Similarities and Differences in Homelessness in Amsterdam and New York City
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Similarities and Differences in
Homelessness in Amsterdam
and New York City
Johan Sleegers, M.A.
Differences and similarities in homelessness in Amsterdam and New homeless persons with mental illness
York City were examined, particularly in regard to persons most at risk and proactive outreach was a result
for homelessness—those with mental illness and with substance abuse of experiences of service providers in
problems. The Netherlands is a welfare state where rents are controlled Amsterdam supported by research
by the national government and more than half of the housing is public conducted in the United States. As a
housing. Virtually all homeless people in Amsterdam are unemployed consequence, development of new
and receive some sort of social security benefit. Direct comparisons of services for the homeless population
the results of American and Dutch studies on homelessness are impos- in Amsterdam and New York City is
sible, mainly because the estimates are uncertain. Because of the Dutch very similar in its small-scale ap-
welfare system, Amsterdam has a smaller proportion of homeless peo- proach, with an emphasis on transi-
ple than New York City, although more people are homeless in Amster- tional housing and specialized care
dam today than 15 years ago. Neither a lack of affordable housing or for such problems as mental illness
sufficient income nor unemployment has been a direct cause of the in- and substance abuse.
crease of homelessness. As in New York City, many of the homeless in Whereas new specific services ad-
Amsterdam are mentally ill or have substance use disorders. The in- dressing the needs of the homeless
crease in the number of homeless people in Amsterdam consists large- may be very similar in the two coun-
ly of mentally ill people who would have been admitted to a mental hos- tries, the overall social context is cer-
pital 20 years ago and of older, long-term heroin abusers who can no tainly not similar, nor, probably, are
longer live independently. Thus institutional factors such as fragmenta- the causes of homelessness. The goal
tion of services and lack of community programs for difficult-to-serve of this study was to examine the sim-
people are a likely explanation for the growing number of homeless ilarities and differences in homeless-
people in Amsterdam. (Psychiatric Services 51:100–104, 2000) ness in Amsterdam and New York
City. First, a rough sketch of the
Dutch social context is given, com-
H
omelessness is often thought existed: long-term shelters for older paring the housing situation, unem-
to be rare in countries with a homeless people who mostly had al- ployment, and the social security sys-
superior safety net (1). How- cohol abuse problems and emer- tem in the Netherlands and in the
ever, this is not the case. In the gency shelters where homeless peo- United States. Second, the Dutch ap-
Netherlands, which is a welfare state, ple were allowed to sleep for five proach of developing services for
the number of homeless people was nights a month. Both types of ser- specific groups of individuals who are
estimated at 20,000 in 1995 (2). This vices still exist. most at risk of becoming homeless,
point prevalence estimate of .13 per- Present public policies aimed at such as mentally ill persons and indi-
cent of the Dutch population is simi- ending homelessness in Amsterdam viduals with substance abuse prob-
lar to some of the lower estimates of are often based on the results of lems, is described.
the number of homeless people in American research. Many service
the United States (1,3–5). programs for the homeless in Am- Definitions and numbers
Amsterdam has never had large, sterdam have been borrowed from In the Netherlands the definition of
warehouse-style shelters. Fifteen successful programs in New York homelessness (2) is identical to the
years ago only two types of services City. For example, the implementa- narrow definition of homelessness
for homeless people in Amsterdam tion of separate housing programs for used in the United States (6) and
comprises people who live on the
street or reside in shelters. As in the
Mr. Sleegers is affiliated with the department of youth and mental health of the Munic- United States, in the Netherlands the
ipal Health Service, P.O. Box 2200, 1000 CE Amsterdam, the Netherlands (e-mail, number of homeless people is rela-
jmwsle@xs4all.nl). tively higher in large cities. In Am-
100 PSYCHIATRIC SERVICES ♦ January 2000 Vol. 51 No. 1sterdam the number of homeless in- ports the idea that the homeless pop- rectly through increased prices (1). dividuals was estimated to be be- ulation in European countries con- The housing market in the Nether- tween 2,000 (7) and 6,550 (8) in sists almost exclusively of people with lands is very unlike that in the United 1990, which is two to five times the multiple problems who are chroni- States. To a large extent, the Dutch national average. The number of cally homeless and that this homeless rental housing market is a nonprofit homeless people in New York City population is relatively smaller than system, funded by the national gov- was estimated to be between 70,000 that in the United States (13,14). A ernment and aimed at the socially and 90,000 in the early 1990s (6), study of a sample of 180 homeless in- fair distribution of available housing. which is six to eight times higher than dividuals recruited at emergency Rents are controlled by the national the national rate. shelters and drop-in centers in Am- government. Nevertheless, in the A study by Cohen (6) found that sterdam found that 60 percent of the 1980s housing rents increased almost approximately 50 percent of home- respondents had been homeless for twice as much as the general price in- less people in New York City lived on more than one year (9). A represen- dex (47 percent versus 25 percent) the street, compared with around 10 tative sample taken from all service (17). More than half of the total percent in Amsterdam (9). Further- locations, including long-stay shel- housing stock in Amsterdam is public more, Cohen reported that roughly a ters, would certainly have found a housing (18). The quality of public third of the homeless population of higher rate. housing is good, and housing assis- New York City were young adults, a tance helps low-income residents pay fifth were homeless families, and 90 the rent. percent of the shelter population In the 1970s the national govern- were members of ethnic minority ment stimulated urban renewal pro- groups. Of the Amsterdam homeless As in grams. The first goal of these pro- population, around 10 percent were grams was to improve the quality of young adults (10,11), less than 10 New York City, houses, but since the early 1980s lo- percent were women with children, cal authorities have also tried to cre- and 40 percent were members of an many of the homeless ate a more mixed housing stock, mix- ethnic minority group (10). ing privately owned homes and pub- It is impossible to compare the in Amsterdam are mentally lic housing in the same neighborhood varying results of American research and locating expensive houses next to with the results of the few Dutch ill or have a substance low-cost housing. studies on homelessness, mainly be- Usually, urban redevelopment in cause considerable uncertainty sur- abuse problem, Amsterdam did not permanently rounds the estimates reported. Cer- evict residents. Tenants had the op- tainly, it is hard to believe that the or both. portunity to return to their homes af- prevalence of homelessness is about ter the renewal of the neighborhood. as high in Amsterdam as it is in New Although the higher quality of the York City. The point prevalence houses led to increased rents, tenants method of estimating may obscure were able to pay the higher rent be- differences between the homeless The social context cause of the national rent-subsidy situation in the two countries, be- The shortage of affordable housing is program. Housing policies of the na- cause it does not take into account an important cause of the increase in tional government and the local au- the many people who are homeless homelessness in the United States. thorities did not have any effect on for a short period of time, and it over- However, no agreement exists about the shortage of housing in the 1980s. represents chronic long-term home- whether the housing market has gen- In Amsterdam the number of indi- less people. erated a direct or only an indirect ef- viduals and families who were classi- The results of two surveys in the fect. Some argue that urban revital- fied by housing associations and local U.S. revealed a high turnover in the ization and gentrification brought authorities as most urgently in need homeless population. A national tele- about a tighter rental market, while of housing fluctuated between phone survey reported a five-year others assert that it was a process 50,000 and 60,000 applicants in the prevalence of literal homelessness of with interacting factors, such as long- 1980s and declined to 43,000 appli- 3.6 percent (12), and a study of shel- term joblessness and lagging govern- cants in the early 1990s (18). Only a ter admission rates in Philadelphia ment benefits. Nevertheless, it is few applicants for housing are home- and New York City reported that, generally agreed that more people less. Most are families who want bet- over five years, 3.27 percent of New became homeless because their de- ter housing or individuals who want York City’s population spent time in a creased income was too small to pay to start living independently. public shelter (4). the increased rent (1,3,15,16). The Virtually all homeless people in No comparable period prevalence almost complete demolition of flop- Amsterdam are unemployed and re- estimates of homelessness exist for houses or cubicle hotels also led peo- ceive some sort of social security the Netherlands. However, Euro- ple to homelessness, whether direct- benefit (10). Table 1 presents data pean research on homelessness sup- ly as a result of eviction (15) or indi- from several sources on socioeco- PSYCHIATRIC SERVICES ♦ January 2000 Vol. 51 No. 1 101
Table 1 ture on tenant-based rent assistance
Socioeconomic variables relevant to the context of homelessness in the United more than doubled, from 629 million
States and the Netherlands, in percentages Dutch guilders in 1980 to 1,473 mil-
lion in 1988 (17). The rent subsidy
Variable U.S. Netherlands made it possible for residents with a
low income to keep paying their rent.
National unemployment rate during the recession in the
early 1980s1 9.5 12.0
National unemployment rate in 19972 4.9 5.0
Vulnerability to homelessness
Unemployment in New York City and Amsterdam in 19973 8.5 11.0 Among the poor, those with mental
National proportion of persons unemployed longer than one year1 10 50 illness and substance abusers are the
Chance of finding a job within a month4 37 6 most vulnerable to homelessness
Individuals and families receiving general assistance in New (23,25). In addition, they may find it
York City and Amsterdam5 15 10
more difficult to arrange informal,
1 From the Social and Cultural Report (19) makeshift housing (26). The litera-
2 From the Bureau of Labor Statistics (20) and Statistics Netherlands (17) ture on contemporary homelessness
3 From the Bureau of Labor Statistics (20) and Statistics Amsterdam (18)
4
in the United States often includes
From De Beer (21)
5 The number of individuals in New York City who received Home Relief in 1995 combined with
estimates of the prevalence of mental
the number of families who received Aid to Families With Dependent Children in 1995 (22). illness and substance abuse among
The number of individuals and families in Amsterdam receiving general assistance in the early the homeless. The reported results of
1990s (18) surveys vary greatly because of dif-
ferences in definitions of mental ill-
ness and in survey methods (27).
nomic variables relevant to home- The level of general assistance pay- Few studies of mental illness and
lessness (17–22). In the early 1980s ments, which is slightly lower than homelessness are available in the
the unemployment rate in both the the legal minimum wage, is consid- Netherlands. Only two surveys re-
Netherlands and the United States ered the social minimum in the ported DSM-III prevalence rates of
increased dramatically. In the same Netherlands. Every legal resident in mental disorder obtained by struc-
period, safety-net programs in both the Netherlands who has no income tured interviews (11,28). Both sur-
countries changed significantly. The is eligible for general assistance. Par- veys were conducted in Amsterdam.
Reagan administration tightened eli- allel to the strong increase in unem- Table 2 presents the results of these
gibility for federal entitlements, and ployment, the number of individuals two surveys and compares them with
eligibility for other safety-net pro- and families receiving such assistance results from American surveys (27).
grams, such as food stamps and fed- in Amsterdam increased sharply in Table 2 also shows that comparable
eral housing assistance, also changed the early 1980s. More than 80,000 in- community surveys found higher
(3,23). For many in the U.S., declin- dividuals and families in Amster- prevalence rates of mental disorders
ing wages and the declining value dam—11.5 percent of the city’s pop- in American households than in
and availability of public assistance ulation—received general assistance Dutch households (28–31) but that,
put housing out of reach (15). in 1984 (18). After 1984 the number proportionally, more people are hos-
In the Netherlands, the social se- of recipients declined slightly but re- pitalized in mental hospitals in the
curity system has also changed in the mained high at around 10 percent, Netherlands than in the United
last ten to 15 years (19). In the early despite the end of the economic re- States (32,33). Although the restruc-
1980s, the national government tried cession and an increasing number of turing of mental health care in the
to lower expenditures on social secu- new jobs. The continued elevation in Netherlands did not involve a large
rity by freezing the level of individual the number of people receiving gen- reduction in mental hospital popula-
benefits. However, mainly because of eral assistance was an effect of high, tions, it did result in a decline in
rising unemployment and the grow- long-term employment in Amster- length of stay (31), a decrease in first
ing number of people eligible for dis- dam and of the volume policy of the admissions (34), and a doubling of
ability benefits, the costs of the social national government. the number of readmissions (35). In
security system still rapidly in- General assistance payments in other words, the function of the men-
creased. Therefore, the national gov- Amsterdam, in combination with a tal hospital as a stable residential en-
ernment changed its policy in the late rent subsidy, are enough to ensure a vironment for persons with chronic
1980s and early 1990s—instead of decent standard of living for most re- mental illness has disappeared in the
lowering the level of benefits again, it cipients, whereas in the United Netherlands, as it has in the United
restricted eligibility for unemploy- States general assistance benefits and States.
ment benefits, disability benefits, payments from Aid to Families With Redevelopment of old-style mental
and early-retirement settlements. As Dependent Children are often not hospitals into community-based care
a result of this volume policy, rela- enough to pay the rent (24). When in and the corresponding shift in treat-
tively more people became depen- the 1980s the Dutch national govern- ment policies did not lead to large
dent on the lower general assistance ment cut social security benefits and numbers of hospitalized chronic
payments from their municipality. housing rents increased, the expendi- mentally ill people becoming home-
102 PSYCHIATRIC SERVICES ♦ January 2000 Vol. 51 No. 1less in Amsterdam; however, it prob- Table 2
ably had an indirect effect. Many of Prevalence of mental disorders in the United States and the Netherlands, in per-
the mentally ill homeless population centages
of today would have been admitted
to a mental hospital ten or 20 years Variable U.S. Netherlands
ago. Now hospitals discharge individ-
uals with severe mental disorders af- Prevalence among homeless people1
Schizophrenia 1–13 3–14
ter a short stay, often without arrang- Mood disorder 14–30 24–25
ing for continuity of care in a com- Anxiety disorder 18–39 22–47
munity setting. As observed in the Alcohol abuse and dependence 57–63 31–46
United States (36), this practice may Drug abuse and dependence 31–37 60
lead to exacerbation of symptoms Antisocial personality disorder 16–37 14–58
Prevalence in the community2
and homelessness. Schizophrenia .5 .2
According to Jencks (1), abuse of Mood disorder 11.3 7.6
crack cocaine was one of the major Anxiety disorder 17.2 12.4
causes of increasing homelessness in Substance abuse and dependence 11.3 8.9
the United States. In Amsterdam, Daily number of inpatients per 100,000 inhabitants3
1980 76 154
the problem of hard drug abuse is 1995 32 138
mainly one of heroin. Crack was not
used by many people in Amsterdam 1 The rates for all disorders reflect lifetime prevalence rates of DSM-III diagnoses using the Diag-
in the 1980s, but since the early nostic Interview Schedule in surveys of homeless people in the U.S. (27) and in the Netherlands
(11,28).
1990s, crack has become popular as a 2 The rates for all disorders reflect 12-month community prevalence rates of DSM-III-R diag-
secondary drug with most heroin noses using the Composite International Diagnostic Interview in the U.S. (29) and the Nether-
users. The number of heroin abusers lands (30).
3 For the U.S. the 1980 rate is from Jencks (1) and the 1995 rate is from Bachrach (32); the rates for
in the Netherlands in 1995 was esti-
the Netherlands are from the Netherlands Institute of Mental Health (31).
mated at 25,000 to 27,000 individuals
(37). Of these heroin abusers, 6,300
live in Amsterdam. It is mainly an
older cohort of people who started the problem of homelessness and its employment nor poverty are a likely
using heroin 15 to 20 years ago. solutions. Comparing the varying re- explanation of the increase of home-
Since the mid-1970s, harm reduc- sults of American research with the lessness in Amsterdam, especially be-
tion has been at the core of the results of the few Dutch studies on cause of the housing assistance pro-
Dutch drug policy. It is directed not homelessness is difficult, mainly be- gram of the national government,
only at abstinence but also at regula- cause of the considerable uncertainty which can be seen as the ultimate
tion of the addiction if abstinence is about the estimates reported. How- safety net for preventing homeless-
not yet attainable. Among heroin ever, several differences and similari- ness in Amsterdam. However, the
abusers in Amsterdam, the number ties can be observed. high unemployment rate, along with
of fatal overdoses and the incidence First, relatively more people expe- the fact that very few low-skill jobs
of HIV are lower than in cities in oth- rience homelessness in New York exist in Amsterdam compared with
er countries (38,39). As a conse- City than in Amsterdam. Point preva- New York City, is probably one of the
quence, and because there are very lence estimates obscure an important reasons why rehabilitation is difficult,
few new young users, the average age difference: in the Netherlands the and therefore one of the reasons why
of a heroin abuser in the Netherlands homeless population consists almost homelessness is a chronic condition
increased in 1997 to 38.7 years. In re- exclusively of people with multiple for many homeless individuals in
cent years the use of shelters by these problems who are chronically home- Amsterdam.
“veteran” drug abusers has increased less, whereas the United States has a Third, as in New York City, many
because they are less and less capable high turnover in the homeless popu- of the homeless in Amsterdam are
of living without professional sup- lation, which is also more heteroge- mentally ill or have a substance abuse
port, especially long-term shelter neous than the Dutch homeless pop- problem, or both. Even though Am-
with in-house medical care and ulation. sterdam has a good safety net, there
methadone dispensation. Second, not as many people be- are more homeless people there to-
come homeless in Amsterdam as in day than 15 years ago. Such institu-
Discussion and conclusions New York City because of the Dutch tional factors as the fragmentation of
Cultural differences underlie the welfare system. The Dutch social se- mental health services, poor intera-
structural differences and contrast- curity system is not as good as it was gency cooperation, and the lack of
ing public policies in New York City in the 1970s because, as in the Unit- community programs for difficult-to-
and Amsterdam. Ideas about profit ed States, eligibility for national ben- serve individuals are a likely explana-
making, solidarity, government regu- efits has been tightened. However, tion of the increase of homelessness
lation, and individual freedom rule for many people it still ensures a de- in Amsterdam. The Dutch safety net
how a society and its citizens define cent standard of living. Neither un- is not sufficient to prevent the most
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