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Neuropsychological Function in Homeless Adults: Two Case Studies

Neuropsychological Function in Homeless Adults: Two Case Studies

“We are too much accustomed to attribute to a single cause that which is the product of several, and the majority of our controversies come from that.” – Marcus Aurelius

Much of the psychological literature on homelessness attempts to identify prominent causal factors. Psychosocial factors or unfortunate circumstance (Crane, Byrne, Fu, Lipmann, Mirabelli, Rota-Bartelink, Ryan, Shea, Watt & Warnes, 2005), psychological difficulty or addiction (Folsom & Jeste, 2002; Fazel, Khosla, Doll, & Geddes, 2008), and more recently Traumatic Brain Injury (TBI) (Topolovec-Vranic, Ennis, Colantonio, Cusimano, Hwang, Kontos, Ouchterlony, & Stergiopoulos, 2012) have all been researched and proposed as causal factors in homelessness studies.

There are problems inherent in this kind of research however, and addiction can be used to illustrate this. For an addict, negative psychosocial factors, psychological difficulty, and even TBI may be experienced as a result of their addiction. Using all their money to maintain their addiction would create psychosocial problems, dependency would create psychological difficulty and heavy drug use can bring with it psychosis-like symptoms, relationships and behaviours would be affected by their habit creating psychosocial and psychological difficulty, and alcoholics can experience falls which may result in TBI. One proposed causal factor, addiction, then becomes entangled with many.

When asked as the participant in a study, however, the homeless individual alone decides the cause of their homelessness, and may cite one specific cause according to how they choose to describe their own story and how much they understand or acknowledge the influence of a given factor. The addict may not wish to talk of their addiction and instead explain that rent arrears forced them on to the streets, neglecting to state that the arrears were acquired through a drug habit. Causal data gathered from homeless populations is therefore subjectively reported, and may be coloured by memory and smudged by bias.

Mental illness or TBI are flagged as risk factors in the homelessness literature. However, homeless people who carry these conditions may have obtained them during their time on the streets and not before it. Causal research therefore falls into the post hoc ergo propter hoc logical fallacy, and such studies remain limited with regard to utility. There is, however, a common thread that binds every causal proposition: cognitive dysfunction. Mental illness, negative psychosocial factors, and TBI each carries with it some measure of cognitive deficit.

Though previous attempts to measure cognitive functioning in the homeless have been made, it remains an area in need of more consideration (Spence, Stevens, & Parks, 2004). Tackling homelessness requires more than simply giving homeless people somewhere to live. There are a number of skills required to maintain stable housing which can be compromised by cognitive difficulty. Data from neuropsychological tests can identify common problems in areas such as planning, attention, decision-making, or problem solving. Highlighting common deficits in cognition would enable cognitive rehabilitation strategies to be devised which would better prepare the homeless for their return to society.

With the above in mind, a study was devised which recruited two matched participants, one who had been homeless for eighteen months at the point of testing but occasionally used an overnight shelter (OS) and one who has recently entered a halfway house after three years on the streets (HH). A brief neuropsychological test battery consisting of the Wisconsin Card Sorting Task (WCST) and the Iowa Gambling Task (IGT) to examine set-shifting (adaptability) and decision-making would be administered, and scores from these tests would be compared with each other. It was thought that marked differences in performance on the tests may show that cognitive ability and an individual’s ability to progress to social housing are related, and that measures of cognition may be a predictor of the success of that transition.


On both tasks, participant HH out-performed participant OS. Scores from the WCST showed OS making more preservative errors and failure to maintain set errors than HH, and scores from the IGT showed HH $100 in profit compared to OS who finished with -$500. Remarkably, both participants selected the same number of cards from the ‘advantageous’ and ‘disadvantageous’ decks. However, HH’s results displayed a strategy suggesting an implicit understanding of the game, favouring one risky and one safe deck, compared to OS’s random selections from all four decks. Additionally, OS failed to move beyond the rule for one set when completing the WCST.

Chart Depicting Results of Specific Card Selections – Iowa Gambling Task

Due to the preliminary nature of the study and small sample size, it was accepted that few reliable inferences can be drawn. However, the findings suggest four possibilities:

  1. That halfway housing increases cognitive performance relative to sporadic stays in overnight shelters.
  2. That participant OS experiences cognitive difficulty which may contribute to his current status and deny him the possibility of securing halfway housing.
  3. That halfway housing increases the chance of recovery and overnight shelter housing reduces it. 4) That cognitive capacity has nothing to do with homelessness.

Increasing the number of participants in future research would undoubtedly help to address the first, third, and fourth possibilities, as would increasing the number and type of neuropsychological tests in the battery. The second possibility is perhaps the one that the data can most reliably point to, that participant OS experiences cognitive difficulty. Additional testing such as that described above would also help to confirm this. In keeping with the ethos of the study, it would not be appropriate to speculate whether or not these difficulties were a driver to his current state of homelessness, or were a result of being homeless.

Psychological research on homeless populations describes psychological difficulty in the form of mental illness or addiction. Often, there is considerable support available for those released from mental health wards with similar afflictions.  After-care can involve monthly appointments with a care coordinator, and regular visits from mental health support workers. This facilitates their transition back to society, and increases the odds of the transition being a successful one. For the homeless, few such advocacies are available. Despite this, and as discussed above, many homeless people are as mentally vulnerable as those who have moved from a mental health ward back into the community.

Using neuropsychological test batteries it would be possible to identify cognition deficits common to homeless populations. This would create a greater understanding of the kind of support required for the homeless to successfully reintegrate. Whilst causal research remains valid, there is now a need for more neuropsychological research in the homelessness literature. From this, strategies may then be devised that support homeless people to move forward, rather than asking them what they see when they look back.


Crane, M., Byrne, K., Fu, R., Lipmann, B., Mirabelli, F., Rota-Bartelink, A., Ryan, M., Shea, R., Watt, H., & Warnes, A. M. (2005). The causes of homelessness in later life: findings from a 3-nation study. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences. 60 (3) pp. S152 - S159.

Fazel, S., Khosla, V., Doll, H., & Geddes, J. (2008). The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis. PLoS medicine. 5 (12) e225.

Folsom, D., & Jeste, D. V. (2002). Schizophrenia in homeless persons: a systematic review of the literature. Acta Psychiatrica Scandinavica. 105 (6) pp. 404 - 413.

Spence, S., Stevens, R., & Parks, R. (2004). Cognitive dysfunction in homeless adults: a systematic review. Journal of the Royal Society of Medicine. 97 (8) pp. 375 - 379.

Topolovec-Vranic, J., Ennis, N., Colantonio, A., Cusimano, M. D., Hwang, S. W., Kontos, P., Ouchterlony, D. & Stergiopoulos, V. (2012). Traumatic brain injury among people who are homeless: a systematic review. BMC public health.  12 (1) pp. 1059 – 1066.

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