings: Theme 2 2) Avoiding traumatic victimization, particularly rape, although eclipsed by the struggle to meet basic needs, required survival skills: • Remain hypervigilant. • Constant appraisal of the environment. Safe havens were sparse. • Learning to live with the constant threat of trauma.

16. 42 year-old female: • “……He looked very innocent…yeah. And he forced himself on me and I tried to jump off the car you know well I did and it scraped up all my…I still have all the scars here…where I fell on my elbow on the street. To keep yourself alive it took a lot, you know. It’s terrible. But it’s something you’ve got to learn how to live with.”

17. Findings: Theme 3 3) Poor health status was perceived to be a direct result of homelessness and victimization. 62 year-old female: • “I was in New Orleans during Katrina….so that put me out of housing and into a state of desperation, panic and depression and a whole bunch of other stuff. I wasn’t eating properly and I had a potassium depletion episode. And it felt like a heart attack. And when I went to the hospital…I went to the hospital like 3 times in one week.”

18. Findings: Theme 4 4) Strategies used to avoid victimization often increased psychiatric symptoms. 32 year-old female: • “You feel like there’s no one you can talk to. And you feel like you have to keep everything to yourself. Ah hum…to certain guys I talk to…you know…but for the most part…no I don’t…I don’t open up and tell people about myself you know cause I feel like I’m leaving myself wide open for something to happen.”

19. Findings: Theme 5 5)Concern for self and survival, concern for being responsible and caring for others, concern for self and others as interdependent beings. 56 year-old female: • “For one thing I’m more stable…I take my medication…I go to my doctors appointments. I’m in church. And I have a very good relationship with my children today and my parents….I’m responsible...I wanted to live…and I was just existing and I knew there had to be a better way. And I want it that way you know. Not because somebody else wanted it for me but because I wanted it.”

20. Discussion • The strengths of the participants in this study emerged in stories of survival and growth. • Altruistic themes emerged as they spoke of rising from the depths of despair following trauma and developing concern for others. • Participants discussed deeply profound and newly constructed meanings of suffering. • The transformative nature and process of recovery needs to be further explored among this population.

21. Acknowledgements Research Participants Dr. Janna Lesser Ph.D. Associate Professor The Committee on Scholarship The Dean’s Scholarship Award The Center for Community-Based Health Promotion with Women and Children The University of Texas Health Science Center School of Nursing

22. References Appelbaum, T. & Grisso, P. (2001). MacCat-CR MacCarthur Competence Assessment Tool for Clinical Research. Sarasota, Florid: professional Resources Press. Cheung, A. & Hwang, S. (2004). Risk of death among homeless women: a cohort study and review of the literature. Canadian Medical Association Journal, 170(8), 1243-1247. Flaskerud, J. & Winslow, B. (1998). Conceptualizing vulnerable populations: health related research. Nursing Research, 47(2), 69-78. Jainchill, N., Hawke, J. & Yagelka, J. (2005). Gender, psychopathology, and patterns of homelessness among clients in shelter-based TC’s. Journal of Clinical Psychology, 73: 667- 677. Kushel, M., Evans, J. Perry, S., Robertson, M. & Moss, A. (2003). No door to lock: Victimization among homeless and marginally housed persons. Archives of Internal Medicine,163(20), 2492- 2499. Lee, B. (2005). Danger on the streets – marginality and victimization among homeless people. American Behavioral Scientist, 48(1), 33-44. Nyamathi, A., Stein, J., & Bayley, L. (2000). Predictors of mental distress and poor physical health among homeless women. Psychology and Health, 15, 483-500. Schanzer, B., Dominguez, B., Shrout, P., & Canton, C. (2007). Homelessness, health status, and health care use. American Journal of Public Health, 97(3), 464-469.