We interviewed 15 people with lived experience of SMI and homelessness (n = 12 men; n = 3 women) and 11 caregivers (n = 6 men; n = 5 women). See Table 1 for characteristics of the study sample. There were more men with SMI interviewed than women: this was because more men had experienced homelessness and because the women who had been homeless were more inaccessible and living in more remote areas. One potential participant refused to participate, one was chained at home and four others were too ill to be interviewed.
Table 1
Characteristics of participants in the study
People with lived experience of SMI and homelessness |
Interview | Gender | Type of homelessness experienced | Linked interviews |
IDI 3 | Female | Long-term | IDIs 1, 2 |
IDI 7 | Male | Long-term | IDI 6 |
IDI 11 | Male | Long-term and intermittent linked with alcoholic relapse | IDI 9 |
IDI 12 | Male | Intermittent | |
IDI 13 | Male | Intermittent | |
IDI 14 | Male | Single homeless episode | IDI 15 |
IDI 16 | Male | Intermittent | |
IDI 18 | Male | Intermittent | |
IDI 19 | Male | Intermittent | |
IDI 20 | Male | Intermittent homelessness reported by caregiver; person with SMI reported that they had stayed in other people’s homes | IDI 21 |
IDI 22 | Male | Intermittent | |
IDI 23 | Male | Long-term | IDI 24 |
IDI 24 | Male | Intermittent | IDI 23 |
IDI 25 | Female | Intermittent | |
IDI 26 | Female | Intermittent | |
Caregivers |
Interview | Gender | Relationship to person with SMI | Linked interviews |
IDI 1 | Female | Community member/friend | IDIs 2, 3 |
IDI 2 | Female | Community member* | IDIs 1, 3 |
IDI 4 | Male | Community member* | |
IDI 5 | Female | Sister* | |
IDI 6 | Male | Community member* | IDI 7 |
IDI 8 | Male | Employer | |
IDI 9 | Male | Nephew* | IDI 11 |
IDI 10 | Male | Father* | |
IDI 15 | Male | Father* | IDI 14 |
IDI 17 | Female | Mother* | |
IDI 21 | Female | Wife* | IDI 20 |
*- official PRIME caregiver |
The sample comprised people with extended episodes of homelessness as well as those who experienced briefer periods of episodic homelessness. Long-term homelessness ranged from 1 year to over 20 years. Intermittent homelessness was characterized by people cycling between living on the streets and their original homes. Some of those experiencing intermittent homelessness remained in areas near to their homes of origin, others traveled far from home, and/or to multiple different locations during these episodes.
Pathways Into Homelessness
Experience of mental ill health and family conflict and relationship strain were prominent in the narratives describing pathways into homelessness. Escape from coercion also emerged as an important theme.
Experience of mental ill health
Both people with SMI and their caregivers described the onset or escalation of mental health problems prior to homelessness. The nature of these problems was grouped into the following categories: confusion; feelings of anxiety or restlessness; strange/disturbing experiences; substance use; and suicidality.
Confusion was articulated as ‘not knowing’, being aware or remembering, being confused, or doing things for ‘inexplicable reasons’ or ‘haphazardly’:
“My mind went blank even when I was in the middle of a conversation. Then the illness became worse and I started to lose control of myself like a dead person. I became very ill." (IDI 7)
Worry, stress, and restlessness were commonly described using the term ‘chinket’, conveying a feeling of emotional distress. Sometimes this occurred in the context of unusual experiences:
"I felt anxious and I couldn’t settle down in the house… Something I didn't know talked to me…I left the house because I thought that [the anxiety] will leave me when I leave the neighborhood." (IDI 23)
The onset of mental illness and homelessness was also explained by people with SMI in terms of bewitchment.
“I had a disagreement with someone, and they did ‘asmat’ [a spell] on me. They buried a deer's neck in my farm. They cut the neck and buried it in my workplace. I became ill and left.” (IDI 7)
Alcohol and other substance use were commonly linked with spending nights outside of the house. One caregiver described a pattern of his uncle drinking alcohol, stopping medication, relapsing and sleeping on the streets:
"The biggest problem we are experiencing now is that his illness relapses and he becomes very ill when he… drinks...His life becomes terrible, because he refuses to take the medication, leaves the house and starts living out in the streets... " (IDI 9)
Family conflict and relationship strain
Family conflict prior to homelessness was recounted by people with SMI and caregivers and was linked with the experience of mental ill health and/or behavioural changes. In some cases, people with SMI spoke of family conflict leading to mental health problems and their perceived need to leave the home; in other cases, changes in the behaviour of the person with SMI were reported to be triggers for conflict. Family conflict was expressed in marital, nuclear and extended family relationships.
Some people with SMI described feeling alienated, excluded, and/or exploited in the family home:
"It was nothing but toiling. Only toiling…They were nagging me. They didn't want me to live in the house." (IDI 3)
Conflict within marriages was commonly reported. One woman with SMI described her husband’s substance abuse and irresponsible behaviour as driving her into homelessness.
Other aspects of family interactions described by participants as triggers for homelessness were abandonment, neglect and violence. One man with SMI described being abandoned abruptly by his uncle with whom he was living, leading to a homeless episode. Violence in the home and extended family was reported, with people with SMI as occasionally perpetrators, but more described as being victims of violence. In only one case, a woman with SMI described acting violently. She subsequently left her home due to guilt, feeling that she deserved to be punished:
"I said to myself, ‘How could one beat one's own mother?’ and left the house... I felt bad that I beat my mother and I decided that I should be eaten alive by hyenas." (IDI 26)
For some, unmanageability of the person with SMI was reported to have overwhelmed the family unit. It was common that families had exhausted their financial and emotional resources, as well as their treatment options (both holy water and within formal health care) prior to the person becoming homeless. Conflicts over adherence to medication were reported, as were conflicts over drinking alcohol.
Several people with SMI described financial issues as important pathways into homelessness via impact on family relationships and a sense of having lost one’s worth and value; financial problems included job loss, loss of money, and generally feeling like a financial burden to their families.
"They are already poor…My family spent a lot of money...They lost their property to seek treatments for me. So I decided that they shouldn't know when I leave the house and I left the house." (IDI 21)
Escape/change in environment
Respondents described the “escape” of people with SMI from formal health care, holy water treatment, restraint and/or family monitoring. Caregivers were more likely to describe people with SMI as “escaping” or “slipping our watch”, while those with SMI were more likely to describe mental ill health as leading them to leave home and/or treatment. One caregiver described how her brother escaped from a psychiatric facility in Addis Ababa; several others described escape from holy water treatment. Escape led to situations of high risk and/or vulnerability, including imprisonment.
Escape was used to justify the use of restraint. One man reported how:
“I slept in the forest at night. The holy water attendants feared that I would be eaten alive by hyenas and they bought a chain and a padlock, they chained me and kept me behind a closed door.” (IDI 22)
Restraint was also used in the transport of people with SMI to receive treatment and several people tried to escape during this process.
Other people with SMI left their homes because they associated their mental health problems with their physical environments, and in other cases, people with SMI described a preference for homelessness:
“It is my way of life…I am a street dweller. That is just my way of life. I rove the street and live outside the house.... I can't live in the house." (IDI 24)
Discrimination from the community in terms of housing and general social ostracization contributed to homelessness for several people. Several were evicted from rented houses when landlords discovered their mental illness. One found the gossip in the community about his condition to be unbearable:
"People gossiped about my illness…After that, I decided that it would be better for me to live in a place where no one knows about my illness...” (IDI 22)
Pathways out of homelessness
The most salient pathways out of homelessness were medical treatment as a catalyst to accessing other supports, family and community intervention and support, and self-return.
Medical treatment
Receiving medical treatment for both mental and physical illness was a contributing factor to ending homelessness when it also acted as a starting point for people to access other supports. Health care services were accessed both within and outside the district. Psychiatric treatment included hospitalization in Addis Ababa and outpatient treatment provided more locally with injectable and oral medication; at least one homeless man reported being given treatment involuntarily.
One non-related caregiver described the return to housing of a woman with long-term homelessness who required hospitalization for typhoid and was given mental health care during her hospital stay:
"I brought her here for another illness… It was very difficult to give her treatment, but she was not aggressive because she was very ill…My neighbours who knew that I am worrying told me that her son had built a house for her. I didn't even worry about getting his permission and went to the compound…I broke into one of the houses and cleaned it…She entered the house that day...” (IDI 2)
Another person with SMI with long-term homelessness was given involuntary treatment. This man had been assaulting women in the town and there were concerns from the community. His behaviour improved with the treatment. After witnessing his improvement, the community mobilized resources to provide him with sustainable housing:
"He had to be held by eighteen people to be injected with the medication…He showed a significant improvement and there were only eight of us needed when he was injected for the second time…Only three people held him for the third time…Surprisingly, he remembered the exact date and went to the hospital [by himself, to get the next injection]. When I saw that, I started worrying [about finding a house for him]." (IDI 4)
Others with SMI sought out treatment for themselves, and said that this was the reason they were able to return to their homes:
“I heard that some health professionals have come…I went there and got medical treatment…Now, I go every month by myself and bring the medication…I got back home after I started medical treatment in the hospital.” (IDI 13)
Family and community support
Family and community support were usually essential in either encouraging or forcibly returning people to housing. Community members helped homeless people with mental illness in different ways, for example, in the case of the woman who was given treatment during her hospitalization. Several members of the community supported her while she was homeless and continued to help her transition back to housing. They took ongoing measures until she became more accustomed to her new living situation, including helping her with basic needs and demolishing the temporary shelter where she had previously been living on the streets to disincentivize her from returning to homelessness.
Family members were usually the central figures in helping people to return home. One man with SMI was brought home to his family after he escaped holy water treatment and traveled to Addis Ababa where he was living on the streets:
"I paid for radio announcement. I finished all my money to find him. Luckily, people found him using the signs I gave them and they brought him back home. I tie him up and keep him in the house after that." (IDI 10)
People with frequent homeless episodes described a pattern of being taken home habitually by both family and community members. Sometimes searching would occur on a daily basis, or for prolonged periods of time in the case of people with long-term homelessness. Searching and retrieving people in the evenings after nightfall was reported; caregivers described being fearful of the risks to the person of sleeping outside as well as to themselves:
“Something bad could happen to me when I go out to see him at night. But, I do that because I am his mother. I did this for eight years...I went to the place where he chews khat and brought him back home." (IDI 17)
Occasionally, strangers allowed homeless people to stay with them. In one extraordinary case, a man traveled to a faraway area in search of Orthodox Christian holy water and stayed with a Muslim family living nearby. They hosted him and facilitated his return home when he was ready:
“They said they are Muslims and don't go to the holy water place, but they showed me where it is found. They told me that I could bring the holy water home and pour it on my body. I lived with them for one month…Then, I told them that I left my house because of my illness and that my parents would be mourning my death if they couldn't find me. So they gave me money for transportation and I came back home.” (IDI 22)
In other cases, temporary shelter and prepared food was provided for homeless study participants within Orthodox church compounds (outside of the context of the holy water treatment previously described), wherein homeless people would spend nights in the compounds, leave in the daytime and return at nightfall. The most common way for non-related people to help homeless people with SMI was through the provision of food and water.
Self-return
Self-return was a common pathway in returning to housing among people who experienced intermittent homelessness. One caregiver described her sister’s patterns of staying outside the home when she is unwell, and how the family responded:
"My mother doesn't lock the door when she sleeps because she knows that she usually will come back home…But she says that she stays outside late because she wants to be eaten alive by hyenas...Actually we search for her when she stays outside late…If we don't find her, we just wait for her until she comes back home by herself. She usually comes back home after one night." (IDI 5)
People with SMI described exercising personal agency in making decisions about when to both leave and return home:
"I was fine when I lived outside the house. So I thought that I would be fine if I came back home. That was why I came here…I returned home by myself." (IDI 23)
Another man described this in poetic terms:
"I just wandered the street and the road led me straight to my house…Yes. I came here by myself. The road led me straight to my house." (IDI 24)
Self-return also emerged as a theme in connection with intermittent homelessness and alcohol abuse and occasionally led to serious consequences, such as the loss of livelihood:
"Yes, he went there sometimes, to drink…when he felt anxious…He got back home by himself. He put firewood on the donkeys' back and went there. But, he left the donkeys there and came back home alone” (IDI 21)