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Blueprint for Change: Ending Chronic
Homelessness for Persons with Serious
Mental Illnesses and Co-Occurring Substance Use Disorders
Chapter 2: Learn about the Population
People who are homeless are people first. They also may have
disorders including serious mental illnesses and substance use. The fact
that they have illnesses that may significantly disrupt their lives doesn’t
diminish their rights, their responsibilities, or their dreams. People with
serious mental illnesses and/or co-occurring substance use disorders become
homeless because they are poor, and because mainstream health, mental
health, housing, vocational, and social services programs are unable or
unwilling to serve them. They also are subject to ongoing discrimination,
stigma, and even violence.
For example, probably no condition is as closely connected with
homelessness as chronic alcohol dependence (Baumohl and Huebner, 1991). As
Stark (1987) notes:
Conceivably, the homeless could have been stereotyped as unemployed
men who needed jobs or job training, as elderly people who needed our
concern and care, or as individuals who were physically and mentally
disabled. Because, instead, they were stereotyped as alcoholics, the
societal answer to their problems often related to some form of
institutionalization, whether jail or detoxification program. (p. 12)
Unfortunately, some key facts about serious mental illnesses and
substance use disorders are widely unrecognized or misunderstood. The most
important fact is that people with serious mental illnesses and/or
co-occurring substance use disorders can and do recover. Indeed, from a
medical perspective, most mental illnesses today are considered to be as
treatable as general medical conditions (HHS, 1999). Further, from a
rehabilitation perspective, people with serious mental illnesses move beyond
their disabilities to reclaim valued roles in society (Ahern and Fisher,
2001).
People with substance use disorders recover, as well. Fifty-five percent of
individuals who remain in Alcoholics Anonymous for more than 90 days will be
sober after one year, and 50 percent will be sober after five years (Ringwald,
2002). The very fact that people who have serious mental illnesses and substance
use disorders have learned to survive on the streets speaks to their strength,
their resiliency, and their perseverance, all protective factors that can be
harnessed to help them recover.
To help people with serious mental illnesses and/or co-occurring substance
use disorders avoid becoming homeless or exit homelessness, communities and
providers must understand who they are and why they are vulnerable. This chapter
examines (1) individual risk factors, (2) service delivery challenges, and (3)
societal or structural factors that make it difficult for people with serious
mental illnesses or co-occurring disorders to escape homelessness.
Individual Risk Factors
Mental Illness
Though only about five percent of people with serious mental illnesses are
homeless at any given point in time, as many as two-thirds of all people with
serious mental illnesses have experienced homelessness or have been at risk of
homelessness at some point in their lives (Tessler and Dennis, 1989). The
numbers are staggering, but they only begin to tell the story.
The symptoms of serious mental illnesses[1] may increase vulnerability to
homelessness. Depending on the disorder, people with a mental illness may
experience a range of behaviors that threaten their housing stability.
Individuals whose mental illnesses or co-occurring substance use disorders are
untreated may disturb their neighbors, be a threat to themselves or others, miss
rent or utility payments, or neglect their housekeeping, and be evicted.
Serious mental illnesses can be cyclic in nature, and some individuals may
experience a recurrence or exacerbation of their symptoms in situations that
seem stressful or unpredictable. Further, because many people with mental
illnesses have difficulty developing and maintaining comfortable social
relationships, they may become lonely and isolated and have conflicts with
family, employers, landlords, and neighbors. These conflicts can result in
homelessness if appropriate treatment and services are not available. People who
are hospitalized or jailed may lose their housing when they are unable to pay
their rent.
Alcohol and Drug Use
Substance use is both a precipitating factor and a consequence of being
homeless (Zerger, 2002). Notes McCarty (1990, p.1):
Street life for homeless men and women abusing drugs and alcohol can be
confusing, dangerous, and frustrating. Individuals shuffle unsteadily
between detoxification centers, shelters, bus stations, subways, day
programs, jail, abandoned buildings, and soup kitchens. It is a painful life
complicated by, but also made more bearable because of, the use and abuse of
alcohol.
Researchers estimate that as many as half of all people who are homeless have
diagnosable substance use disorders at some point in their lives
(McMurray-Avila, 2001; Baumohl and Huebner, 1991). Alcohol abuse is more common,
occurring in as many as 30 percent to 40 percent of people who are homeless
(Stark, 1987; Baumohl and Huebner, 1991). Indeed, there still exists a cadre of
older, white male, skid row alcoholics (Koegel and Burnam, 1987). Increasingly,
however, individuals who are homeless and have substance use disorders are
younger and include women, minorities, poly-drug users, and individuals with
co-occurring mental illnesses (McMurray-Avila, 2001). They have less education
and fewer skills than their older counterparts.
Substance use and abuse frequently lead to loss of housing, and make it more
difficult for individuals to find safe, sober housing once they become homeless.
People with substance use disorders who are homeless face enormous competition
for limited treatment slots. Those who do receive treatment are more likely to
get care for a co-occurring mental illness (SAMHSA, 2002a).
Co-occurring Disorders
Substance use problems are a complicating factor for many people who have
serious mental illnesses. An estimated 50 percent of adults with serious mental
illnesses who are homeless have a co-occurring substance use disorder (Fischer
and Breakey, 1991). Among veterans who are homeless, one-third to nearly
one-half have co-occurring mental illnesses and substance use disorders (Kasprow,
Rosenheck et al., 2002).
People with both disorders are at greater risk for homelessness because they
tend to have more severe mental symptoms, to deny both their mental illness and
their substance use problems, to refuse treatment and medication, and to abuse
multiple substances. Untreated, they may be antisocial, aggressive, and
sometimes violent, and they have high rates of suicidal behavior and ideation.
Once homeless, people with co-occurring disorders have more problems, need
more help or are unable to benefit from services, and are more likely to remain
homeless than other groups of people (Winarski, 1998). They are more likely to
be older, male, and unemployed; to be homeless longer and living in harsher
conditions; and to suffer greater distress, demoralization, and alienation from
their families. They tend to be isolated, mistrustful, and resistant to help
(Dixon and Osher, 1995). Lack of appropriate treatment for co-occurring
disorders means that even individuals who are motivated to get help may be
unable to find it or have to face long waits.
Physical Health Problems
People with serious mental illnesses and/or co-occurring substance use
disorders often have significant co-morbid medical conditions, including
malnutrition, diabetes, liver disease, neurological impairments, and pulmonary
and heart disease. Homeless people with alcohol disorders are in especially poor
health; they experience both the deleterious effects of alcohol and of
homelessness (Wright and Weber, 1987). Further, life on the streets makes it
difficult for individuals to receive appropriate care for chronic conditions and
often leads to such acute problems as upper respiratory infections, skin
conditions, and serious dental health problems. In addition, people who are
homeless, particularly those with serious mental illnesses or co-occurring
disorders, are at risk for life-threatening infectious diseases such as
tuberculosis, Hepatitis B and C, and HIV/AIDS (Federal Task Force on
Homelessness and Severe Mental Illness, 1992; McMurray-Avila, 2001).
Victimization
The relationship among homelessness, mental illness, substance use, and
victimization—including physical and sexual abuse—is multidimensional. People
who have been abused are more vulnerable to ongoing stresses that may lead to
mental illness, substance use, and homelessness. While the association between
childhood abuse, mental illness, and substance use is increasingly recognized, a
number of studies have found high rates of childhood physical and sexual abuse
in adults who are homeless, as well (Fischer, 1992). Indeed, research points to
high prevalence rates of sexual abuse and other trauma in the lives of people
with serious mental illnesses and substance use disorders who are homeless,
particularly women (Goodman et al., 1995; Herman et al., 1997).
In studies that ask about lifetime abuse, between 51 and 97 percent of women
with serious mental illnesses report some form of physical or sexual abuse, with
a significant portion suffering multiple traumas (Goodman et al., 1997).
Forty-one percent to 71 percent of women in treatment for drug or alcohol
disorders report being sexually abused as children or adults, and more than
one-third have been victims of violent crimes (Alexander, 1996).
Abuse in childhood may leave individuals vulnerable to ongoing abuse in adult
relationships. For some women, domestic violence precipitates homelessness.
Mental health providers may treat women who have experienced physical and sexual
abuse inappropriately by using such techniques as physical restraints or forced
medication that may remind the women of the original abuse they suffered
(National Association of State Mental Health Program Directors [NASMHPD], 1998).
These women require trauma-sensitive services to help them regain psychiatric
and residential stability.
Finally, people who are homeless may become victims of further assault on the
streets and in shelters. Those individuals who have fewer resources and skills
to overcome the effects of trauma—especially people who have serious mental
illnesses, including post-traumatic stress disorder (PTSD)—are particularly
likely to be victimized while homeless, and to suffer more severe consequences
of ongoing abuse (Fischer, 1992).
Minority Status
Racial and ethnic minorities are dramatically overrepresented among homeless
populations. Nationally, compared to all U.S. adults in 1996, individuals who
were homeless were disproportionately Black non-Hispanics (40 percent versus 11
percent in the general population) and American Indians (8 percent versus 1
percent in the general population) (Burt et al., 1999). Though these percentages
vary around the country, research shows that people of color comprise a
disproportionate share of the homeless populations in their communities (Burt,
1999).
Some of these groups are at heightened risk for substance use disorders. The
highest rates of alcoholism in the homeless population are found among American
Indians, both men and women (Wright, 1987). Crack cocaine use is prevalent among
homeless African-American men and women in urban areas (Zerger, 2002).
Further, racial and ethnic minorities have less access to mental health
services than do whites. They are less likely to receive needed care, and the
services they do receive are likely to be poor in quality (HHS, 2001).
Inattention to race and ethnicity creates significant barriers to successful
treatment. Race, ethnicity, and culture influence how individuals express mental
health problems, how they seek help, and how their problems can best be resolved
(HHS, 2001). In addition, different racial and ethnic minorities respond
differently to psychiatric medications (SAMHSA, 2002b).
Race and ethnicity also are major factors in defining alcohol and drug use
and corresponding treatment needs. For example, "the needs, perspectives, and
social networks of younger African Americans addicted to crack cocaine will
differ from those of older White skid-row-type alcoholics, and neither of these
groups will have the same characteristics as chemically dependent Mexican
Americans and Native Americans" (Conrad et al., 1993, p. 239). People of color
who feel disconnected from society and have untreated mental illnesses and/or
co-occurring substance use disorders may be difficult to engage into treatment,
especially if outreach workers and treatment staff are not sensitive to their
cultural and linguistic needs.
Sexual Minorities
Homeless sexual minorities, especially youth, also are at increased risk for
negative outcomes. Forty-two percent of homeless youth identify as lesbian, gay,
or bisexual (Orion Center, 1986). Researchers comparing gay, lesbian, bisexual,
and transgender (GLBT) homeless youth with their heterosexual counterparts found
that GLBT adolescents left home more frequently, were victimized more
frequently, used highly addictive substances more frequently, had higher rates
of psychopathology, and had more sexual partners than heterosexual homeless
youth (Cochran et al., 2002).
Transgender individuals are especially stigmatized. They may become homeless
as a direct result of job or housing discrimination. Researchers report that as
many as 60 percent have been victims of harassment or violence, and 37 percent
have experienced economic discrimination (Lombardi, 2001).
Diminished Social Supports
People with mental illnesses who become homeless have less contact with their
families and are more likely to have poor family relationships than those who
are not homeless. Relationships often deteriorate over time, as parents or other
relatives become exhausted and frustrated caring for a relative who may have
recurring periods of disturbing or frightening behavior. Without the ongoing
care and persistent advocacy that family members provide, many people with
serious mental illnesses are at greater risk for homelessness.
Likewise, people with substance use disorders who are homeless have less
social support than people who are not homeless. Yet, interestingly, among
homeless groups, people who drink tend to report more support than people who
don’t drink, in part because drinking can be a social activity (Fischer and
Breakey, 1987). Severing the bonds with their "friends" who use alcohol or drugs
may compound feelings of social isolation among people who are homeless
(McMurray-Avila, 2001).
Criminal Justice System Involvement
Homeless people, especially those with mental illnesses and/or co-occurring
substance use disorders, come into frequent contact with the criminal justice
system both as offenders and as victims. Often, homeless people are arrested for
minor offenses, including trespassing, petty theft, shoplifting, and
prostitution.
Studies reveal that a person with a mental illness has a 64 percent greater
chance of being arrested for committing the same offense as a person who does
not have a mental illness (Teplin, 1984). A person’s contact with the criminal
justice system may be even more likely following the enactment of
"anti-homeless" legislation, including anti-begging, sleeping, and vagrancy
ordinances, which is occurring in many of the country’s largest cities (National
Coalition for the Homeless [NCH] and National Law Center on Homelessness and
Poverty, 2002).
People with substance use disorders who are homeless are more likely than
persons who have not experienced homelessness to have arrest histories, to have
been arrested in the past year, and to report felony convictions (Fisher and
Breakey, 1987). Fifty percent of all arrests of homeless people relate to
drinking in public spaces (McMurray-Avila, 2001).
Though some individuals with serious mental illnesses or co-occurring mental
illnesses and substance use disorders are diverted to treatment, the U.S.
Department of Justice (DOJ) reports that nearly 284,000 people with mental
illnesses were in jails and prisons in 1998 (Ditton, 1999). Twenty percent of
state prison inmates, 19 percent of Federal prison inmates, and 30 percent of
local jail inmates with mental illnesses were homeless in the year before their
arrest (Ditton, 1999). In addition, offenders report a high incidence of
substance use, and more than half are under the influence at the time of their
crime (CSAT, in press). Among detainees with mental illnesses, 72 percent also
have a co-occurring substance use disorder (Ditton, 1999).
Despite research findings that people with substance use disorders benefit in
particular from treatment while incarcerated, individuals with serious mental
illnesses or co-occurring disorders may receive inadequate or inappropriate
treatment in jails and prisons, if they receive any at all. Without an
appropriate discharge plan, they are vulnerable to repeat cycles of
homelessness.
Finally, as noted previously, people with serious mental illnesses and/or
co-occurring substance use disorders living on the streets or in shelters
frequently are victims of criminal activity. Poverty, poor survival skills, and
illegal activity place people with serious mental illnesses or co-occurring
disorders in dangerous situations in which they are vulnerable to attack
(Fischer, 1992).
Service System Challenges
Fiscal Barriers
Treatment Gaps
Significant fiscal barriers prevent people with serious mental illnesses
and/or co-occurring substance use disorders from receiving the care they need.
Perhaps the most important of these are the ways in which limited funds are used
in both the mental health and substance abuse treatment systems, which can
result in significant gaps in the ability of both systems to treat people in
need.
Estimates are that about 20 percent of the U.S. population is affected by
mental illnesses in any given year, but only one-third of people in need of
mental health treatment receive it (HHS, 1999). On the substance use side, a
recent report estimates that some 23 million people need treatment for
alcoholism or the use of illicit drugs, but fewer than one-quarter of
individuals receive it (Horgan et al., 2001).
Coverage Gaps
There are gaps in coverage, as well. The critical work of finding and
engaging people who have serious mental illnesses and/or co-occurring substance
use disorders into treatment is often not a reimbursable service. Payers who
fund mainstream mental health and substance abuse treatment services favor
clinic and institution-based care (Post, 2001). For example, Medicaid is a joint
Federal/state program but is state-administered, and states vary considerably in
the degree to which they conduct outreach to homeless people. Though Medicaid
has instituted some outreach efforts, they are not specifically targeted to
homeless people (GAO, 2000a).
When case management is available to people who are homeless, caseloads are
usually high, permitting little more than office-based contact and infrequent
monitoring. Providers struggle to pay for services provided in atypical
settings, such as shelters and on the streets, or nonmedical services, such as
social model substance abuse treatment programs.
Further, providers may be reluctant to serve people with no health insurance
coverage, which is the case for many people with serious mental illnesses and/or
co-occurring substance use disorders who are homeless. Many are eligible for,
but unable to access, these benefits. Those covered by Medicaid or Medicare
often are not attractive to providers in managed care systems that receive less
reimbursement than they would under a fee-for-service arrangement (Bianco and
Milstrey-Wells, 2001).
Persons with disabilities may be eligible for support through the Social
Security Administration’s Social Security Income (SSI) or Social Security
Disability Insurance (SSDI) programs. Persons who are poor and disabled or
elderly may be eligible for the SSI program. Persons who have a sufficient work
history and become disabled may be eligible for the SSDI program. Homeless
people who have substance use disorders are less likely than those with serious
mental illnesses or co-occurring disorders to be receiving Federal disability
benefits (Baumohl and Huebner, 1991). This is in large part because individuals
with substance use disorders, no matter how severe, are not considered disabled
under Social Security Administration guidelines for the purpose of receiving SSI,
unless they have other disabling health conditions not attributable to their
substance use.
However, people with substance use disorders often are unable to establish
SSI eligibility without a coordinated effort to document the qualifying
disability and consistent advocacy through the application and appeals process
(C. Wilkins, personal communication, April 1, 2003). Also, even if SSI
eligibility is established and the person is qualified for Medicaid, many states
offer limited Medicaid coverage for substance abuse treatment services.
Categorical Funding
Finally, categorical funding—which requires that providers offer only a
specific type of service with funds from a particular source (Federal, state,
local, private, etc.)—may make it difficult to tailor services to individual
needs. In its report, Ending Chronic Homelessness: Strategies for Action,
the U.S. Department of Health and Human Services (HHS) uses the phrase "funding
silos" to describe this problem, which arises in part because most mainstream
programs administered by HHS were created to respond to a unique need or
population (HHS, 2003). The same is true for categorical programs in other
Federal agencies, as well as in state and local programs.
Funding silos lead to problems in coordination, eligibility, and flexibility,
the HHS report notes. This is especially problematic for individuals whose
disabilities cross service system boundaries. For example, few mainstream or
targeted assistance programs pay for the sustained engagement and motivational
efforts required to treat homeless people with co-occurring mental illnesses and
substance use disorders. The HHS report notes:
The most telling example of [eligibility gaps] involves homeless persons
with substance use disorders and co-occurring mental illnesses and primary
health care problems. They may have access to limited substance abuse
treatments supported by the Substance Abuse Prevention and Treatment Block
Grant. But, they may find that they do not meet eligibility criteria for
receipt of Medicaid coverage, nor qualify as having a serious and persistent
mental illness for access to services supported by the Community Mental
Health Services Block Grant (p. 20).
Categorical funding also is likely to cause gaps in coverage as an individual
prepares to exit homelessness and is required to deal with multiple service
agencies, each with its own case management staff (HHS, 2003).
Fragmented Services
People with serious mental illnesses and/or co-occurring substance use
disorders who are homeless require a broad range of housing, health and mental
health care, substance abuse treatment, and social services, all of which
typically are provided by separate agencies with separate funding streams. The
burden of coordination falls on the individual, but people with serious mental
illnesses or co-occurring disorders, especially those who are homeless, are
ill-prepared to negotiate a fragmented service system unaided.
Lack of Discharge Planning
Service system fragmentation is especially evident in the transition from an
institution, such as a hospital or jail, to the community. Some people with
serious mental illnesses may be released from a hospital before their symptoms
are stabilized adequately, especially if their health insurance plan specifies a
predetermined length of stay. Others are released without adequate discharge
plans. As noted previously, people with substance use disorders may be
discharged from detoxification programs back to the streets.
A lack of coordination between the hospital and community-based providers to
ensure appropriate housing, treatment, income, and supports means these
individuals fall through the cracks in the system and may become homeless. Many
local officials also cite the absence of available resources as a significant
barrier to helping people successfully make these transitions (Rickards and
Ross, 1999).
The same is true for individuals leaving jails and prisons. Nationally, only
one-third of inmates with mental illnesses in jails and prisons receive any
discharge planning services. Frequently, they are released with bus tokens, a
few pills, and the address of a mental health center (Bazelon Center for Mental
Health Law, 2001). They are subject to further arrest or to unnecessary
hospitalization as they attempt to cope with their mental illnesses and life on
the streets. Likewise, individuals with substance use disorders who are not
connected to appropriate community services are more likely to cycle repeatedly
between jail or prison and the community.
Lack of Integrated Treatment for Co-occurring Mental Illnesses and Substance
Use Disorders
Substance abuse is an issue for at least half of all people with serious
mental illnesses who are homeless. Typically, mental health and substance abuse
services are provided by two separate systems, placing the burden of combined
treatment on the individual and leading to higher rates of treatment
noncompliance. People who are homeless also interact with the homeless service
system.
People with co-occurring disorders who are homeless frequently are excluded
from mental health treatment programs because of their substance use disorder,
from substance abuse treatment programs because of their mental illness, and
from homeless service programs because of their mental illnesses and substance
use disorders. Those who do receive care may get treatment for their substance
use or their mental illness, but the vast majority of individuals do not receive
treatment for both (Watkins et al., 2001). More recent models emphasize the
integration of mental health and substance abuse treatment for people with the
most serious disorders, but few such programs are available (SAMHSA, 2002b).
Inadequate Screening and Assessment
Screening and assessment of people with serious mental illnesses and/or
co-occurring substance use disorders can be problematic in the best of
circumstances, but homelessness adds another layer of difficulty. Outreach
workers may conduct an initial assessment, which often has to be short and
unobtrusive to avoid frightening away potential clients. A more complete
assessment may be possible when clients have developed a greater degree of trust
and comfort with outreach staff (Interagency Council on the Homeless, 1991).
Adequate initial assessment of persons with serious mental illnesses or
co-occurring disorders is made more difficult by the fact that shelter staff may
lack the training or time to conduct a thorough psychiatric assessment, and
there are few reliable screeners for co-occurring disorders. There are, however,
some agreed upon early assessment tools for substance use disorders. A study of
different assessment methods in Boston’s Long Island Shelter found that case
managers could identify substance use problems by using a set of open-ended
questions that include information on consumption patterns and personal problems
associated with drinking (Garrett and Schutt, 1987).
Self-reported substance use is a common assessment method, but the validity
of self-reports has been called into question by several studies indicating that
people vastly underreport the use of substances, especially illicit drugs (Zerger,
2002). An Institute of Medicine report on the treatment of alcohol problems
notes that the validity of self-reports is decreased when items on the
assessment are vague or overly general, contact with the respondent is brief, or
the respondent is not aware that self-reports will be checked against other
sources of information (Institute of Medicine, 1990).
Determining the presence of serious mental illnesses in a person with a
substance use disorder, or the presence of a substance use disorder in a person
with a mental illness, is particularly difficult. Symptoms of mental illnesses
and substance use may mimic or mask each other. Research indicates that
identifying substance use disorders in acute-care psychiatric settings has been
especially problematic, with rates of nondetection as high as 98 percent (Ananth
et al., 1989). While numerous instruments are available to assess mental
illnesses or substance use, no single, agreed-upon assessment tool exists for
co-occurring disorders (SAMHSA, 2002b).
Lack of Access to Mainstream Services
People who are homeless and have serious mental illnesses and/or co-occurring
substance use disorders are eligible for a host of mainstream health, social
service, and income support programs that are intended to meet the needs of all
low-income people, not only those who are homeless. Though such programs are a
valuable resource for providing needed services and supports, people who are
homeless often face significant enrollment barriers (Post, 2001).
For example, regulations may restrict eligibility for certain programs. Some
individuals, such as single homeless adults without children, particularly those
with substance use disorders and/or a history of felony or drug convictions,
have limited eligibility for mainstream services. Individuals with a primary
diagnosis of a substance use disorder, for instance, are excluded from receiving
Federal SSI benefits. Other barriers include complicated application procedures
and requirements made even more difficult by the lack of a fixed address or
documentation required to apply for and receive benefits (HHS, 2003; GAO, 2000a;
SAMHSA and Health Resources and Services Administration [HRSA], 2002c).
Further, many mainstream service providers have neither the resources nor
experience to provide people who are homeless with many of the services and
benefits for which they are eligible. In the absence of incentives to do so,
many mainstream programs often fail to reach out to and serve people who are
homeless, viewing it as a low-priority or as the responsibility of the homeless
service system (SAMHSA and HRSA, 2002c).
Lack of Client-Centered Services
Many people with serious mental illnesses and/or co-occurring substance use
disorders know what they need and how they want to be treated, but too often,
their wants and needs are ignored. Treatment plans are designed for them,
rather than with them, and their choices are limited. This affects both
their willingness to engage in services and to remain in treatment.
Studies examining the perception of need among the general homeless
population often find discrepancies between what individuals want and what
providers believe they need. For example, in a recent nationwide study of
homeless assistance providers and clients, individuals rated their top three
needs as help finding a job, help finding affordable housing, and help with
housing expenses (Burt et al., 1999). Nine percent of respondents mentioned
alcohol and drug use treatment as something they needed "right now" (the 13th
most frequent response), and five percent mentioned detoxification (Zerger,
2002).
Likewise, in a study of individuals entering the Center for Mental Health
Services’ Access to Community Care and Effective Services and Supports program,
researchers found that 88 percent of their expressed needs were not being met
(National Resource Center on Homelessness and Mental Illness, 1995). Oakley and
Dennis (1996) conclude that "shelter, sustenance, and security needs should be
met before addressing an individual’s need for treatment."
Retention in treatment is a significant problem for people in alcohol and
drug treatment, especially those who are homeless. A study of the National
Institute on Alcohol Abuse and Alcoholism Cooperative Agreement Program found
that all grantees lost two-thirds or more of their clients to premature exit,
and the majority lost more than 80 percent, regardless of the particular
intervention they chose (Orwin et al., 1999).
Some of the reasons for premature exit included lack of motivation, delay in
starting treatment, and dissatisfaction with degree of program structure or
program environment. In particular, individuals cited the need to give up their
job or, for women, the inability to have their children with them, as reasons
for leaving. When people with substance use disorders fail in treatment, they
tend to return to the "highly precarious circumstances that precipitated their
homelessness" (Orwin et al., 1999).
Individuals reluctant to follow through on treatment goals that do not meet
their needs increase their vulnerability to homelessness. They are difficult to
re-engage in services once they have had negative experiences with an
unresponsive treatment system.
Societal Risk Factors
Poverty
People with serious mental illnesses are among the most impoverished in our
Nation. The President’s New Freedom Commission (2003) found that: "People with
mental illnesses have one of the lowest employment rates of employment of any
group with disabilities—only about 1 in 3 is employed". Because many are unable
to work full-time, they must rely on public benefit programs, such as SSI. For
many individuals with serious mental illnesses, such benefits provide their only
means of support. As noted previously, people with substance use disorders are
not eligible for SSI based on substance-related disability alone. Many work
episodically, in part to support their addictions.
In 2001, the monthly SSI payment was $531. Even with SSI supplements,
provided by fewer than half the states, SSI recipients remain well below the
Federal poverty level. In addition, though eligible to receive benefits, many
people with serious mental illnesses are not enrolled. They face significant
enrollment barriers, including lack of appropriate documentation and complex
application procedures. These hurdles are particularly difficult for people who
are homeless. The absence of a fixed permanent address makes it difficult to
apply successfully for benefits since information about required appointments or
the status of one’s application often is communicated by mail. Lack of benefits
frequently leads to homelessness and the inability to exit homelessness.
Lack of Affordable Housing
A dearth of appropriate, accessible, and affordable housing is considered by
many to be the number one barrier to residential stability for people with
serious mental illnesses and/or co-occurring substance use disorders. Not one
housing market in the United States exists in which an individual receiving SSI
benefits can afford to rent a modest efficiency or one-bedroom unit. In 2000,
people with disabilities receiving SSI needed to pay, on average, 98 percent of
their SSI benefits to rent a modest, one-bedroom unit at fair market rent, as
determined by the U.S. department of Housing and Urban Development (O’Hara and
Miller, 2001).
Housing Barriers for People with Serious Mental Illnesses
Many people with serious mental illnesses qualify for Federal Housing Choice
(formerly Section 8) vouchers. These subsidies require that people pay only 30
percent of their income for rent and utilities. However, many people are on
waiting lists for years before they receive a subsidy. Also, receipt of a
Housing Choice voucher does not guarantee housing, particularly where affordable
housing is in short supply.
As a result, many people for whom SSI or SSDI are their only source of income
are forced to live in overcrowded or substandard living environments that place
them at physical and emotional risk. Others are living with aging parents or
relatives, many of whom themselves are living on fixed, low incomes. Living
precariously, people with serious mental illnesses are one small crisis—such as
a rise in the cost of their medication—away from becoming homeless. Those who
are doubled-up living with friends or other individuals in similar circumstances
live at the whim of their hosts and may be evicted after a disagreement of even
the most trivial matter.
Further, many mainstream affordable housing providers are reluctant to serve
people with serious mental illnesses, especially those who have been homeless.
That reluctance in part is because of the misperception that people with mental
illnesses need supervision or round-the-clock support, and in part because of
their low incomes and lack of credit history. Until recently, even many mental
health professionals presumed that most people with serious mental illnesses
required supervised, treatment-oriented, group living arrangements to be
successful in their communities. Research, however, provides strong evidence
that people with mental illnesses neither need to nor want to live in such
settings (Carling, 1993).
Housing Barriers for People with Substance Use Disorders
Housing is especially problematic for people with substance use disorders,
particularly for those with co-occurring mental illnesses. Their behaviors place
them at high risk for eviction, arrest, and incarceration. Once homeless, they
are unlikely to succeed in treatment without the availability of safe, sober
housing (Baumohl and Huebner, 1991; Stark, 1987).
Few housing landlords (public or private), mental health agencies, and
nonprofit developers will rent to people who are actively abusing alcohol or
other drugs. Use of illegal drugs may be cause to deny admission or evict a
person from federally assisted housing (Federal Register, 2001). Individuals who
have engaged in drug-related criminal activity must be denied admission
to public housing and most other federally assisted programs (Federal Register,
2001).
Discrimination and Stigma in Housing
Finally, despite statutes such as the Fair Housing Amendments Act,
allegations of housing discrimination based on mental illnesses are common (HHS,
1999). Stigma and discrimination can be overt, such as vocal community
opposition to group living situations, or they can be less obvious, such as
steering public funds away from housing initiatives that serve controversial
populations.
The so-called "not-in-my-back-yard" (NIMBY) syndrome may affect individuals
or it may affect broader public policy that affects people with serious mental
illnesses and substance use disorders in housing and in social and health
services (Federal Task Force on Homelessness and Severe Mental Illness, 1992). "NIMBY-ism" was a significant problem faced by the NIAAA grantees when trying to site housing for people with substance use disorders who were homeless (Conrad et
al., 1993).
Lack of Employment
People who are homeless want and need to work, but few are employed in jobs
that can help them escape homelessness. A recent nationwide survey of homeless
assistance providers and clients found that 44 percent of homeless people were
working, but most were employed in short-term jobs with low pay and no benefits
(Burt et al., 1999). An earlier study revealed that 80 percent of the homeless
population in inner-city Los Angeles was unemployed, but 66 percent of
individuals were looking for work (NIAAA, 1992).
Among people with serious mental illnesses, the unemployment rate hovers at
90 percent (HHS, 1999). Many people with serious mental illnesses are unable to
work consistently, if at all, in part due to active symptoms of these illnesses.
Frequently, they experience interruptions of education and employment. The
low-paying, often menial jobs for which they qualify do not pay a living wage
and usually do not include health care benefits, which leaves them vulnerable to
becoming and remaining homeless. Further, many people who receive Federal income
and entitlements are reluctant to seek employment because they fear the loss of
benefits, including much-needed health insurance.
People with substance use disorders often exhibit problem behaviors that
interfere with job success. In the previously cited Los Angeles study, homeless
people with alcohol disorders were more likely than those without alcohol or
other disorders to report not working at all in the past year, to have worked
fewer months at a greater number of jobs, and to have experienced a longer time
period since their most recent job. However, they tended to be more successful
in recent job experiences than homeless individuals with mental illnesses (NIAAA,
1992).
Discrimination and Stigma Associated with Disabilities and Disadvantages
Statutes such as the Americans with Disabilities Act and the Fair Housing
Amendments Act spell out the rights of people with disabilities and the
penalties for discriminating against them. Still, discrimination and stigma
associated with mental illness, co-occurring substance use disorder, and
homelessness often are major impediments to accessing housing and services (SAMHSA
and HRSA, 2002c).
For instance, people with substance use disorders may be "ostracized,
discriminated against, and deprived of basic human rights. Their families,
treatment providers, and even researchers may face comparable stigmas and
attitudes" (CSAT, 2002).
Further, despite the fact that public understanding of mental illnesses has
grown since the 1950s, stigma and fear have increased. In a 1996 survey, the
public’s perception of mental illnesses was frequently associated with the fear
of violence (HHS, 1999). Selective media reporting may reinforce negative
stereotypes linking mental illnesses and violence, though studies have shown
that the absolute risk of violence posed by persons with mental illnesses is
small (HHS, 1999; Mulvey, 1994).
Complicating the issue, providers of mental health, substance use, and other
social services may have negative attitudes toward serving people who are
homeless. Discrimination by landlords and other housing and service providers,
in turn, may lead to fear and mistrust on the part of individuals, causing them
not to seek the housing and supports they need (SAMHSA, 2002a).
Guiding Principles for a System of Care
Providers of services to people with serious mental illnesses and/or
co-occurring substance use disorders and people who are homeless face a daunting
challenge to address their clients’ multiple, complex needs. But they cannot
design programs for their clients; they must create them with
their clients. Services for people with serious mental illnesses or co-occurring
disorders who are homeless must be built on a foundation of core values that
both put people first and support recovery from multiple conditions. The
next chapter outlines a set of underlying principles to guide development of a
comprehensive system of care for people with serious mental illnesses and/or
co-occurring disorders who are homeless.
[1] For the purpose of the Blueprint, "serious mental
illness" refers to having one or more of the following: diagnosed mental
illness, diagnosable mental illness, condition attributable to a mental illness
or co-occurring health conditions that include mental illness. The disorder is
associated with significant limitations in the performance of one or more major
life activities, including but not limited to the following: basic activities of
daily life (e.g., bathing, eating, care for health condition), instrumental
activities of daily life (e.g., domestic activities or managing money),
interpersonal relations (e.g., regulating aggressive behavior), or school or
work. The disorder has endured or can be expected to endure continuously or with
major episodes for at least one year.
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