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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Category: General | Guest Entry

Voices from the Field Blog: How’s Nashville Campaign Celebrates First Year’s Accomplishments

by Darby Penney
July 23, 2014

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Homeless and Housing Resource Network contributing writer Darby Penney charts the work that has led up to the inauguration of the How’s Nashville campaign to end chronic homelessness by reaching out to diverse stakeholders and building a sense of common purpose across service systems.

How’s Nashville, a broad-based community initiative to end chronic homelessness, successfully housed and supported 545 formerly homeless individuals in its first year of operation, according to Steven Samra, a member of the city’s Metropolitan Homelessness Commission, which started the campaign in June 2013. Almost 200 people were housed during the first 100 days.

How’s Nashville exceeded expectations by bringing together community partners from diverse sectors—including real estate developers, landlords, mental health and substance abuse service providers, anti-poverty organizations, health care agencies, veterans organizations, educators, and various government agencies—to identify the city’s most vulnerable homeless citizens and meet their needs for housing and wraparound supports.

Working in collaboration with the national 100,000 Homes Campaign, How’s Nashville was kicked off with a three-day effort, called Registry Week, in which teams of staff and volunteers surveyed Nashville’s homeless residents using the Vulnerability Index Service Prioritization Decision Assistance Tool (VI-SPDAT). This instrument grew out of research conducted by Dr. Jim O'Connell for Boston's Healthcare for the Homeless organization, which determined specific health conditions that led to the premature death of homeless persons. The survey reached 469 people in Nashville, of whom 222, or 47%, were identified as vulnerable or at risk of premature death on the streets.

Based on the survey results, a by-name list of those in highest need was compiled, and those individuals were given priority for immediate services using a Housing First approach. This was supplemented by providing the newly housed people with Critical Time Intervention (CTI) through a contract with Centerstone, a major local behavioral health care provider. CTI is a time-limited model of case management that provides the most intensive services during the first three months a person is housed, when people’s adjustment to their new living arrangements is most acute; interactions are scaled back as people become accustomed to their new living situations.

Samra notes that How’s Nashville’s first-year success stands in sharp contrast to an earlier local effort in 2009, which was not successful due to lack of community readiness and organizational collaborations. In one case, 27 residents of a large homeless encampment were successfully housed, and all of them lost their housing within the first year. “Where we failed in 2009 was that we did not have strong community readiness, and resources were not well-aligned to provide the wraparound services people needed,” he said. “We hadn’t raised enough awareness in the community, and services were very siloed.”

By contrast, the work leading up to the inauguration of the How’s Nashville campaign focused on developing a strong team of local leaders who had not necessarily worked together in the past, educating them about the tools and resources needed to make a concerted effort to end homelessness, and building a sense of mission and shared values among the community partners. In addition, there was a grassroots fundraising campaign that quickly raised $75,000 to help with expenses that were not covered by various government funds, which brought more positive media attention to How’s Nashville.

Other important contributions to the success of the campaign included development of a Memorandum of Understanding (MOU) with the city’s Metropolitan Development and Housing Agency to set aside a percentage of HUD Section 8 housing vouchers for people on How’s Nashville’s priority list. In addition, a major local developer was recruited as a campaign partner, and he reached out to other developers, who agreed to donate 1% of new rental units to the campaign.

How’s Nashville succeeded in mobilizing community resources to house people at the rate of 45 per month during its first year, almost tripling the rate from the previous year. Some of those housed in the past year were people who were back on the street after the earlier efforts in 2009. What made this possible? Steven Samra believes that the Metropolitan Homelessness Commission’s ability to reach out to diverse stakeholders and build a sense of common purpose was a vital ingredient. “For the first time in Nashville, this campaign really brought people and agencies together across service systems,” he said. “The energy has been catching!”

What needs still exist? As How’s Nashville continues to move forward in its efforts toward ending homelessness, Samra would like to see the development of peer support services provided by formerly homeless people. “We need to put more emphasis on the intersection between homelessness, recovery, and peer support,” he said.

More information on the How’s Nashville campaign is available at: http://howsnashville.org/

References
Herman, D. B., & Mandiberg, J. M. (2010). Critical time intervention: Model description and implications for the significance of timing in social work interventions. Research on Social Work Practice, 20(5), 502-508.

Juneau Economic Development Council. (2009). Vulnerability Index: Prioritizing the street homeless population by mortality risk. Retreived from http://www.jedc.org/forms/Vulnerability%20Index.pdf

Kanis, R., McCannon, J., Craig, C., & Mergl, K. A. (2012). An end to chronic homelessness: An introduction to the 100,000 Homes Campaign. Journal of Health Care for the Poor and Underserved, 23(1), 321-326.

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

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Nashville Changes Strategy to End Homelessness

by Steven Samra
August 06, 2013

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In 2005 Nashville joined many other cities in the development and implementation of a 10-year plan to end homelessness. Unfortunately, despite the best intentions, Nashville has, like many American cities, struggled to accomplish the goal. A cadre of obstacles and barriers, including, but certainly not limited to scarce resources, reliance on “readiness” as a precursor to obtaining housing, a closed Homeless Management Information System, lack of affordable units and housing vouchers, all contributed to the challenge of procuring housing.  A lack of coordination among area behavioral health providers exacerbated these challenges, and frustration and hopelessness were increasing within the homeless community with each passing year.  

Thanks to the efforts of a new Executive Director at the Nashville Metropolitan Homelessness Commission and a committed team of Commissioners, partners, and volunteers, a partnership with the 100,000 Homes Campaign, and a collaboration of several local providers and faith-based organizations, the situation appears to be changing for the better.  

On May 29-31, 2013, twenty teams comprised of over 100 community volunteers canvassed the streets and campsites of Nashville, Tennessee, using the Vulnerability Index to survey and create a priority list of individuals experiencing street homelessness who are most at risk of premature death if they remain homeless. The Vulnerability Index, created by Dr. Jim O’Connell, President of the Boston Healthcare for the Homeless program, identifies those who have been homeless the longest and are the most vulnerable. In addition to gathering the names, pictures, and dates of birth of individuals sleeping on the streets, the teams also captured data on their health status, institutional history (jail, prison, hospital, and military), length of homelessness, patterns of shelter use, and their previous housing histories.

A heavily attended community meeting was held on June 4, 2013, to discuss the results of the survey and kick off the start of a new campaign, “How’s Nashville”. The immediate goal of the campaign is to house 200 of the most vulnerable and chronically homeless into housing within 100 days. Once this is completed, How’s Nashville will continue the effort to house the city’s most vulnerable members with the ultimate goal of ending homelessness within the city by 2015.  Although using a Housing First approach is often more cost effective than alternate methods, and certainly more so than managing homelessness on the street, there are still costs associated with providing housing to those experiencing homelessness.  

Community members rose to the financial challenge associated with the campaign, donating $36,000 during the June meeting to help defray move-in costs associated with the transition from street to home.  Outreach workers began immediately moving individuals identified as high priority into housing at the end of the meeting, and invited attendees to walk with them to a welcome home celebration. Through the city’s efforts, one individual was identified as “most vulnerable” and was moved into housing after more than 7 years of life on the street.

The campaign is off to a strong start with 43 people successfully housed and supported during the month of June.  Conversely, from January to May 2013, just 19 people experiencing homelessness were placed into housing.  uly is also off to a solid start and should meet or exceed the minimum number of placements needed to meet the final housing goal of 200 people housed within 100 days.  

Nashville’s homeless population may finally have reason for optimism instead of pessimism.  There will continue to be challenges associated with scarce resources and the city’s approach is far from perfect.  Clearly however, Nashville has turned a corner and embraced a new approach that is proven to dramatically reduce homelessness.  With the momentum of the How’s Nashville campaign firmly pushing the effort forward, for the first time in many years, Nashville is housing those experiencing homelessness in a systematic, logical, and coordinated manner. The future appears brighter for the city’s most vulnerable residents than it has been for a very long time.

Interested in being a HRC Guest Blogger? Email us at generalinquiry@center4si.com.

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Category: General | Guest Entry