TBI and the Invisible People

In 1985, Lucille Ball temporarily stepped away from comedy to star as Florabelle, a homeless woman living on the streets of New York City in the movie “Stone Pillow”. The movie itself did not get a lot of acclaim, but there was a line at the very end that has stayed with me for 35 years. It came from a young social worker who had gotten to know Florabelle while spending some time pretending to be homeless as part of a research project. She asked “How can I stay warm when you’re cold?”

How, indeed?

We call them the “invisible people” because that’s the way that many of the homeless self-identify. This is all too understandable due to the fact that so many people walk or drive by those living on the streets without ever making eye contact. Or, more accurately, a conscious effort is made to not even glance in their direction for fear of being forced to acknowledge all that it means that there are people who literally sleep on the streets because they have no place to go.

Many people justify turning away because they believe that the vast majority of those who are homeless are responsible for their circumstances due to alcohol or drug addiction. Or, even that that is the way they want to live. Even if common sense didn’t contradict that sort of thinking, research has. Yes, there are a fair number of homeless individuals who have substance issues, but the percentage is not all that much higher than in those who are not homeless, especially when taking into consideration all the hardships that go with life on the street that could influence drinking or using drugs.

Close your eyes and pick any day on the calendar and the statistics for that day will show that there were more than a half million people in the U.S. who were classified as homeless. The U.S. Department of Housing and Urban Development reported that, on an average night in 2019, 567,715 people “lacked a fixed, regular, and adequate nighttime residence”. Most people who are familiar with this crisis agree on two things when it comes to this number: that it is unconscionably high and vastly undercounted.

Determining an accurate number for our homeless population is difficult. This is partly due to political arguments about how to define what constitutes being homeless, the fluidity of the those moving in and out of situations and the efforts by many to hide their homelessness. This last reason is especially true of children who are still in school. Nearly 20% of those who are homeless are under the age of 18.

If simply counting the number of homeless is challenging, understanding the causes is even more so. We do know that there is usually not just one single cause but rather that a number of factors combined that culminated in someone becoming homeless.  A recent survey conducted by the U.S. Conference of Mayors in major cities across the U.S. reported that the most common reasons for homelessness are:

1. lack of affordable housing
2. unemployment
3. poverty
4. mental illness and the lack of needed services
5. substance abuse and the lack of needed services

Is traumatic brain injury (TBI) a significant cause of homelessness? A recent project sponsored through the Canadian Institutes of Health Research, which is the major federal agency responsible for funding health and medical research in Canada, has found that individuals who are homeless are ten times more likely to show evidence of having sustained moderate or severe traumatic brain injuries than the general population.

Untreated TBI can be life-changing, physically, mentally and emotionally and can exacerbate financial, employment and relationship struggles. TBI may represent an underappreciated factor contributing to initial homelessness, as well as making it even more difficult to return to the mainstream. Being homeless or “marginally housed”, which might mean moving from couch to couch while staying with friends and relatives, is not a lifestyle that allows for keeping up with doctors’ appointments and staying on medication.

In an interview with Neurology Today, William J. Panenka, MD, assistant professor of neurology and psychiatry at the University of British Columbia, said, “The fallout from TBI, including concentration, memory, and mood issues, are challenging enough for someone who is connected into the medical system and has a support network, but for people who are barely surviving and have nowhere to go, that is a completely different equation.”

There is a sad irony in that TBI, which is often referred to as the “invisible injury”, may be one of the reasons that so many of the “invisible people” are homeless.

One area that requires more study is the question of which comes first; the TBI or the homelessness. Is traumatic brain injury one of the underlying causes of homelessness? Or, is it the other way around? Do the extreme conditions that are confronted by those living on the street, which very often include violence, result in more injuries to the brain than found in the general population?

Common sense, once again, would seem to say that the answer would be “yes” to both, and that TBI is both a cause of homelessness as well as a consequence. The more important question, however, is how to use this information. Homelessness is a public health concern here in the U.S. and around the globe. If TBI is a contributing factor, then finding ways to treat it should be a priority.

Current recommendations include educating those providing healthcare to this population to be aware of the increased possibility of untreated TBI and lower the required thresholds for accurate testing. This, combined with finding secure housing so that those needing follow-up care are more likely to able to get it, would be the first step.