The Culture of Homelessness
The concept of culture provides an important lens through which the characteristics, needs, and treatment of homeless mentally ill clients can be understood. Cultural dimensions of this client group are derived from a number of subcultures, such as membership in ethnic minority groups and health and welfare service systems (First, Roth, and Arewa, 1988; Gaw, 1993; Rossi, 1988; Welch and Toff, 1987). These subcultures overlap with the conditions of homelessness and mental illness. The intermix of these cultural dimensions with each other and with the dominant American culture has been characterized as "cross-cultural" relationships. For case management services to be effective, these relationships need to be understood and negotiated through a process of cultural bridging (Manoleas, 1994; Lefley and Bestman, 1991; Schwab, Drake, and Elisabeth, 1988). In serving the homeless mentally ill, cultural bridging involves taking into account the influence of a number of subcultures, but especially the cultural dimensions of homelessness. The identification of the mentally ill among the homeless population has been wrought with numerous conceptual and methodological problems (Susser, Goldfinger, and White, 1990; Bachrach, 1992a). Homeless mentally ill persons include those who suffer from mental disorders and have become homeless, as well as persons who become ill while they are homeless. Persons with severe and persistent mental illness, often labeled the chronically mentally ill, pose a set of special treatment and service needs (Bassuk, 1984a; Lefley, 1990; Leshner, 1992). This client group may be identified in terms of three maj or criteria: diagnosis, duration, and disability (Bachrach, 1988, 1992b; Levine and Haggard, 1989). These criteria are incorporated into the definition of severe mental illness as "a severe and persistent mental or emotional disorder (e.g., schizophrenia, schizoaffective disorders, and mood disorders) that disrupts functional capacities for such primary aspects of life as self-care, household management, interpersonal relationships, and work or school" (Levine and Rog, 1990, p. 963). It is this group of homeless men-
tally ill that is the most difficult to reach and to which case management services are increasingly directed.