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Homelessness and Substance Abuse: Which Comes First?


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The present paper uses a social selection and social adaptation framework to investigate whether problematic substance use normally precedes or follows homelessness. Clarifying temporal order is important for policy and program design. The paper uses information from a large dataset (N�4,291) gathered at two services in Melbourne, supplemented by 65 indepth interviews. We found that 43% of the sample had substance abuse problems. Of these people, one-third had substance abuse problems before they became homeless and two-thirds developed these problems after they became homeless. We also found that young people were more at risk of developing substance abuse problems after becoming homeless than older people and that most people with substance abuse issues remain homeless for 12 months or longer. The paper concludes with three policy recommendations.
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Australian Social Work
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Homelessness and Substance Abuse: Which Comes First?
Guy Johnson a; Chris Chamberlain a
a RMIT University, Victoria, Australia
Online Publication Date: 01 December 2008
To cite this Article Johnson, Guy and Chamberlain, Chris(2008)'Homelessness and Substance Abuse: Which Comes First?',Australian
Social Work,61:4,342 — 356
To link to this Article: DOI: 10.1080/03124070802428191
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Homelessness and Substance Abuse:
Which Comes First?
Guy Johnson & Chris Chamberlain
RMIT University, Victoria, Australia
The present paper uses a social selection and social adaptation framework to investigate
whether problematic substance use normally precedes or follows homelessness. Clarifying
temporal order is important for policy and program design. The paper uses information
from a large dataset (N4,291) gathered at two services in Melbourne, supplemented
by 65 indepth interviews. We found that 43% of the sample had substance abuse
problems. Of these people, one-third had substance abuse problems before they became
homeless and two-thirds developed these problems after they became homeless. We also
found that young people were more at risk of developing substance abuse problems after
becoming homeless than older people and that most people with substance abuse issues
remain homeless for 12 months or longer. The paper concludes with three policy
Keywords: Homelessness; Substance Abuse; Housing And Support
There is a common perception that substance abuse and homelessness are linked, but
there is considerable contention about the direction of the relationship (Kemp, Neale,
& Robertson, 2006; Mallett, Rosenthal, & Keys, 2005; Neale, 2001; Snow & Anderson,
1993). Does substance abuse typically precede or follow homelessness? In the present
paper, we distinguish between recreational substance use and problematic substance
use, or substance abuse. First, we review the literature; then, we explain how we
operationalised the terms ‘‘problematic substance use’’ and ‘‘substance abuse’’ in our
Some studies indicate that substance abuse is a risk factor for homelessness,
whereas others suggest that homelessness ‘‘induces drug use’’ (Neale, 2001, p. 354).
This is commonly known as the debate about substance abuse as either a cause or
Correspondence to: Dr Guy Johnson, Australian Housing and Urban Research Institute, RMIT University, GPO
Box 2476V, Melbourne, Vic. 3000, Australia. E-mail:
Accepted 21 July 2008
ISSN 0312-407X (print)/ISSN 1447-0748 (online) #2008 Australian Association of Social Workers
DOI: 10.1080/03124070802428191
Australian Social Work
Vol. 61, No. 4, December 2008, pp. 342356
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consequence of homelessness (Culhane, 2005; Hartwell, 2003; Morrell-Bellai,
Goering, & Boydell, 2000; Neale, 2001; Neil & Fopp, 1993; Victorian Homelessness
Strategy, 2002). We also refer to this debate as the argument about temporal order, or
what comes first.
Johnson, Freels, Parsons, and Vangeest (1997) also referred to the argument about
cause and consequence, but they frame the debate using the ideas of social selection
and social adaptation. The social selection model views substance abuse as just one of
a number of causes or triggers of homelessness. Some studies suggest that substance
abuse is the major reason for homelessness (Baum & Burnes, 1993), whereas others
suggest that it is just one of many contributing factors (Neale, 1997; Snow &
Anderson, 1993; Timmer, Eitzen, & Talley, 1994).
The key proposition underpinning the social selection model is that homelessness
represents the end point in a process characterised by the gradual depletion of an
individual’s economic and social resources. As people’s substance use increases, so
their financial reserves are exhausted as they maintain an increasingly expensive
‘‘habit’. They either fall into rent arrears, which leads to eviction (Bessant et al.,
2002), or family relationships break down, leading to homelessness (Coumans &
Spreen, 2003). Fountain and Howes found that 63% of their sample of homeless
people in Britain cited drug or alcohol use as a reason for first becoming homeless.
They concluded that ‘‘Drug use is traditionally seen as one of the major routes into
homelessness, and this was borne out by our survey’’ (Fountain & Howes, 2002,
p. 10).
Media commentaries in Australia imply that problematic drug use is a major cause
of homelessness (Zufferey & Chung, 2006) and people in the wider community
apparently endorse this position. In a recent survey of 993 people in Melbourne, 91%
identified substance abuse as the primary cause of homelessness (Hanover Welfare
Services, 2006).
The social adaptation model focuses on substance abuse as a consequence of
homelessness. It draws upon the long established sociological argument that social
behaviour can be best understood by examining the social context in which it occurs.
Newly homeless people encounter an environment where substance use is an accepted
social practice. For some people, involvement with drugs stems from their initiation
or socialisation into the homeless subculture (Auerswald & Eyre, 2002; Ginzler,
Cochran, Domenech-Rodriguez, Cauce, & Whitbeck, 2003; Hartwell, 2003; Johnson,
Freels, Parsons, & Vangeest, 1997; Johnson, Gronda, & Coutts, 2008; Rice, Milburn,
Rotheram-Borus, Mallett, & Rosenthal, 2005). For other people, drug use emerges as
a means of coping with the uncertainty, instability, and chaotic conditions that
characterise their day-to-day lives (Neale, 2001; Rowe, 2002; Teesson, Hodder, &
Buhrich, 2003). Although individuals respond in ways that make sense to them, the
thrust of this argument is that the behaviour of the homeless is best understood as an
‘‘adaptation to environmental exigencies’’ (Snow & Anderson, 1993, p. 38).
This paper draws on a large sample of homeless people (N4,291) to investigate
whether substance abuse normally precedes or follows homelessness. This is a
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complicated issue because there is considerable variation between individual cases
and homelessness is rarely caused by one factor operating independently. We show
that both approaches help to understand the relationship between homelessness and
problematic substance use. Nonetheless, we argue that it is more common for
substance abuse to follow homelessness rather than to precede it. We also show that
young people are particularly vulnerable to developing problematic substance abuse
in the homeless population, and that people who have substance abuse problems
usually remain homeless for 12 months or longer. Finally, we make three policy
We collected information at two high-volume services in inner Melbourne. Both
agencies work with people who are at risk of homelessness, as well as those who are
actually homeless. On average, each agency works with 6,0007,000 households each
year. A case file is created for every household that presents to each service and we
obtained permission to read these case files from both agencies and our university ethics
At one agency, the protocol was that clients must give written consent for us to
examine their case file. At the other agency the protocol was that clients could opt out of
the research by signing a form. The case files could not be de-identified because they
were currently in use by staff at both services, but clients’ names were not recorded and
each record was allocated a number for identification purposes. Many files contained a
great deal of retrospective information about people’s housing histories and we could
follow people’s experiences of homelessness over many months or years.
First, we discuss the definition of homelessness used in the research and the
representativeness of our sample. Then we explain how we operationalised the terms
problematic substance use and substance abuse. Finally, we explain how we used
qualitative data to supplement the quantitative database.
The number of homeless people in our sample depends on the definition of
homelessness that is used. In Australia, there has been debate about the definition of
homelessness, with disagreement about many fundamental issues (Chamberlain &
Johnson, 2001; Crane & Brannock, 1996; Neil & Fopp, 1993). In the present paper, we
use an approach known as the ‘‘cultural definition of homelessness’, which the
Australian Bureau of Statistics uses to enumerate the homeless population (Chamber-
lain, 1999; Chamberlain & Mackenzie, 2003).
The core idea underpinning the cultural definition of homelessness is that there are
shared community standards about the minimum accommodation that people can
expect to achieve in contemporary society (Chamberlain & MacKenzie, 1992). The
minimum for a single person (or couple) is a small rental flat with a bedroom, living
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room, kitchen, and bathroom, as well as an element of security of tenure provided by a
lease. This has led to the identification of ‘‘primary’, ‘‘secondary’’, and ‘‘tertiary’’
Primary homelessness includes all people without conventional accommodation,
such as people living on the streets or using cars or railway carriages for temporary
shelter. Secondary homelessness includes people who move frequently from one form
of temporary shelter to another, including emergency accommodation. Tertiary
homelessness refers to people staying in boarding houses on a medium- to long-term
basis, defined as 13 weeks or longer. These people are homeless because their
accommodation does not have the characteristics identified in the minimum
community standard.
We examined a total of 5,526 cases over the period January 2005June 2006 and
coded each file on 30 variables, including whether the household was ‘‘homeless’’ or
‘‘at risk’. We identified 334 cases in which people had been coded at both agencies
and these duplicates cases were removed from the database, along with six cases that
contained insufficient information. This reduced the database to 5,186 households. In
the present paper, we are only interested in the homeless population and we had
information on 4,291 homeless households.
There is no sampling frame of homeless people in Australia and this makes it difficult
to assess the typicality of our sample. Nonetheless, we suspect that the sample is
representative of the inner city homeless for two reasons. First, we drew our data from
the two principal high-volume services in the inner city. Second, when we compared the
demographic characteristics of the sample (e.g. age, household type, gender) with the
characteristics of the population using the services, the two profiles were similar.
Substance Abuse
The number of people identified with substance abuse problems depends on the
definition of problematic substance use that is used. Defining substance abuse tends to
follow either clinical or operational approaches, both of which have limitations (for a
useful summary, see Snow, Anderson, & Koegel, 1994).
In the present paper, we distinguish between ‘‘recreational’’ substance use and
‘‘problematic’’ substance use or substance ‘‘abuse’. We operationalise problematic
substance use or substance abuse following the work of Mallett, Edwards, Keys, Myers,
and Rosenthal (2003). Problematic substance use is when drug use dominates a person’s
life at the expense of other activities and has negative mental and/or physical side effects.
We classified people as having a substance abuse problem if they met at least one of the
following criteria:
.the individual had approached the agency for a referral to a drug treatment service;
.the individual was currently in, or had been in, a detoxification or rehabilitation
centre; or
.the case notes identified substance abuse as an issue.
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Problematic substance abuse was often self-reported, but sometimes it was based
on an assessment made by staff.
Clarifying the chronological sequence of homelessness and substance abuse is
difficult and, in itself, insufficient to establish causal linkages (Johnson et al., 1997).
Nevertheless, at both agencies, staff endeavoured to make a broad-based assessment
of the issues that resulted in the person becoming homeless. Housing and support
workers know that problematic substance use is often an issue for presenting clients
and they are used to asking questions to ascertain whether this is relevant.
Problematic substance use is routinely recorded on the case file with brief details.
We used information from the initial assessment, often combined with information
from other parts of the case history, to assess whether substance abuse preceded or
followed homelessness.
Our findings provide an indicator of the extent of problematic substance use
among the inner city homeless, although it may be an underestimate because some
people may not have disclosed this information. Similarly, our findings provide an
indicator of whether substance abuse precedes or follows homelessness, but relevant
information may have been missing from some case histories.
Qualitative Data
There are limitations in determining how processes unfold when using quantitative
data. Therefore, we supplement our analysis with information from 65 indepth
interviews. The use of multiple techniques is known as ‘‘triangulation’’ and this is a
standard approach in the social sciences: ‘‘triangular techniques ...attempt to map
out, or explain more fully the richness and complexity of human behaviour by
studying it ...using a variety of methods, even combining qualitative and
quantitative methods’’ (Burns, 1994, p. 272).
The 65 respondents were recruited from the participating agencies. Agency staff
recruited people who were or had been homeless and were willing to participate in
the study. Approval was obtained from our university ethics committee. A cross-
section of homeless people using the agencies was interviewed and they matched the
main sample in terms of basic social characteristics, such as age, gender, and
household type. Half the respondents had substance abuse issues, and some
interviews elicited a great deal of information about substance abuse and the process
of becoming homeless. On average, the interviews lasted an hour.
The interviews were tape recorded and transcribed for qualitative analysis. We used
narrative analysis to organise information according to temporal sequence (Labov,
1997), paying particular attention to pathways into and out of homelessness,
engagement with the homeless subculture, and whether substance abuse preceded of
followed homelessness. We use the qualitative data to illustrate what happens when
substance abuse precedes homelessness and what happens when substance abuse
follows homelessness. People’s names and various personal details have been changed
to ensure confidentiality.
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Prevalence of Substance Abuse
The first task was to establish how many people in the sample had substance abuse
problems. Studies that focus on the number of people with substance abuse problems
are referred to as prevalence studies. A common finding is that homeless people have
higher rates of problematic substance use than people in the general community
(Teesson, Hodder, & Buhrich, 2003). In their recent study of 210 homeless people in
Sydney, Teesson et al. (2003, p. 467) found that ‘‘homeless people were six times more
likely to have a drug use disorder and 33 times more likely to have an opiate use
disorder than the Australian general population’’. One welfare service in Melbourne
reported that the prevalence rate of heroin use among its clients was ‘‘10 times greater
than in the general community’’ (Horn, 2001, p. 8).
Although the empirical link between substance abuse and homelessness is well
established, reported rates of problematic drug use among the homeless vary, with
estimates ranging from 25% to 70% (Hirst, 1989; Jordon, 1995; Victorian Home-
lessness Strategy, 2002). Estimates vary because of different sampling procedures, as
well as different definitions of problematic drug use and homelessness.
We found that 43% of our sample had substance abuse problems. The most
common drug was heroin, but a minority identified alcohol or prescription drugs.
Our findings are consistent with recent studies indicating that drugs have displaced
alcohol as the most abused substance among the homeless, particularly among the
young (Glasser & Zywiak, 2003; Johnson et al., 1997).
Substance Abuse as a Precursor to Homelessness
The first model we examine is the social selection approach. We start by identifying
how many people in our sample had substance abuse issues prior to becoming
homeless. Then, we identify three typical stages leading to homelessness for those
with problematic drug use.
We found that 15% of the sample had substance abuse problems prior to becoming
homeless for the first time. In the public domain, substance abuse is regularly seen as
the main cause of homelessness, yet for most people in our sample other factors
resulted in them becoming homeless. This finding is important for two reasons. First,
when attributions of cause are incorrect, it can lead to inappropriate policy and
program design. Second, by focusing on substance abuse as a causal factor,
individuals are commonly blamed for the situation, diverting attention away from
the structural factors that contribute to homelessness.
Many people in Australia use drugs for recreational purposes (Marks 1989;
McAllister & Makkai, 2001), but here we describe the substance abuse pathway into
homelessness. Studies of homeless pathways commonly point to a series of ruptures
with mainstream life (Hartwell, 2003; Johnson et al., 2008; Keys, Mallett, &
Rosenthal, 2006). We identify three stages in the substance abuse pathway. First,
there is a break with the mainstream labour market; second, there is the loss of
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support from family and friends; and, finally, there is the acquisition of new social
The first stage is characterised by people’s changing relationship with the labour
market. Substance abuse often starts to interfere with people’s ability to work,
commonly leading to job loss (Bessant et al., 2002; Zlotnick, Robertson, & Tam,
2002). For example, Cynthia
was a hairdresser working in a regional city. After
dabbling in drugs for a number of years, she was introduced to heroin by her
boyfriend. Over time her heroin use became more frequent and she started ‘‘working
extra hours’’ to support her habit. Slowly her ‘‘habit’’ burgeoned out of control and
her work ‘‘started to get messy’’. Cynthia left before she was sacked but, in a country
town, rumours spread quickly and she was unable to find alternative employment.
Andrew, a storeman, had a similar experience. As his heroin use escalated, he
started to miss work more frequently, citing a range of illnesses and problems at
home to explain his repeated absences. Eventually, he ended up ‘‘having to leave that
job’. He got another job, but ‘‘they suspected I was using’’ and he was sacked.
When people lose their jobs, it is the loss of income that has the biggest impact.
People start to look for alternative sources of income to support their habit, what
Rowe (2002) called the ‘‘business of raising money’. This ‘‘business’’ has a significant
influence on people’s day-to-day lives, because the cost of illicit drugs is high and
people on low incomes have to devote large amounts of time to securing money.
Everything else tends to fall by the wayside besides raising money and ‘‘scoring’.
People use a range of strategies to raise money but, initially, the most common
strategies are the use of credit cards and borrowing money from friends and relatives.
This signals the start of the second stage of the substance abuse pathway, which is
characterised by changes to existing social networks. Snow and Anderson (1993)
argued that the erosion of support networks, particularly friends and family, is:
Regarded as particularly critical in the determination of homelessness. A person
does not become homeless ... simply because he or she is an alcoholic, but because
these disabilities exhaust the patience or resources otherwise available in our social
networks. (Snow & Anderson, 1993, p. 256)
People who lose these vital social supports, or do not have them to start with, are
acutely vulnerable to homelessness.
Respondents told us that borrowing money strained friendships to breaking point.
Tony’s best friend tried to help but, eventually, ‘‘He said to me ...I only see you when
you want money. And it was true. I always made up lies to borrow money. Eventually
he stopped lending me money.’’
When existing friends would no longer assist, other friends and acquaintances were
approached. Tony said, ‘‘I tried everyone I could think of but no-one would lend me
money’’. Gradually, his friends stopped coming to see him as a result of his
continuing demands.
Names and extraneous details have been changed to preserve anonymity.
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Many substance abusers still relied on their families for support. Families typically
try to assist their children, but when children break promises it puts acute pressure on
many parents. Toby said that he ‘‘burnt my bridges with my family. I did some really
shitty things.’ Bert said, ‘‘One night when I was ‘off my face’ I fell over in the laundry.
I reached out for the sink and I ended up pulling the boiler over. That was it. My
father said ‘get out’.’’
Most families tried hard to help children who were in trouble, but when parents
were pushed too far many withdrew their support.
As established social networks collapsed, new networks started to form. This
signals the third stage of the substance abuse pathway. These networks were
dominated by others with substance abuse problems (Rice et al., 2005). Danny said
this ‘‘new crowd’’ were no longer ‘‘dabblers’’ (an occasional user) but were a ‘‘very
different crowd from those I met at drug parties’. John’s remark illustrates the highly
opportunistic nature of these friendships: ‘‘They were your friends, but really they’re
not your friends, because they’ve smacked money off you. If they were your real
friends, they wouldn’t give you that stuff.’’
Once the support of family and friends had collapsed, most people who had
substance abuse problems were at acute risk of homelessness. Toby ‘‘just wasn’t
getting the bills paid’’ because of his habit, whereas Tan’s worsening habit meant that
his housing hung by a slender thread: ‘‘ Sometimes you will only pay your board, you
know ...and if you don’t pay your board, you get kicked out, and that’s what
happens sometimes’’.
Most people who are at risk of homelessness report high levels of anxiety and
psychological distress at the prospect of losing their accommodation (van Doorn,
2005; Wong & Piliavin, 2001; Wong, 2002), but people with substance abuse
problems tended to ‘‘slide’’ into homelessness. This reflects the fact that many were
already connected to the drug scene and for most ‘‘feeding their habit’’ was the
priority. After losing his accommodation, John said, ‘‘I didn’t care ... It didn’t bother
me ... You know, I was already walking around with nowhere to go. I didn’t realise I
was one of them.’’
Substance Abuse as an Adaptation to Homelessness
Recently, more researchers have focused on substance abuse as adaptation. When
people are homeless, they adapt in order to survive. Although responses may vary
from person to person, using drugs is a common form of adaptation.
In the present study, 43% of the sample had substance abuse issues. Table 1 shows
that two-thirds (66%) developed problematic substance use after they became
homeless. Our data confirm that substance abuse is common among the homeless
population, but, for many people, substance abuse follows homelessness. Drug use is
an adaptive response to an unpleasant and stressful environment and drug use creates
new problems for many people.
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There are two common explanations as to why people become involved in
problematic substance use after they become homeless. First, some people take drugs
as a way to cope with or escape the harsh, oppressive environment that confronts
them (Neale, 2001). Toby said: ‘‘The only way I could deal with that place (a run
down boarding house) was to use drugs and I did use them’. David said that using
heroin helped him to forget about his troubles: ‘‘Using smack was a way for me to
hide ... You just hide away from everything ... You take your mind off everything
else because the one thing you’ve got to do each day is make sure you get your hit.’’
For Cameron, the situation was similar. Cameron had tried a range of drugs before
he became homeless, describing himself as an ‘‘on and off again’’ user. However, once
homeless, Cameron’s drug use worsened considerably as he tried to deal with his new
circumstances. It soon got to the point where substance abuse was a major issue in
Cameron’s life: ‘‘I didn’t realise how bad my drug use had got habit was
climbing and climbing. Everything was pretty much out of control at that point.’
The second reason for problematic substance use stems from increasing
involvement in the homeless subculture, where drug use is a common and accepted
social practice. Drug use is commonly a form of initiation into the homeless
subculture (Auerswald & Eyre, 2002; Fitzpatrick, 2000). Tess said she started to use
heroin ‘‘because everybody around me was using smack’’. Joan was more explicit
about the influence of her homeless peers: ‘‘Just peer pressure, I suppose. People
around me were doing it and I wanted to fit in.’
Many homeless people strive for a sense of ‘‘belonging somewhere’, particularly
those who experience homelessness when they are young. As Goffman (1961, p. 280)
noted, ‘‘Without something to belong to, we have no stable self ...Our sense of
being a person can come from being drawn into a wider social unit.’’
Through interaction with other people in similar situations, the homeless
subculture provides ‘‘an essentially non-stigmatising reference group and a source
of interpersonal validation’’ (Snow & Anderson, 1993, p. 173). By mixing with other
homeless people, some find a measure of support and security.
Involvement in the homeless subculture is particularly important for young people
who often lack a sense of belonging somewhere following the breakdown in their
family relationships. This involvement in the subculture is often accompanied by
initiation into substance use.
Table 2 shows that that 60% of our sample who had their first experience of
homelessness when they were 18 years of age or younger (teenagers) had
subsequently become involved in problematic substance use. In contrast, only 14%
Table 1 Substance Abuse Identified Before or After Homelessness
Substance abuse before homelessness 656 34
Substance abuse after homelessness 1,284 66
Total 1,940 100
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of those who had first experienced homelessness when they were 19 years or older
(adults) had subsequently developed substance abuse problems.
Involvement with the homeless subculture is a ‘‘double-edged sword’’ (Grigsby,
Baumann, Gregorich, & Roberts-Grey, 1990). On the one hand, associating with
other homeless people can provide a ‘‘refuge from the exclusion they suffer’’ (Rice et
al., 2005) and can suppress the insecurity typically associated with being homeless.
On the other hand, participation in the homeless subculture can lead to
entrenchment in the homeless population. This happens because many of the social
practices people learn in order to survive homelessness make it difficult for them to
get out of homelessness (Grigsby et al., 1990). Alexis had never injected drugs prior to
becoming homeless but she soon learnt: ‘‘I bought the smack from a girl who showed
me how to hit up ... she just gave it to me in bits ...That’s how I learned to inject
People who are long-term homeless often use boarding houses or squats. These are
dangerous places and drug use is sometimes the only link between residents. Palik
told us about an inner city boarding house:
I was more frightened in there than when I was on the streets. I was trembling
because there were all these big dudes ... There was nothing I could talk to them
about apart from drugs. The only thing we had in common was heroin.
Boarding houses provide easy access to drugs. Palik’s dealer lived in the same
boarding house.
Regardless of whether substance abuse precedes or follows homelessness, it
typically locks people into the homeless population. Table 3 uses three temporal
classifications (short-term, medium-term, and long-term homelessness) to demon-
strate that homeless people with substance abuse issues are more likely to get stuck in
the homeless population. Table 3 shows that 82% of people who had substance abuse
issues had been homeless for 12 months or longer. In contrast, only 50% of those who
had no substance abuse issues had been homeless for that long. When people have
substance abuse problems they become marginalised from mainstream institutions
and getting out of homelessness becomes more difficult.
Not only do people with substance abuse problems face barriers to getting out of
homelessness, but they also have difficulties remaining housed. Table 4 shows that
Table 2 Proportion of Respondents Developing Substance Abuse Issues Following
Homelessness According to Age when they First Became Homeless
Age at first homelessnes (years)
18 or younger
19 or older
% Respondents developing substance
abuse following homelessness
60 14 35
*Excludes 656 people who had substance abuse issues before they became homeless.
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76% of those who were substance abusers had experienced two or more periods of
homelessness. These people had attempted to return to secure accommodation, but
had become homeless again. Unless homeless people with substance abuse issues have
access to ongoing assistance, they often relapse and return to problematic substance
use (Milby, Schumacher, Wallace, Freedman, & Vuchinich, 2005) and subsequently
lose their accommodation.
This paper set out to investigate whether most people become homeless because of
problematic substance use problems or whether substance abuse typically occurs
later. We applied the social selection and social adaptation framework of Johnson
et al. (1997) and found that both approaches helped us understand the relationship
between substance abuse and homelessness. However, we found that the social
adaptation account was a better fit overall. Nearly 45% of our sample had substance
abuse issues, but two-thirds developed these problems after they had become
homeless. Next, we comment on three policy implications of these findings.
First, the data indicate that people who first experience homelessness when they are
18 years of age or under are more likely to develop substance abuse issues than people
who become homeless when aged 19 years or older. Of those who had become
homeless as teenagers, 60% had developed substance abuse issues. In contrast, of
those who had become homeless as adults, only 14% had become substance abusers.
For some homeless teenagers, substance use is a way of coping with the boredom and
Table 3 Duration of Homelessness According to Experience of Substance Abuse
No substance abuse
Substance abuse
Duration of homelessness
Short term
(B3 months)
31 7 20
Medium term
(311 months)
19 11 16
Long term
(12 months or longer)
50 82 64
Total 100% 100% 100%
Table 4 Proportion of Respondents who had two or more Episodes of Homelessness
According to Experience of Substance Abuse
No substance abuse
Substance abuse
% Respondents with two or more
episodes of homelessness
48 76 61
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frustration of their daily lives. For other young people, substance use is part of the
process of socialisation into the homeless subculture. The first policy challenge is how
to prevent young homeless people from engaging with the homeless subculture where
substance abuse often begins.
Most teenagers have their first experience of homelessness while they are still at
school (Crane & Brannock, 1996; O’Connor, 1989). It is widely recognised that
schools are sites for early intervention because it is easier to help homeless young
people when they are still at school and located in their local community
(Chamberlain & Mackenzie, 1998; Department of Family and Community Services,
2003; House of Representatives, 1995). Early intervention involves strategies that
assist homeless teenagers to reunite with their family or make the transition to
independent living. It is only when homeless students drop out of school and leave
behind their local ties that they are likely to get involved with the homeless subculture
where substance abuse is common (Hartwell, 2003, p. 484).
Second, we found that irrespective of whether substance use preceded or followed
homelessness, people with substance abuse problems tended to stay in the homeless
population longer than other homeless people. When this happens, these people’s
social networks start to change and include mainly homeless people (Rice et al.,
2005). Recent research suggests that ‘‘the removal of oneself from a lifestyle centred
on drug use, and the ability to adjust to a new lifestyle, is integral to recovery from
problematic drug use’’ (Rowe, 2002, p. 6). However, people who received assistance
for their drug problems often returned to emergency accommodation or boarding
houses where they were in contact with others who had substance abuse problems.
This maintains people’s exposure to drugs and increases the possibility that they will
relapse (Anderson, Shannon, Schyb, & Goldstein, 2002; Johnson et al., 2008).
Other people in recovery were rehoused in neighbourhoods where illegal drug
activity was high and this made it difficult for them to maintain abstinence
(Anderson et al., 2002). Policy makers and service providers have long recognised that
the desirable policy option is that people should be assisted into permanent housing
in communities where drug use is low (Milby et al., 2005). This may not be possible
at the present time because substance abuse is widespread in public housing estates
(Bessant et al., 2002) and there is also an acute shortage of public housing in most
cities. Given the constraints in the housing market are unlikely to change in the
foreseeable future, one policy alternative is to foster better links between state and
community housing providers and specialist clinical services. Research has shown
that a more integrated, holistic approach can reduce the prospect of relapse (Milby
et al., 2005; Padgett, Gulcur, & Tsemberis, 2006) and help fill the vacuum that often
‘‘accompanies the removal from an all consuming drug dependency’’ (Bessant et al.,
This highlights the third policy issue that relates to long-term support for people
who are rehoused. As we have seen, 76% of people with problematic substance use
issues had returned to conventional housing, but these tenancies had subsequently
failed (Table 4). Housing provides a stable base that is necessary to start the process of
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recovery but, on its own, the provision of housing is rarely sufficient. People in
recovery typically have a range of problems to resolve. Long-term homelessness and
substance abuse can have a devastating impact on people’s physical and psychological
health and their connectedness to mainstream society. For young people in recovery,
it often takes time to come to terms with the traumatic events that led to their
homelessness and substance abuse, and it is unrealistic to think that their recovery
will be achieved quickly. As Hartwell (2003, p. 498) noted, most people do not change
within ‘‘three, six, or nine months of substance use treatment’. Unless governments
fund ongoing support to help formerly homeless people with substance abuse
problems to remain housed, it is clear that some people will experience further
episodes of homelessness. When this happens, the costs to the individual, as well as to
the community, are high.
The relationship between problematic substance use and homelessness is complex
and there is a great deal of variation between individual cases. We have also pointed
to various limitations of our database and that relevant information may have been
missing from some case files.
According to Hartwell (2003, p. 476), the question of cause and consequence is
‘‘inherently misleading’. We agree that framing the debate in terms of cause is
problematic and underplays the complexity of people’s situation. However, a focus on
temporal sequence provides useful information on the role of substance abuse as a
trigger for homelessness and as an adaptation to homelessness. This research
confirms that a substantial minority of the homeless population have substance abuse
issues, but it challenges the view that substance abuse is the primary cause of
homelessness. For young people, homelessness often leads to substance abuse. Early
intervention strategies are the best way to prevent this from happening.
The authors thank the homeless people interviewed for the present study. The
authors also thank the staff at the Salvation Army Crisis Services (St Kilda, Vic.,
Australia) and HomeGround Services for their assistance. Thanks also to the
anonymous referees. Financial support for the research came from an Australian
Research Council grant (LP0560760).
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... There are several societal factors that predispose people to houselessness including social inequities, poverty, and lack of affordable housing [2]. These societal factors often intersect with individual hardships such as medical and psychiatric conditions, disability, limited supportive networks or social capital, and substance use disorder that lead individuals to become and remain houseless [3][4][5]. Housing instability has notable associations with poorer health, including increased rates of cardiovascular disease, poisoning, and injuries associated with mortality risk [6]. Additionally, rates of chronic health conditions including hypertension, diabetes, hyperlipidemia, and metabolic syndromes are higher among the unhoused community [7][8][9], with approximately half of the unhoused and vulnerably housed having 3 or more chronic health conditions [10]. ...
... In terms of food groups, most participants reported consuming most food groups including protein (19/20, median 7 [3][4][5][6][7][8] [22]. Figure 1 depicts the number of the participants who consumed each food group in the following frequencies: never, less than 4 days in a week, more than 4 days in a week. ...
Full-text available
Background Those experiencing houselessness rely on obtaining food from community organizers and donations. Simultaneously, the houseless face disproportionally high rates of medical conditions that may be affected by diet including diabetes, hypertension, and hyperlipidemia. There is limited literature on the resources and barriers of the houseless community regarding optimal nutrition from an actionable perspective. Further, less data is available on how street medicine organizations may best impact the nutrition of the unhoused they serve. Elucidating this information will inform how organizational efforts may best support the nutrition of the houseless community. Methods In partnership with the medical student-run organization, Chicago Street Medicine, at Northwestern University Feinberg School of Medicine, twenty adults experiencing houselessness in Chicago, Illinois participated in the cross-sectional study. A 10-item survey was verbally administered to characterize the participants’ daily food intake, food sources, barriers, resources, and nutritional preferences and needs. All data was directly transcribed into REDCap. Descriptive statistics were generated. Results Individuals consumed a median of 2 snacks and meals per day (IQR: 1–3). No participant consumed adequate servings of every food group, with only one participant meeting the dietary intake requirements for one food group. Participants most often received their food from donations (n = 15), purchasing themselves (n = 11), food pantries (n = 4), and shelters (n = 3). Eleven of nineteen participants endorsed dental concerns as a major barrier to consuming certain foods. Twelve participants had access to a can opener and twelve could heat their meals on a stove or microwave. Seven had access to kitchen facilities where they may prepare a meal. Approximately half of participants had been counseled by a physician to maintain a particular diet, with most related to reducing sugar intake. Conclusion Most houseless participants were unable to acquire a balanced diet and often relied on organizational efforts to eat. Organizations should consider the chronic health conditions, dentition needs, and physical resources and barriers to optimal nutrition when obtaining food to distribute to the unhoused.
... The prevalence of substance use varies among youth experiencing homelessness, with differences observed based on sociodemographic characteristics. For example, research suggests that substance use in this population is associated with age (DiGuiseppi et al., 2020;Johnson & Chamberlain, 2008;Nyamathi et al., 2012;Patterson et al., 2012;Santa Maria et al., 2018;Tompsett et al., 2013), race and ethnicity (Bousman et al., 2005;Combs et al., 2020;Nyamathi et al., 2012;Rice et al., 2011;Santa Maria et al., 2018), sexual orientation (Combs et al., 2020;DiGuiseppi et al., 2020;Maria et al., 2020;Salomonsen-Sautel et al., 2008;Santa Maria et al., 2018), gender identity (Hadland et al., 2011;Hathazi et al., 2009), and region (Ferguson et al., 2010;Santa Maria et al., 2018). ...
... In addition, YEH with high sexual risk behaviors, compared to those with low sexual risk behaviors, have been shown to engage in higher rates of substance use as well as experience greater childhood adversities (Maria et al., 2020). Notably, high rates of substance use among YEH are associated with longer duration of homelessness (Gomez et al., 2010;Johnson & Chamberlain, 2008;Lightfoot et al., 2018;Thompson et al., 2015), lower education (Bender, Yang, et al., 2015;Combs et al., 2020), and a history of foster care (Bender, Yang, et al., 2015;Berzin et al., 2011;Combs et al., 2020;Nyamathi et al., 2012). ...
... Compared to non-sexual minorities, sexual minorities disproportionately experience unstable housing, often due to homophobia, rejection, and abuse that forces them from their homes (Baams et al., 2019;Romero et al., 2020). Furthermore, stimulants are often used as a form of coping with stressful feelings associated with being unstably housed as well as a means of survival (Johnson & Chamberlain, 2008). For example, stimulants may be utilized to stay awake to protect belongings, facilitate social interaction with others, or as an alternative to psychiatric medications (Bungay et al., 2006). ...
... For example, stimulants may be utilized to stay awake to protect belongings, facilitate social interaction with others, or as an alternative to psychiatric medications (Bungay et al., 2006). Unstably housed MSM may also use stimulants to obtain a sense of belonging, to bond with others, or due to perceived social norms (Barman-Adhikari et al., 2016;Johnson & Chamberlain, 2008). Additionally, transactional sex has a strong association with unstable housing and can be used as a mechanism to obtain financial support or shelter among unstably housed individuals (Mimiaga et al., 2009). ...
Stimulant use is an important driver of HIV/STI transmission among men who have sex with men (MSM). Evaluating factors associated with increased stimulant use is critical to inform HIV prevention programming efforts. This study seeks to use machine learning variable selection techniques to determine characteristics associated with increased stimulant use and whether these factors differ by HIV status. Data from a longitudinal cohort of predominantly Black/Latinx MSM in Los Angeles, CA was used. Every 6 months from 8/2014-12/2020, participants underwent STI testing and completed surveys evaluating the following: demographics, substance use, sexual risk behaviors, and last partnership characteristics. Least absolute shrinkage and selection operator (lasso) was used to select variables and create predictive models for an interval increase in self-reported stimulant use across study visits. Mixed-effects logistic regression was then used to describe associations between selected variables and the same outcome. Models were also stratified based on HIV status to evaluate differences in predictors associated with increased stimulant use. Among 2095 study visits from 467 MSM, increased stimulant use was reported at 20.9% (n = 438) visits. Increased stimulant use was positively associated with unstable housing (adjusted [a]OR 1.81; 95% CI 1.27-2.57), STI diagnosis (1.59; 1.14-2.21), transactional sex (2.30; 1.60-3.30), and last partner stimulant use (2.21; 1.62-3.00). Among MSM living with HIV, increased stimulant use was associated with binge drinking, vaping/cigarette use (aOR 1.99; 95% CI 1.36-2.92), and regular use of poppers (2.28; 1.38-3.76). Among HIV-negative MSM, increased stimulant use was associated with participating in group sex while intoxicated (aOR 1.81; 95% CI 1.04-3.18), transactional sex (2.53; 1.40-2.55), and last partner injection drug use (1.96; 1.02-3.74). Our findings demonstrate that lasso can be a useful tool for variable selection and creation of predictive models. These results indicate that risk behaviors associated with increased stimulant use may differ based on HIV status and suggest that co-substance use and partnership contexts should be considered in the development of HIV prevention/treatment interventions.
... In what refers to the risky behaviors mentioned above, substance use has been related to higher rates of victimization in homeless populations (Bender et al. 2014;Booth et al. 2002;Heerde Jessica and Hemphill 2014;Hudson et al. 2010;Lee and Schreck 2005), as well as with criminal behavior and contact with the justice system (Roy et al. 2014). Alcohol and/or drug use can represent both a precipitating factor and a consequence of homelessness (Fountain et al. 2003;Johnson and Chamberlain 2008;Zerger 2002). With regard to the latter, a person may resort to substance use as a way of coping with the harsh living conditions this situation entails (Cabrera and José Rubio 2002;Dietz 2007; Heerde Jessica and Hemphill 2014). ...
... Similarly, it can be used as a unique and indispensable disinhibitor for engaging in certain antisocial conducts, for example, begging." Additionally, substance use can arise as part of the process of socialization into the homeless subculture, where it is a common and accepted social practice, since interaction with other homeless people can provide a sense of support and security and a source of positive social validation (Johnson and Chamberlain 2008;Snow and Anderson 1993). Finally, the treatment of substance abuse surely becomes very difficult under the living conditions homelessness entails (Dietz 2007). ...
Segmentation analysis and logistic regression were used to test the prob-abilistic connection between exposure to high-risk situations and victimiza-tion events, as posited by Lifestyle-exposure theory, in a sample of homeless people. The results support the hypothesis put forward. First, those who had engaged in risky behaviors had suffered victimization events to a greater extent. Second, this was particularly true for participants who had done so more frequently or had engaged in a wider range of such behaviors. The highest risk profile included those who had been arrested on several occa-sions and also reported having used drugs during the previous month or, otherwise, had served a sentence different from prison in the past. Implications of these findings are discussed considering that homeless peo-ple’s engagement in risky behaviors, as well as, in general, their greater degree of exposure to situations in which risk of victimization is high, often stem from the situation they are going through. A major conclusion is that any effort to eradicate violence against homeless people should contemplate strategies for combating homelessness itself.
... Structural inequities-including economic disparities, lack of employment opportunities and inadequate infrastructure for public housing and supportive services-are the main drivers of growing houselessness in rural areas [59,60]. At the individual level, houselessness is likely exacerbated by drug use in rural communities that have been disproportionately impacted by the opioid crisis [61][62][63][64]. ...
Full-text available
Background Research conducted in urban areas has highlighted the impact of housing instability on people who inject drugs (PWID), revealing that it exacerbates vulnerability to drug-related harms and impedes syringe service program (SSP) use. However, few studies have explored the effects of houselessness on SSP use among rural PWID. This study examines the relationship between houselessness and SSP utilization among PWID in eight rural areas across 10 states. Methods PWID were recruited using respondent-driven sampling for a cross-sectional survey that queried self-reported drug use and SSP utilization in the prior 30 days, houselessness in the prior 6 months and sociodemographic characteristics. Using binomial logistic regression, we examined the relationship between experiencing houselessness and any SSP use. To assess the relationship between houselessness and the frequency of SSP use, we conducted multinomial logistic regression analyses among participants reporting any past 30-day SSP use. Results Among 2394 rural PWID, 56.5% had experienced houselessness in the prior 6 months, and 43.5% reported past 30-day SSP use. PWID who had experienced houselessness were more likely to report using an SSP compared to their housed counterparts (adjusted odds ratio [aOR] = 1.24 [95% confidence intervals [CI] 1.01, 1.52]). Among those who had used an SSP at least once (n = 972), those who experienced houselessness were just as likely to report SSP use two (aOR = 0.90 [95% CI 0.60, 1.36]) and three times (aOR = 1.18 [95% CI 0.77, 1.98]) compared to once. However, they were less likely to visit an SSP four or more times compared to once in the prior 30 days (aOR = 0.59 [95% CI 0.40, 0.85]). Conclusion This study provides evidence that rural PWID who experience houselessness utilize SSPs at similar or higher rates as their housed counterparts. However, housing instability may pose barriers to more frequent SSP use. These findings are significant as people who experience houselessness are at increased risk for drug-related harms and encounter additional challenges when attempting to access SSPs.
... Significant relationships between survival sex and substance use have been demonstrated in the general population of young adults experiencing homelessness (Chettiar et al., 2010). Although current quantitative research on the topic is largely correlational, qualitative narratives of homelessness and survival sex-involved young adults who engage in substance use indicate that they use substances to cope with or escape the harsh, oppressive environment that confronts them and the stress associated with trading sex for goods and services (Johnson & Chamberlain, 2008). In accordance with prior formative qualitative research (Hussen et al., 2021), we hypothesize that increased engagement in survival sex would be associated with increased meth use. ...
Methamphetamine (Meth) use is a contributor to poor health outcomes among young Black American gay, bisexual, and other men who have sex with men (YB-GBMSM). Emerging research indicates that socioeconomic instability may be a salient antecedent of meth use as men may be encouraged to engage in health-eroding activities, such as survival sex, to care for themselves, and then cope with instability-related stress via use of substances. We examined the degree to which indicators of socioeconomic instability, including homelessness and food insecurity, would directly, and indirectly, predict increases in meth use, via survival sex engagement. Hypotheses were tested using mediated path analysis with data from 100 YB-GBMSM in Atlanta, Georgia. Preliminary analysis results demonstrated positive associations between engaging in survival sex, food insecurity, homelessness, and living with HIV. Findings demonstrated that homelessness and food insecurity were directly associated with increased survival sex engagement but were not directly associated with meth use. Homelessness and food insecurity were indirectly associated with increased severity of meth use, via increased engagement in survival sex. Socioeconomic instability and survival sex engagement may be important intervention targets for future meth use intervention/prevention programming. Integrating programmatic components that address homelessness and food insecurity may decrease YB-GBMSM's need to rely on survival sex to meet their needs and decrease their likelihood of using meth as a result.
... Social and economic stressors may be both a cause and consequence of substance use and related disorders (Asana, Ayvaci, Pollio, Hong, & North, 2018;Braveman & Gottlieb, 2014;DiGuiseppi, Davis, Leightley, & Rice, 2020;Grant et al., 2015;Johnson & Chamberlain, 2008). More specifically, individual experiences of social and economic stress may increase risk of alcohol and drug use disorders (AUD and DUD, respectively) and related adverse outcomes (Giuse et al., 2017;Institute of Medicine, 2011;Mulia et al., 2008;Scheer & Pachankis, 2019;van Draanen et al., 2020), which may in turn increase likelihood of subsequent social and economic stressors and experiences of marginalization (Sheiham, 2009;World Health Organization, 2014). ...
Purpose: We examined the impact of duration and number of homelessness episodes on health outcomes for unsheltered homeless young adults. Methods: We analyzed the 2018/2019 Los Angeles County homeless youth demographic surveys. We addressed five summary health outcomes: physical health, mental health, substance use disorder, tri-morbidity, and any condition. Respondents were classified into three homeless trajectory groups: (1) short-term-homeless < 1 year in one episode, (2) episodic-homeless < 1 year and multiple episodes, and (3) long-term-homeless continuously for > 1 year. Weighted bivariate and multivariate logistic regression models tested the relationship between homeless trajectory group and health, with controls for sociodemographic factors and structural exposures. Results: Mental health and substance use were high among unsheltered young adults compared to national rates. Long-term homeless respondents were significantly more likely than short-term to report a mental health condition (53.3% vs. 39.8%, p < .001), substance use disorder (25.5% vs. 18.3%, p < .001), and physical conditions (26.0% vs. 15.6%, p = .008). Episodic respondents were more likely to report a mental health condition (50.5%, p < .001). In multivariate models, long-term respondents had twice the odds of tri-morbidity (odds ratio [OR] = 2.14, p < .05) and any health condition (OR 2.00, p < .01) as short term and significantly higher odds of a physical health condition (OR = 1.64, p < .05). Discussion: Youth with longer durations and more frequent episodes of homelessness have substantially poorer health outcomes. The association of longer duration to poorer health persisted in multivariate models. Longer duration of unsheltered homelessness may drive the onset of physical and mental health problems.
Full-text available
Information on homelessness form the 2006 Census
Numerous studies have revealed high levels of drug-taking among young people experiencing homelessness. This article draws upon 40 in-depth interviews carried out as part of a five-year longitudinal study of homeless young people (Project i). It is noteworthy that almost all of those who identified their drug use as problematic gave up or reduced their level of use without treatment or professional assistance during the period of the study. The interviews provided insight into the way in which some young people experiencing homelessness view their drug use and the actions they take in light of these understandings. Here we report their stated reasons for giving up or reducing usage and identify some commonalities that may have impacted on the outcomes.
Three definitions of homelessness which have been influential in Australia may be categorised as the literal, the subjectivist and the cultural. The literal definition equates homelessness with 'rooflessness'. The subjectivist definition attempts to establish 'homelessness' by asking people about the adequacy of their accommodation. The cultural definition argues that homelessness is an objective category which is not dependent on people's perceptions. From examining the usefulness of the three definitions in relation to a large body of data collected at an agency providing services for homeless people, we may contend that homelessness is best treated as a concept like poverty, which should be measured objectively and not depend on people's perceptions.
Overview Understanding Homelessness: Industrial and Urban Decline The Root Causes of Homelessness in American Cities Paths To Homelessness The Old Homeless: Sam Sheldon and Henry Walsh Work Versus WelfareA False Choice: Sue Jackson The Economic Marginality of Young Families: Sara, Dave, Elizabeth, and Joshua Left Behind in a De-industrialized, Low-Wage Economy: Bob and Nancy Shagford and Their Children Eviction: Debbie Jones and Her Children Social Service Bureaucracy and Homelessness: Diane Moore Runaway and Throwaway Teens: Jeffrey Giancarlo A Black Teenage Single Mother and Her Son: Michelle and Andre Battered Women and Homelessness: Barbara Evans Conclusion The Complex and Simple Reality of Homelessness Making Homelessness Go Away: Politics and Policy
Social workers have an important role in questioning how social problems such as homelessness are represented in public discourse. Using Carol Bacchi's policy analysis framework, this paper analyses representations of homelessness and service provision in the Australian print media, by examining assumptions underlying these representations, gaps and silences; the effects of these representations; and how these can be defended and disrupted. The study found that print media representations of people can reinforce deep-seated community values that maintain unequal gender and power relations, which has implications for social worker advocacy.
Theory will not directly explain the development of policy and provision for homeless people, but it is an important consideration and one deserving of careful attention. In the UK, however, homelessness has often been explained simplistically and somewhat atheoretically as either a housing or a welfare problem, caused either by structural or by individual factors. Likewise, homeless people have been frequently classified as either deserving or undeserving. Such dualistic explanations are less than adequate and any policy and provision influenced by them will, consequently, also likely be less than optimal. Accordingly, this paper explores the potential of alternative theoretical perspectives (feminism, post‐structuralism, postmodernism, structuration and critical theory) for increasing our understanding of homelessness and so potentially improving policy and provision for homeless people in the future.