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Homelessness, mental health, and substance abuse: Three things tied to one big problem

Editor's Note: Over the next few weeks the High Plains Daily News will be publishing a series of featured articles concerning the homeless. 

By Dan Butcher

Homelessness in the U.S. has been a significant problem for decades and communities have struggled to find solutions. On any given night, over 800,000 ( some estimates are higher or lower depending on the source you use) persons in the U.S. are homeless.

Communities throughout the U.S. are struggling to find solutions for serious and persistent homelessness. Alcohol and drug problems can be causes and consequences of homelessness, as well as co-occurring problems that complicate efforts to succeed in finding stable housing.

The public health implications of homelessness are significant and include syndemic interactions that exacerbate substance abuse, health problems, HIV risk, and mental health symptoms. Mortality rates among homeless persons are more than three times that of persons with some type of housing (O'Connell, 2005).

Homelessness is associated with increased risk to be involved in the criminal justice system. A variety of studies document high rates of homelessness for offenders leaving state prisons and local jails.

Once they are homeless, these individuals are at increased risk to reengage in illegal activities that result in re-incarceration. Homelessness also leaves individuals vulnerable to being victims of crime such as physical and sexual assault.

There have been increases in funding for homeless services in recent years and it appears to be having a beneficial effect, overall homelessness in the U.S. decreased by 3.7%, although there was significant variation among individual states.

Funding has increased for a variety of housing programs, including emergency shelters, permanent housing, and specialized Veteran's Administration programs. As funding increases, service providers, researchers, and local governments debate about what types of services to increase.

Although studies vary, research consistently shows over a third of individuals who are homeless experience alcohol and drug problems. The relationship between homelessness and substance abuse is complex, with studies suggesting that substance use can be both a cause and consequence of homelessness.

Until recently, few services addressed the needs of substance abusing homeless persons who were not motivated to address their substance use. In addition, even when homeless individuals were motivated to address substance abuse problems, access to the variety of services needed were lacking.

Notably lacking has been successful integration of substance abuse treatment, permanent stable housing, and related services such as mental health.

Prevalent stereotypes and stigmas in the world today often dismiss those who are homeless as simply drug addicts or alcoholics. Many homeless people would probably be the first to admit that they took some wrong turns along the way in life. But, then again, life can deal out more than a fair share of trauma, stress, pain and other negative factors that tremendously impact our lives.

Trying to answer the“the chicken or the egg” question, researchers have made a clear discovery. According to the National Coalition for the Homeless, addiction can be both a cause and a result of homelessness.

To further complicate matters, mental illness is often an underlying cause of addiction and, therefore, homelessness as well. This fact makes negative stereotypes about addiction and homelessness all the more ill-founded.

In most cases, homelessness is a temporary circumstance – not a permanent condition. It does not encapsulate who people are. So, from that perspective, the number of people who are homeless is very fluid – not static, as often naively thought. This population is determined through a snapshot in time.

Actually, defining who is “homeless” can vary considerably, depending on the source and context used. But generally, the homeless are those who “lack a fixed, regular, and adequate night-time residence.”

Statistically, more than a half million people are sleeping outside or in an emergency shelter or transitional housing program on any given night, reports the National Alliance to End Homelessness.

The circumstances for “homelessness” can take various forms. People may experience it by being:

Unsheltered – Living on the streets, camping outdoors, or living in cars or abandoned buildings.

Sheltered – Staying in emergency shelters or transitional housing.

Doubled up – Residing with friends or family temporarily.

Homeless people suffer disproportionately from all health problems, and drug abuse and addiction are no exceptions.

Research indicates that substance abuse is more common among the homeless than with the general population. It is estimated that:

About 38% of the homeless abuse alcohol.

Alcohol abuse is more common among the older set within the homeless population.

About 26% of the homeless abuse drugs other than alcohol.

Drug abuse is more common among younger homeless people.

A survey conducted by the United States Conference of Mayors asked 25 cities to share the top reasons for homelessness in their region. 68% reported that substance abuse was the number one reason among single adults. According to a separate research survey, two-thirds of the homeless who were interviewed reported that abuse of drugs and/or alcohol was a major cause of their homelessness. Very similar numbers are reported for homeless military veterans suffering from a substance use disorder.

In other words, the correlation is clear: substance abuse is a major contributing factor for many people becoming and remaining homeless. To cope with highly stressful life situations – such as family conflicts or dysfunction, traumatic loss or harm, devastating medical condition, abrupt career detour or disastrous financial loss, the newly homeless may turn to alcohol and/or drugs in an effort to self-medicate.

Once alcohol and/or other drug dependence forms, research points to users becoming even more entrenched in substance abuse. If this downward spiral is set against the backdrop of homelessness, it is only too obvious that these circumstances are rife with obstacles to attaining relief and recovery.

It is estimated that about two-thirds of the perpetual homeless have a primary substance use disorder or other chronic health condition, according to the Office of National Drug Control Policy. In addition, roughly 30% of people experiencing chronic homelessness have a serious mental illness.

Altogether, such physical and mental health issues may create difficulties in accessing and maintaining stable, affordable and appropriate housing for an individual…or an entire family.4

Shifts in American public policy over the last few decades may account for the high number of mentally ill people(many of whom are substance abusers) living on the street. A trend is underway of releasing mentally ill patients as quickly as possible in order to free up hospital beds. While dumping patients out of psychiatric hospital beds saves the health care system money, it actually increases taxpayer cost overall by shifting care to more expensive jails and prisons. There’s also the question of what’s morally right.

A study of chronically homeless, alcohol-dependent people in New York City was conducted. All of these individuals began drinking as a child.They quickly became dependent on alcohol.It was found that over two-thirds of them were children of alcoholic parents. Many of them suffered abuse in their very own home. And nearly all of them left home by the age of 18. More than half of them had a psychological disorder. Common diagnoses are psychosis and anxiety and mood disorders.8

So, alcohol dependence in childhood often contributes to chronic homelessness. In such cases, alcohol may be a higher priority than paying for housing. Extending that thought, when an alcoholic doesn’t meet such basic needs, it is less likely that treatment and recovery will occur. This can lead to frustration and depression, which in turn fuels more alcohol abuse. It is truly a vicious cycle – one that can spin out of control for an entire lifetime…IF expert help isn’t sought.

Data collection on the homeless and their addictions, at any given time, is difficult to obtain. For one thing, the homeless are not usually included in census data. Also, the homeless in shelters may underreport their alcohol consumption if a condition of their stay is to remain abstinent.

Less than 25% of homeless people with an alcohol and/or drug addiction are likely to get needed treatment. A comprehensive approach is vital for addressing the many factors involved in homelessness.

A review of 20 facilities offering substance abuse treatment to the homeless found these characteristics:

Housing access –A stable living environment is a critical factor in recovery of the homeless.

Well-trained staff –Compassionate, flexible and experienced care is vital to an effective program.
Client-centered services –A tailored treatment plan can provide a better pathway to recovery than a one-size-fits-all program.

Integrated services –Since the homeless often have co-occurring mental issues, having multidisciplinary professionals in-house can provide centralized, coordinated treatment for greater effectiveness.

Comprehensive services –Addressing the many complex needs of a homeless person – including survival and social needs – treats homelessness holistically (treats the whole person, rather than just symptoms).

While psychiatric hospitals and emergency rooms are where the homeless are often treated,other options exist. Non-hospital residential and outpatient programs often provide a broader menu of services.

The most common type of residential treatment for the homeless is hospital detox. Outpatient treatment methods include individual counseling, outpatient detox and 12-Step programs. But, alas, outpatient care does not provide housing – a critical factor to the homeless.

Additional housing options for the homeless that are sensitive to substance use and mental issues include:

Sober or dry housing – Strict abstinence policy. Substance use can result in termination of housing.

Damp housing – People both with and without substance use disorders live together. Abstinence is not monitored. However, illicit substances are prohibited. Alcohol use in public spaces is off limits. In addition, treatment services may be offered.

Wet housing – Uses a harm-reduction approach that refers clients to substance abuse treatment services. However,it does not require participation. Alcohol use, but no illicit substances, permitted.

Up to 80% of homeless Veterans suffer from mental health and/or substance use disorders. The path into and out of homelessness is often complicated by untreated or under treated mental health and substance use disorders.

Even after housing has been obtained, the presence of these disorders can further isolate homeless Veterans, resulting in greater rates of emergency room visits and hospitalizations. Thus, integrating mental health and substance use disorder treatment with community-based permanent housing is important in sustaining housing placements for formerly homeless Veterans.

The promise of housing can be especially beneficial for those homeless combating substance abuse, which frequently overlaps with other mental illnesses, says Joseph Schumacher, PhD, a clinical psychologist at the University of Alabama at Birmingham. He has studied drug addiction among the Birmingham area homeless for 18 years. To treat them, he uses contingency management therapy, which provides work opportunities and housing in exchange for sobriety. The primary intervention was providing apartments to people so long as they passed a urine drug test.

"It ended up working," Schumacher says: After six months, approximately 55 percent of residents who received contingency management treatment remained abstinent, compared with nearly 30 percent of residents receiving behavioral day treatment over the same span of time.

The strength of that program hinges on the fact that even if they falter and fall back on drugs, they are never kicked out of the program entirely, Schumacher says. If someone shows up with a drug-positive urine test, mental health workers provide same-day counseling and program workers place them in safe shelters. They can reapply for the housing program the next week.

"You always have the opportunity to come back and try again," he says. "That's key to a behavioral intervention."

For the last decade, most of the contingency management studies involving homeless people came out of Schumacher's lab. But in 2007, a group from the New York University School of Medicine in New York City found parallel results using a contingency management program to reduce cocaine and alcohol use in homeless people staying at a New York City homeless shelter, adding support for the technique's efficacy.

Schumacher's model isn't without criticism, though. Paul Toro says that based on his own experiences with housing programs, he prefers a housing-first model rather than Schumacher's abstinence-first because he believes it's more important to get people off the streets than off drugs. Once homeless people are in stable situations, they are more likely to be able to break their addictions, he says.

Other research suggests that helping mentally ill homeless people find permanent housing also helps society by lowering costs in the long run. A 2006 study by the Denver Housing First Collaborative found that the public cost of caring for Denver's homeless, which includes emergency care, shelter, detox programs and incarceration, was $43,239 per person annually. Moving those people into permanent homes reduced that figure to $11,694 annually, saving the city $31,545 per individual. That more than covers the $13,400-per-year it costs to house each individual. A similar 2006 report by Portland's Community Engagement Program found that providing housing to homeless people dropped public costs from $42,075 to $17,199 per person.

"It's a bargain for society to keep them off the streets and get them into a stable situation," Toro says.

Herman and his colleagues working with the Critical Time Intervention have found similar results: Homeless people are most likely to stay in stable housing when programs identify the person's specific needs and develop individual plans for addressing them, he says.

The challenge ultimately is in organizing someone's potential support structures, from formal services such as housing, income support and medical care, as well as more informal ones, including getting periodic help from family members, religious and neighborhood communities, even "the local guy who runs the news stand on the corner," Herman says. The trick is to make sure people stay on track once they get started in the right direction.

"The most effective approaches require some workers—social services workers, mental health workers, outreach workers—to go out to the places where these people are," he says. "The best thing may not be to say, 'Won't you come with me, and we'll get you psychiatric help,' because that might not be at the top of their priorities. But you might say, 'We can offer you a place to sleep, we can offer you a place to wash up, to see a doctor, to deal with sores on your feet.'"

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