Voices from the Field Blog: Trauma, Men’s Behavioral Health Issues, and Homelessness

by Darby Penney
May 18, 2015

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Homeless and Housing Resource Network contributing writer Darby Penney discusses the behavioral health and trauma concerns of men experiencing homelessness with Steven Samra, Commissioner, Nashville (Tennessee) Metropolitan Homelessness Commission.

“The pressures placed on men in our society to be tough, strong, and macho make it hard for some men to admit that they have mental health problems, maybe even to themselves,” said Steven Samra, Commissioner, Nashville (Tennessee) Metropolitan Homelessness Commission. “Men have been taught to be tight-lipped about emotional matters. The reluctance to speak openly about these issues can be even more pronounced for men experiencing homelessness, because any sign of vulnerability can make a man a target on the street,” Samra added. Though men may feel this attitude is self-protective, it can keep them from seeking help with the very issues that may prolong their homelessness.

Samra, who also serves as an advocate on Tennessee’s Statewide Task Force to End Homelessness, believes that, because men are socialized to steer clear of expressing emotions other than anger, it is often hard for men experiencing homelessness to seriously consider the need for change in their lives. “We need to recognize that men can get complacent with the dysfunctional but familiar life of homelessness,” Samra said. Transition is hard—it requires changing the mindset that says a man should be totally self-sufficient, that he doesn’t need help. It is hard to identify a path out of homelessness when men are in denial about addiction or mental health issues.”


Trauma is widespread among men who experience homelessness, but this topic may also be taboo for many men. Research shows that the vast majority of men experiencing homelessness are trauma survivors. One study found that trauma affected 90 percent of men experiencing homelessness studied (Buhrich, Hodder, & Teesson, 2000), while another reported that 69 percent of men experiencing homelessness with co-occurring disorders studied had experienced a life-altering traumatic event (Christensen et al., 2005). Data also show that trauma is even more common among this population than are mental health problems or substance abuse problems. According to data from the Substance Abuse and Mental Health Services Administration (SAMHSA, 2003), fewer than 4 in 10 individuals experiencing homelessness are dependent on alcohol, and fewer than 3 in 10 abuse other drugs. Between 20 and 50 percent of people experiencing homelessness have a diagnosable serious mental illness (SAMHSA, 2013).

“Violence and victimization are a daily reality to most people experiencing homelessness I see,” according to Barry Zevin, M.D., medical director of San Francisco’s Homeless Outreach Team (Scott, 2015). “Whether that was in childhood at the hands of parents, whether that was in adolescence, or sexual trauma, whether that’s in the streets. It’s just practically universal…The most widely shared problem among people experiencing homelesness is not substance abuse or mental illness—it’s trauma,” Dr. Zevin said.

The pervasiveness of trauma among men experiencing homelessness underscores the importance of bringing trauma-informed approaches to homeless services. While awareness of the impact of trauma has increased among homeless service providers in recent years, much remains to be done to ensure that there is greater uniformity and consistency of trauma-informed services for people experiencing homelessness, according to leaders in the field (Hopper, Bassuk, & Olivet, 2010).

Among the key considerations in implementing trauma-informed service approaches is recognizing that trauma survivors feel safe when they have maximum control over their circumstances and what happens to them. Because men who are experiencing homelessness have control over so few areas of their life, it is important for service providers to use a client-centered approach to avoid “helping” in a top-down manner. The person being served needs to have the final say about decisions that affect his life in order to feel safe and avoid re-traumatization.

“Housing First models make so much sense for men experiencing homelessness who are trauma survivors and/or have behavioral health issues,” said Samra. “People can’t deal with their complex personal struggles while they are just trying to survive. Once a man has a place to live, he is much more likely to be able to feel safe enough to begin a process of examining his life and choosing to make some changes toward his recovery.”

References
Christensen, R. C., Hodgkins, C. C., Garces, L., Estlund, K. L., Miller, M. D., & Touchton, R. (2005). Homeless, mentally ill and addicted: The need for abuse and trauma services. Journal of Health Care for the Poor and Underserved, 16(4), 615–622.

Hopper, E. K., Bassuk, E. L., & Olivet, J. (2010). Shelter from the storm: Trauma-informed care in homelessness services settings. The Open Health Services and Policy Journal, 3(2), 80–100.

Norman, R. E., Byambaa, M., De, R., Butchart, A., Scott, J., & Vos, T. (2012). The long-term health consequences of child physical abuse, emotional abuse, and neglect: A systematic review and meta-analysis. PLoS medicine, 9(11), e1001349.

Scott, C. (2015). More homeless bedeviled by trauma than mental illness, experts say. Healthline News, March 27, 2015. Available at http://www.healthline.com/health-news/more-homeless-bedeviled-by-trauma-than-mental-illness-032715#1

Substance Abuse and Mental Health Services Administration. (2003). Blueprint for change: Ending chronic homelessness for persons with serious mental illnesses and co-occurring substance use disorders. DHHS Pub. No. SMA-04-3870. Rockville, MD: Author.

Substance Abuse and Mental Health Services Administration. (2013). Behavioral health services for people who are homeless. Treatment Improvement Protocol (TIP) Series 55. DHHS Pub. No. SMA-13-4734. Rockville, MD: Author.

Interested in being an HRC Guest Blogger? Email us at HomelessPrograms@samhsa.hhs.gov.

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Voices from the Field Blog: Peer Support for Veterans Involved in the Justice System

by Darby Penney
May 29, 2014

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Homeless and Housing Resource Network contributing writer Darby Penney highlights the work of MISSION DIRECT VET (Maintaining Independence and Sobriety through Systems Integration, Outreach and Networking-Diversion and Recovery for Traumatized Veterans), which is a treatment program that serves veterans with co-occurring mental health and substance abuse issues.

“Shortly after the opening of the pilot site for our Jail Diversion-Trauma Recovery program, we quickly realized that one of the veterans involved in our program was homeless,” said David Goldstein, a team member of MISSION DIRECT VET in Massachusetts. “So the two of us got in the car and drove over to the local veterans’ shelter. We were introduced to the staff, and after the veteran told his story of how PTSD (post-traumatic stress disorder) contributed to his homelessness and his involvement with the courts, he was welcomed with open arms. The warmth present in the room brought me to tears. This was my first, and certainly not my last, experience with a homeless veteran and a welcoming shelter.”

The MISSION DIRECT VET program began with a single pilot site in Worcester, MA in 2009 that has expanded to two other sites in the state. Its goal is to serve veterans with mental health, substance abuse, and other trauma-related issues who are involved with the criminal justice system in order to divert them from jail into trauma-informed services. Originally funded through a five-year SAMHSA grant, the program continues now with state funding.

MISSION-DIRECT VET is a manualized treatment program for people with co-occurring mental health and substance abuse issues. It is the primary treatment service that is offered, and it is supplemented by 12 months of peer support services and case management. Referrals and linkages to vital community-based services such as veterans’ services, vocational and independent living skills programs, family support, and transitional residence programs are also central to the program.

Veterans are over-represented among people experiencing homelessness (e.g., in 2010, veterans accounted for about 10 percent of the total U.S. adult population and 16 percent of the homeless adult population). The good news is that homelessness among veterans has declined by an estimated 25 percent since 2007, according to the U.S. Department of Housing and Urban Development’s 2013 Annual Homeless Assessment Report. 

The National Alliance to End Homelessness reports that homeless veterans include service members from every era since World War II. While Vietnam-era veterans are at greater risk of homelessness than those from other eras, veterans of recent conflicts are more likely to be more gravely disabled. One recent study found two-thirds of homeless Iraq and Afghanistan veterans were diagnosed with PTSD, a rate far higher than earlier generations of veterans (Tsai et al., 2013).

This is where programs that offer a strong peer support component can be especially helpful. MISSION-DIRECT VET team member David Goldstein is a Vietnam veteran, a trauma survivor, and person in recovery. He provides the veterans who participate in the program with one-on-one peer mentoring, facilitates veterans support groups, and connects veterans to resources in the community. Perhaps most importantly, he listens, sits with people who are in trouble, and offers a non-judgmental perspective of someone who has been through many of the same experiences as the people he serves.

While Goldstein has seen the success stories of many of the veterans who have been through the program, he cautions that there are still areas for improvement. “Veterans who go into homeless shelters are often there, directly or indirectly, because of substance abuse issues with drugs and/or alcohol that are often related to PTSD. Because of the rules of the shelters subsidized by the VA (Veterans Administration), they may be asked to leave due to abusing the very substances that got them there to begin with. To keep these veterans from falling back into homelessness, the protocols for these shelters must change,” he said.

References
Henry, M., Cortes, A., & Morris, S. (2013). The 2013 Annual Homeless Assessment Report (AHAR) to Congress. Washington, DC: The U.S. Department of Housing and Urban Development, Office of Community Planning and Development.

National Alliance to End Homelessness. (n.d.). Veterans. Washington, DC: National Alliance to End Homelessness. [Website article]. Retrieved from http://www.endhomelessness.org/pages/veterans

National Center for Veterans Analysis and Statistics. (2012). Profile of Sheltered Homeless Veterans for Fiscal Years 2009 and 2010.  Washington, DC: The U.S. Department of Veterans Affairs.Retrieved from http://www.va.gov/vetdata/docs/SpecialReports/Homeless_Veterans_2009-2010.pdf

Tsai, J., Pietrzak, R. H., & Rosenheck, R. A. (2013). Homeless veterans who served in Iraq and Afghanistan: Gender differences, combat exposure, and comparisons with previous cohorts of homeless veterans. Administration and Policy in Mental Health and Mental Health Services Research, 40(5), 400-405.

Interested in being an HRC Guest Blogger? E-mail us at HomelessPrograms@samhsa.hhs.gov.

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Category: General | Guest Entry