homeless man sitting on the chair


Research is showing that a remarkably high proportion of homeless men have suffered a traumatic brain injury in the past, raising the possibility that TBIs may cause behaviors directly leading to homelessness. Experts discuss their research.

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  • Dr. Jane Topolovec-Vranic, Associate Scientist, St. Michael’s Hospital, Toronto, and Assistant Professor of Occupational Science, University of Toronto
  • Dr. Steven Hwang, Director, Center for Urban Health Solutions, St. Michael’s Hospital, Toronto, and Professor of Medicine, University of Toronto

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16-42 TBI’s and Homelessness

Nancy Benson: Go to any big city in the United States, and homelessness is obvious out on the streets. According to a report to congress, more than 600,000 people are homeless in the United States on any given night. Over the course of a year, more than three-and-a-half million Americans may be homeless at some point. A number of studies are finding many of them have one thing in common: they had a traumatic brain injury, or TBI, before homelessness struck.

Dr. Jane Topolovec-Vranic: It’s definitely a new area of study, but it seems to be a consistent theme that at least half of individuals who are homeless have experienced traumatic brain injuries in their past. And what we’re also finding is that usually the first such injury is occurring prior to the individual becoming homeless, usually in the early teenage years.

Benson: Dr. Jane Topolovec-Vranic is an associate scientist at St. Michael’s hospital in Toronto and assistant professor of occupational science at the University of Toronto.

Topolovec-Vranic: On average, 45 percent of these men across the study that we looked at, but it varied. We surveyed over a hundred men in our local shelter, one of the largest shelters that we have here in Toronto, and the shelter has different programs in it. So depending on which program we sampled from, the rates varied a little bit with the highest rates, about 65 percent of the men we looked at in the hostel unit – the more transient program in the shelter – had a positive screen for a past TBI.

Dr. Stephen Hwang:  More than half of the men, about 58 percent in one study that we did, had a history of traumatic brain injury, and among the women it was lower, it was 42 percent. Regardless of that difference by sex, the prevalence of TBI is far higher in the homeless population than in the general population. It’s probably five or more times higher.

Benson: That’s Dr. Stephen Hwang, director of the center for urban health solutions at St. Michael’s Hospital and professor of medicine at the University of Toronto. He says the data doesn’t exist yet to say for sure that TBI’s cause homelessness. But it’s important to note that often, people were living normal lives then their traumatic brain injury occurred. Hwang and Topolevec-Vranec say it’s easy to see how such an injury could trigger a downward spiral.

Hwang: People with TBI often have troubles with executive function, so they have trouble organizing and sequencing what they need to do. They have trouble controlling their emotions and they sometimes have difficulty with outbursts of anger and difficulty kind of modulating their emotions so all of those behaviors related to TBI could certainly increase your risk of becoming homeless.

Benson: No one is without risk. It’s often been said that millions of Americans are just one paycheck away from homelessness, but Topolovec-Vranec’s study shows most of us might also be one bad accident away. Many of the injuries that precede a decline into homelessness could have happened to anyone.

Topolovec-Vranic: Many of them, so about 66 percent of the men, had sustained at least one of their injuries as a result of an assault, but many of them, up around 40 percent, had sustained at least one injury by sports and recreation, or motor vehicle collisions of falls. So this is interesting because I think we have so many assumptions around how these injuries may be happening and the fact that some people are sustaining these injuries by mechanisms everyone’s at risk for: sports and recreation or motor vehicle collisions or falling. I think it raises more questions.

Benson: Topolevec-Vranec says often, an injury is enough to tip the balance for someone already living on the edge… who might have fallen into homelessness anyway. But sometimes, it’s pretty clear that the injury was responsible.

Topolovec-Vranic: I met a woman at a conference who was hearing my presentation. At the end she said, “You know my brother, her was in a motorcycle accident when he was younger and he just changed after that. Like he had a brain injury and his personality changed and he couldn’t keep his job and really kind of alienated himself from his family. And now he’s on the streets and we can’t get him back. He just has no interest in being part of the family or getting a job or anything like that.”

Benson: However, both Topolevec-Vranec and Hwang emphasize that traumatic brain injuries are unfortunately common… And there are many people who suffer traumatic brain injuries without falling into homelessness.

Topolovec-Vranic: The reason why this work is getting a lot of attention right now is we hear do much in the media about concussions and it’s particularly with sports and youth, you know parents being concerned about some of the longer term implications that we’re hearing about with early concussions. So, this type of work seems to resonate in terms of “Oh my goodness, if my child’s playing sports and getting concussions, can they become homeless one day?” That is not the point we’re hoping to make. It’s more for individuals who are right not working with homeless persons and seeing behaviors that may be, you know, aggression or look like substance use or even the irritability and anxiety that could also be related to organic injury to the brain rather than personality or being disrespectful.

Benson: Topolevec-Vranec says there’s also a lesson here about the assumptions society often makes about homeless people.

Topolovec-Vranic: It’s not just the choice of these individuals to be on the street or to be alcoholics or drug addicts, that maybe there are changes in the brain that are the result of an injury that kind of contributes to some of these situations and circumstances.

Benson: But perhaps even more importantly, Hwang says all this new research implies that there may be ways to prevent homelessness if we appropriately rehabilitate traumatic brain injuries.

Hwang: The services that we provide to try to rehabilitate and support people that have had traumatic brain injuries may, down the road, help prevent them from becoming homeless. And we should be, perhaps, thinking about…well, first of all, I think we should try to determine through further research if traumatic brain injury is in and of itself increasing people’s risk for becoming homeless and then if it is, a secondary question is “Can we identify a subgroup of people with TBI who are at particularly high risk of becoming homeless. Because ideally you’d like to be able to focus your efforts on a high-risk group rather than everyone who’s ever had a TBI.

Benson: Many variables are likely at work in determining who is at risk and who is not. Topolovec-Vranic says the same injury may physically affect two people differently. And even those who are affected the same way may have different risks for homelessness as a result of varying economics or family support. So before we can start to lower the toll of homelessness… There’s a lot of research yet to do. Our production director is Sean Waldron. I’m Nancy Benson.

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