A DIFFERENT APPROACH TO HOMELESSNESS IN AMERICA

REDUCING HOMELESSNESS THROUGH MENTAL HEALTH AND SUBSTANCE ABUSE SUPPORTIVE SERVICES

EXECUTIVE SUMMARY

The US has been facing a homelessness crisis in the past two decades. While Federal and State programs have been successful at providing sheltered housing to 61% of the homeless population (U.S. Department of Housing and Urban Development, 2021), existing policies have been inadequate in responding to the prevailing physical and mental health problems that have caused and/or are a result of being in the state of homelessness. Federal and State policymakers, Not for Profit organizations for the homeless and volunteer groups must come together to provide supportive services and mental illness and substance abuse interventions nationwide. This approach when combined with the provision of long-term housing for the homeless can help in significantly reducing the homelessness crisis and prevent individuals from becoming homeless again in the future. Existing policy structures will have to be reevaluated and changed to merge existing intervention programs with housing programs without the need for increased budget allocations and funding.

INTRODUCTION

Homelessness in America has been increasing since 2015. This increase can be attributed to a rise in unsheltered homeless individuals by 30% during the period 2015–2020 (National Alliance to End Homelessness, 2021). Providing evidence for an upcoming homelessness crisis in America. The situation can get particularly grim in cities with high density that already house a large portion of the homeless population. The Biden administration has responded to this increase by implementing the Housing First package that prioritizes the provision of sheltered housing above everything else. While this is a steady and fast way to combat homelessness in the short term, few nationwide measures have been taken to focus on reducing the length of stay in shelters and the severity of being in the state of homelessness.

The federal and state governments can focus on long term policies that aim to reduce the causes of homelessness and prevent high risk individuals who have been without a home before from falling into homelessness again. In the absence of long-term intervention, homelessness in America will continue to see fluctuation in homeless rates over the years while witnessing a steady increase in national homelessness rates. The focus of this policy brief will be on two such causes and/or consequences of homelessness — substance abuse and mental illness.

Substance abuse and mental illness is prevalent among those with chronic homelessness. In 2020, chronic homelessness in America increased by 15% from the previous year (U.S. Department of Housing and Urban Development, 2021). As per the National Coalition for the homeless, 38% of chronically homeless individuals rely on alcohol while 26% abuse some form of addictive substance (2021). From data collected as part of the Annual Homelessness Assessment Report (AHAR), it was found that more than half of homeless individuals living in permanent supportive housing experienced some form of mental illness that often coincided with addiction (SAMSHA ADVISORY, 2021, pg. 1). The dependance on addictive substances is a result of living in challenging conditions every day that involve lack of access to long term housing and nutrition, physical disabilities and mental illnesses like post-traumatic stress disorder, schizophrenia, anxiety, bipolar disorder, etc., that may have been a cause and/or consequences of being homeless. Eventually, homeless individuals get trapped into an endless cycle of homelessness, drug abuse and mental illness whereby one condition prevents them from overcoming another.

The existing policies at the state and federal level, enacted as part of SAMSHA programs, target different aspects of homelessness in isolation while overlooking the ways in which lack of affordable housing, mental health, substance abuse and other health problems intersect. Different programs like projects for Assistance in Transition from Homelessness (PATH), Cooperative Agreements to Benefit Homeless Individuals (CABHI) and SSI/SSDI Outreach, Access, and Recovery (SOAR) aid in finding housing and increasing access to social security benefits. Only one program, Treatment for Individuals experiencing homelessness (TIEH), directly addresses mental health and substance abuse disorders among the homeless. These different programs fail to combine sheltered housing with supportive services like mental health assistance, controlled drug use facilities and community support groups. Instead of accessing these intervention techniques through different programs, existing polices need to be modified to include comprehensive housing options that provide resources and support beyond just shelter. Doing so will not only help decrease administrative and budgetary costs but also enable existing programs to reach a wider target homeless population and reduce instability for those experiencing homelessness by decreasing their enrollment in multiple programs.

PROPOSED POLICY OPTIONS

NATIONWIDE APPLICATION OF SUPPORTIVE HOUSING

580, 466 people were experiencing homelessness in America as of January 2020, 66% of which are chronically homeless without any shelter at all (National Alliance to End Homelessness, 2021, pg. 12). They live in make-shift tents on sidewalks or in places that are uninhabitable. These are high risk populations as they are more prone to severe diseases like lung diseases, malnutrition, substance abuse, mental health problems and skin infections. This risk is even higher in high density cities located in California, Florida, New York, Texas and Washington where 45% of the national estimated homeless population resides (Rehab Spot, 2021). Of these states, New York and California have committed to using supportive housing to reduce unsheltered homelessness and eventually help individuals overcome homelessness. The nationwide application of supportive housing options and an increase in the number of housing units available under supportive housing can help in significantly reducing homelessness in America.

Supportive housing is more successful than regular homeless shelters as it not just provides the homeless population with minimum shelter needs but also equips them with resources to combat the conditions that have caused or increased their susceptibility to homelessness. This type of housing provides affordable housing options along with support services for those with a physical disability, mental health problems and addiction. Trained, licensed professionals review each case and provide the necessary services as per need along with educating the tenants with general life skills, parenting, crises management and job search. Launched in 2016, The NYC 15/15 agreement in New York that provided 6000 supportive housing units has been extraordinary in reducing homelessness in New York by 47% in its first five years providing more than 86% of tenants with housing stability for more than a year (Coalition For the Homeless). Thus, supportive housing is a cost-effective tool for reducing homelessness compared to the simple creation of affordable housing units every year to accommodate the increasing homeless population in metropolitan cities.

While converting homeless shelters into supportive housing can pose a budgetary challenge for cities like Los Angeles, San Francisco, New York, etc., cities in states like Mississippi, West Virginia, Wyoming, Arkansas and New Mexico that have the lowest homeless shelter occupancy rates (The U.S. Department of Housing and Urban Development, 2021, pg. 12) can modify their existing homeless shelters to include supportive services and aid in reducing national homelessness rates. On the other hand, cities like Los Angeles, have contractual agreements with sponsoring agencies to provide for permanent housing and supportive housing services separately. Instead, both services can be provided at the same time if city councils enter into joint contractual agreements. Doing so may even help reduce general and administrative costs by requiring fewer offices and human resources.

BEHAVIORAL THERAPY-BASED TREATMENT PROGRAMS FOR ADDICTION AND MENTAL ILLNESS

Treatment programs aimed at reducing addiction among homeless populations have largely been focused on avoidance of drugs and/ or addictive substances. The largest treatment program for mental health and drug abuse and/or those without a home is the SAMHSA TIEH program. While this federal program has exceeded its targets in terms of targeting the appropriate populations and then administering habilitation and rehabilitation, mental health services and substance abuse treatments, the program itself fails to provide accessible treatment and intervention for drug abuse and mental illnesses. The strategic plan of SAMSHA for financial year 2019–2023 heavily focuses on utilizing educational programs on pain management, crisis management and educational workshops on the harmful impacts of various drugs. To reduce mental illness among homeless populations, SAMSHA relies upon trained professionals and healthcare providers to provide treatment and harm reduction strategies. However, the program falls short on addressing the causes of mental illness and drug abuse and helping homeless individuals understand their problems through psychological therapy interventions. Since most of SAMSHA programs refer homeless individuals to healthcare providers and treatment centers, the structure of their programs poses the challenge of obtaining and paying for medical insurance. Even with medical insurance, there may be differences between SAMHSA healthcare providers and in-network providers accepted by different insurance carriers.

To move past the roadblocks in treatment created by educational programs and access to health insurance, permanent and temporary housing shelters should administer behavior and cognitive therapy services to those battling mental illness and substance abuse. In a study published in Nursing Research, researchers found that Dialectical Behavioral Therapy Based Management (DBT-CM) resulted in 65.5% of the sample size of incarcerated homeless women staying abstinent for drug use while only 48.3% of women who were subjected to Health Promotion (HP) programs remained abstinent from drugs (Nyamathi et al., 2017).The health promotion programs are much like the educational programs used by SAMSHA as a means of informing homeless populations of the nature and consequences of addiction and mental illness. While they are informational, combining educational workshops with behavioral therapy can help increase rates of drug abstinence and improve mental illness of homeless individuals. The provision of behavioral therapy based mental health services on a case-by-case basis can prove to be more effective at preventing relapse and increasing stability among the homeless in permanent and temporary shelters. SAMSHA can make contractual agreements with behavioral therapy centers to provide such services and eradicate the need for health insurance. This may require additional budget from the federal government as the existing healthcare services are provided through referrals and not directly sponsored by SAMSHA.

PREVENTING RELAPSE THROUGH CONTROLLED DRUG USE AND FORMATION OF COMMUNITY SUPPORT GROUPS

To tackle the problem of drug addiction and mental illness among the homeless, it is important for policymakers to have an all-rounded approach to addiction and mental health problems. Recovery for such individuals is a never-ending process. Addiction to substances and mental health relapse can happen anytime during a recovered homeless individual’s life and increase their likelihood of becoming homeless again. More so, recovery doesn’t necessarily mean complete abstinence from the use of substances. For some individuals, controlled use of substances can prevent them from falling into severe addiction while still enabling them to lead a healthy life.

Research published by the National Center of Biotechnology Institute (NCBI) in 2020 found that homeless individuals with drug abuse and addiction who were admitted into supervised consumption facilities and managed alcohol programs engaged in less risky behavior, self-harm and drug overdoses (Magwood et al., 2020). Pharmacological intervention was combined with the above programs to help reduce the side effects of drug use. Such drug abuse and harm reduction strategies can prove to be extremely successful in homeless individuals with multiple health problems along with severe mental health problems like post-traumatic stress disorder (PTSD). Administering care for physical and mental health problems all at once can be overwhelming for a homeless person. Using controlled drug intervention techniques can help bring stability into a homeless individual’s life and provide a sense of normalcy and control while at the same time increasing their trust in the healthcare system. Homeless individuals with extreme drug abuse and mental illness will first need to be identified and then admitted into controlled and supervised drug and alcohol programs instead of being admitted into rehabilitation centers. By not subjecting them to complete abstinence, the probability of relapse in the future can be reduced.

Identification of different homeless groups with varying degrees of addiction and mental illness is also important to form community and support groups. Since homeless individuals are put through a governmental process of being moved into transitional, temporary and then permanent housing, the homeless individuals lose community ties with one another thereby preventing the formation of a community. The current community support group programs by SAMSHA provide support and community engagement by connecting homeless population in shelters within a specific geographical area. SAMSHA should partner with the many local volunteer services working on ground to form a network within homeless individuals who have been moved around to similar shelters. The formation of a community and an in-group among the homeless population can aid in their recovery and help establish a sense of belonging for them.

POLICY RECOMMENDATIONS SUMMARY AND CONCLUSIONS

· Nationwide application of Supportive housing

It is recommended that long term interventions techniques be combined with the provision of permanent shelters for the homeless to help reduce homelessness at a national level. The existing housing shelter units can be enhanced by providing supportive services that include providing mental health services and administering drug and alcohol abuse treatment procedures on a case-by-case basis. This policy requires an increase in the number of on ground support staff 24/7.

· Behavioral therapy-based treatment programs for addiction and mental illness

The existing mental health services should be extended to include behavioral therapy-based approaches provided by the housing programs without the need for outside referrals to healthcare providers in order to eliminate the need to purchase health insurance.

· Preventing Relapse through controlled drug use and formation of community support groups

Homeless individuals with severe addiction and mental illness can be provided with supervised and controlled drug use facilities along with pharmacological interventions to ensure a more stable recovery process while also allowing them to adjust to normalcy without intoxication. Formation of a network of community support groups can further help the recovery process and foster a community for the homeless population.

The proposed policy options are targeted at long term care and are not expected to provide significant positive results in a short span of time. It is recommended that these policy options be applied to only permanent housing shelters as the services mentioned in these policies require long-term administering and care for those struggling with mental illness and substance abuse. The inclusion of these policies for temporary and traditional housing will increase administrative costs as each case’s progress will require timely documentation and tracking. SAMSHA PATH program and THP need not require additional funds as part of federal budget allocation if existing interventions such as community-based groups, mental illness treatment programs and drug abuse treatment programs are all combined with the management of permanent housing shelters. As mentioned before, doing so will redirect funds to the provision of housing and may even help reduce administrative costs. The existing policies can avoid the need for additional funding by making contractual agreements with healthcare services and volunteer organizations. The proposed policy options can be implemented after researching and recognizing homeless individuals in need for mental health and drug abuse intervention services.

REFERENCES

The U.S. Department of Housing and Urban Development OFFICE OF COMMUNITY PLANNING AND DEVELOPMENT. (2022, February). The 2021 Annual Assessment Report (AHAR) to Congress . HUD Exchange. Retrieved February 15, 2022, from https://www.hudexchange.info/resource/6573/2021-ahar-part-1--pit-estimates-of-homelessness-in-the-us/

Addiction Center . (2021, October 22). Homelessness and addiction. Addiction Center. Retrieved March 3, 2022, from https://www.addictioncenter.com/addiction/homelessness/

National Alliance to End Homelessness. (2021, August 16). State of Homelessness: 2021 edition. National Alliance to End Homelessness. Retrieved March 3, 2022, from https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness-2021/

Rehab Spot. (2021, September 13). Drug abuse, addiction, and homelessness. Rehab Spot. Retrieved March 3, 2022, from https://www.rehabspot.com/drugs/who-addiction-affects/homelessness/

Coalition For The Homeless. (n.d.). How to end homelessness once and for all. Coalition For The Homeless. Retrieved March 3, 2022, from https://www.coalitionforthehomeless.org/supportive-housing-ends-homelessness/

U.S. Department of Health and Human Services . (n.d.). Substance abuse and mental health services strategic plan …SAMHSA . Retrieved March 4, 2022, from https://d9main.test.ocweb-team.com/sites/default/files/samhsa_strategic_plan_fy19-fy23_final-508.pdf

Nyamathi, A. M. , Shin, S. S. , Smeltzer, J. , Salem, B. E. , Yadav, K. , Ekstrand, M. L. , Turner, S. F. & Faucette, M. (2017). Achieving Drug and Alcohol Abstinence Among Recently Incarcerated Homeless Women. Nursing Research, 66 (6), 432–441. doi: 10.1097/NNR.0000000000000249.

Magwood, O., Salvalaggio, G., Beder, M., Kendall, C., Kpade, V., Daghmach, W., Habonimana, G., Marshall, Z., Snyder, E., O’Shea, T., Lennox, R., Hsu, H., Tugwell, P., & Pottie, K. (2020, January 16). The effectiveness of substance use interventions for homeless and vulnerably housed persons: A systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder. NCBI. Retrieved March 3, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6964917/

“Behavioral Health Services for People Who Are Homeless.” SAMSHA ADVISORY, Substance Abuse and Mental Health Services Administration , 2021, https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-06-04-003.pdf