Voices from the Field Blog: Matching Housing Options to People’s Stages of Change

by Darby Penney
December 31, 2015

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Homeless and Housing writer Darby Penney interviewed Dr. Ken Minkoff, a leading national expert on integrated treatment of individuals with co-occurring psychiatric and substance use disorders, on the range of housing options that need to be available to help people who have experienced homelessness find housing that reflects their self-identified preferences at the stage they are in in their lives.

In order to successfully house people who are experiencing homelessness and have substance use disorders, a “one-size-fits-all approach” must give way to “person-centered, trauma-informed, recovery-oriented, and integrated approaches,” said Ken Minkoff, M.D., Assistant Professor at Harvard, a Senior Systems Consultant for ZiaPartners in San Rafael, CA (www.ziapartners.com), and a leading national expert on integrated treatment of individuals with co-occurring psychiatric and substance use disorders.

“People [experiencing homelessness] commonly have a whole array of co-occurring mental health conditions and substance use disorders; one or more of their mental health or substance use conditions may be significantly out of control, and one of these conditions may be a more significant problem for them than the other. People may also have serious physical health conditions and disabilities, including cognitive issues as a result of substance use or traumatic brain injury, as well as developmental disorders. They may be responsible for children, they may be survivors of domestic violence, and there is a high prevalence of trauma,” he said. “So individuals have different preferences about what their most important goals are at a particular moment, which includes their desired living situations, the kinds of services they want, and how important housing is on their list of needs.”

Dr. Minkoff believes that communities must, therefore, make a range of housing options available so that people experiencing homelessness who also have substance use conditions can choose the type of housing that best fits their vision for a happy life, their preferences about what is their most important next step for help (e.g., housing, employment, medical care, mental health care, or substance use treatment), and their current “stage of change” for each issue in their recovery.

Stage of change is issue specific, not person specific, and best practice interventions, including housing, need to be “stage-matched,” according to Dr. Minkoff. “We need to be respectful of people’s choices,” he said. “We must get much better at acknowledging that people need to have meaningful choices that offer them the kind of support they currently want. For people with substance use conditions, one approach to stage-matched (for substance use) housing is to think of housing options in terms of whether they are ‘wet,’ ‘dry,’ or ‘damp.’ This is not about whether we will ‘let’ you drink or drug—it means that we reach out to you where you are, provide housing that matches where you are in your approach to using substances, and then help you get where you want to go by being successful in that housing,” he said.

“Dry” housing refers to housing—usually group housing—where abstinence from alcohol and drugs is an expectation. “When we invite someone to live in dry housing, we [should not] demand that people follow an inflexible rule in order to keep their housing, because [it may be] the only housing option they are offered,” Dr. Minkoff explained. Ideally, people living in dry housing will have “a genuine desire to live in a setting where everyone will be abstinent … People with substance use issues who choose this housing are usually in a ‘late action’ or ‘maintenance’ stage of change regarding their substance use. They are committed to sobriety.”

Minkoff said that, in dry housing, there should never be a “one-strike, you’re out” policy. “If and when people slip, it is taken seriously, and people in the house wrap around the person with helpfulness. They ask, ‘How can we help you achieve your goal of sobriety?’ But if people revert to using and no longer want to be sober, then we help them find a living situation that fits them better at this point in their life,” he said. “Knowing how to work with people properly is so important,” he said. “You have to be non-punitive and respectful; you need to have the right attitude. There is a big need throughout the entire system to shift to this way of thinking and working with people.”

“Wet” housing refers to housing in which people may drink or use substances in the privacy of their home, unless this leads to behavior that will cause them to lose their housing. Most of us live in “wet housing,” Dr. Minkoff observed. The scattered site housing first approach used by Pathways to Housing (https://pathwaystohousing.org/) and the supportive housing developed in Seattle by DESC (http://www.desc.org/) are two examples. Wet housing is often an apartment in which a person lives independently, with wraparound support focused on maintaining housing.

“You must be very purposeful about developing wet housing,” Minkoff cautioned. “You need to build relationships with people based on where they are currently and help them move from a ‘pre-contemplative’ stage of change regarding their substance use to a ‘contemplative’ stage, in which they are open to discussing their substance use with housing support staff, even though they may not want to change. We need to understand that it is the person’s life and they get to make their own choices. We can help them learn skills that will enable them to keep their housing if they agree to let us help them. So, for example, people don’t need to be sober or take psychiatric medications to stay in wet housing, but what they can’t do is urinate in the hallway. So we talk to them about that, or about the fact that they can’t invite dealers into the building and keep their housing, not whether they drink or drug.” If wet housing is done right, Minkoff noted, people’s drug and alcohol use usually goes down and their mental health improves, because they are in safe housing and have supportive relationships with staff.

“Damp” housing is a variation of the Housing First concept, according to Minkoff, in which people are choosing to live in a group setting because they want social support, but they are not yet interested in being abstinent. The focus is on helping the person be successful in this housing environment, as well as being a successful member of the community. In damp housing, each person has his or her own space, but there are also common areas, shared activities, and a sense of community. It does not come with expectations of sobriety, like dry housing, but offers additional layers of support and expectations, compared to wet housing. Minkoff explained, “The most important message in damp housing is: ‘Although we recommend that you don’t use, it is your decision. However, if you are going to use, the most important requirement is that you are able to talk to us about it and share your experiences with the community, so we can all pull together to help you figure out the right amount of use that will allow you to be successful in this program.’”

“The approach is to let people know we are there for them if they want to come in off the street, and that we realize this can be hard. We welcome people into our community and let them know our job is to help them be successful here. It is their choice whether or not they accept mental health or substance use services. While there aren’t expectations of sobriety, it is expected that any substance use is done in a way that doesn’t hurt the community. And the program must be designed without hidden expectations of sobriety, despite rules to the contrary. That just sets people up to fail,” Minkoff said. “It is important that the expectations in damp housing are transparent to everyone.”

To be responsive to people who are experiencing homelessness and who have substance use conditions, we need to build programs and housing resources that are respectful of people’s choices and reflect their self-identified preferences at the stage they are in in their lives, Minkoff believes. “Unless we understand that different people want different things from their housing, including how they choose to approach using substances, and unless we realize that we are talking about a continuum of housing to match those choices, we will fail people in the housing we provide, as well as waste resources trying to force people into mismatched housing programs,” he said.

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

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Voices from the Field Blog: Maintaining Balance

by Kim Noerager
October 21, 2015

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Housing and Homelessness contributing writer Kim Noerager is an associate at the Center for Social Innovation. Kim has been clean and sober for over 13 years and discovered that staying balanced in all aspects of life is essential to maintaining sobriety. As a result, she has spent a great deal of time refining and identifying her own self-care needs and how to put them into practice.

Self-care is a term that is tossed around easily these days. It seems like, every time I turn around, someone is talking about self-care. It sounds so great. Of course we want to practice self-care.

But what does it really mean? There are the obvious things: eat enough, get enough sleep, get enough exercise, and maintain a work-life balance. Those things seem like no-brainers, until you go to put them into practice. After all, there are only 24 hours in a day. By most conventional wisdom, you should get 8 hours of sleep a night, so that leaves 16 hours. Another 8 hours minimum is spent at work. Another 2 to 3 hours are spent getting ready for work and commuting. So now you’re down to 5 hours. If you get an hour of exercise and spend an hour cooking and eating dinner, you have 3 hours left in the day. Only 3 hours left to run errands, take your kids to their various events, read a book, watch TV, or work those extra hours you need to finish up a project. What about pursuing your passions? Going for long runs or bike rides, painting, photography, dancing, playing or listening to music, gardening, playing games, hiking in the woods, or whatever other things might be your passion?

No wonder it is such a buzzword! No wonder everyone is talking about it! How DO you get it all done?

The real answer is you can’t. Not all of it, not every day. But you can prioritize. You can determine what’s important and do it. You can ask for a flexible work schedule, which can buy you those 2 to 3 hours of getting ready and commuting back. You can work out ride-sharing plans for your children’s activities, and that saves everyone some time. You can cook a few meals at once and have them ready to heat. You can practice saying, “No.” That’s often a very, very hard one, but it’s essential.

For me, most important of all, is finding time to pursue your passions. Thank goodness for the extra hours the weekend buys us all, because that’s the saving grace. Those are the hours to pursue whatever activity feeds your soul. And when your soul is at peace, it’s so much easier to find the rest of the balance.

One of my passions is listening to live music. Something about it just soothes me, even though some would say that the music I listen to wouldn’t necessarily be classified as soothing. Those guitar chords, those keyboard runs, that bass boom, the beat of the drums—those things strike a resonant chord inside me. It takes away all of my troubles, at least for that time.

I know folks who feel similarly about other passions. One of my best friends is barely human unless he gets in at least a 10-mile run every day. Another friend needs time at the beach. Being at or in the water is what speaks to her. Yet another friend can lose herself for hours in painting. It doesn’t matter at all if what she paints is good; it’s the act of painting that’s important.

When we make time for our passions, for the things that make us whole, the rest of it falls into place. When we neglect those things, everything else is a much greater struggle. So, to me, when I talk about self-care, that’s what I mean. I’m talking about feeding my soul. Of course, I still have to take care to avoid Hungry, Angry, Lonely, or Tired (HALT). But I find that being attentive to the spiritual side of life eliminates most of the Lonely or Angry pieces. It also puts me in the right place mentally and spiritually to be able to set and keep the boundaries around work or social obligations, so that I still have time for food, sleep, exercise, and fun. I don’t succeed all the time, not by a long shot. But it gets easier with practice and with knowing yourself. And when I achieve the right balance—ah! There is the place of self-care, and of feeling like I’m exactly where I’m supposed to be.

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

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Voices from the Field Blog: Taking Action on Opioid Addiction

by Kay Peavey
September 16, 2015

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Homeless and Housing Resource Network Contributing Writer Kay S. Peavey explores the surge in opioid use–both prescription painkillers and heroin–and how public officials and community-based programs are responding to the epidemic.

Record numbers of drug overdose deaths have been reported with increasing alarm by the media over the last several years. Fervor is now shifting to the “magic-bullet antidote” that seemingly brings users in the midst of overdosing back to life. Far from media hype, this crisis has been building for years and has fueled demand from caregivers, community-based programs, and public officials for access to proven-effective help.

The Centers for Disease Control and Prevention (CDC) reports that one hundred people die from drug overdose every day in the United Statesi. Deaths from unintentional overdoses of over-prescribed pain relievers alone have quadrupled in the last 15 yearsii. When individuals no longer have access to highly addictive opioids such as hydrocodone and oxycodone, they may turn to heroin, which is less expensive and easier to obtain. In a 2013 study, drug overdose was identified as the leading cause of death among adults who experienced homelessness. More than 80 percent of those deaths involved opioids, either painkillers or heroin.

Responding to this study, the Director of the National Institute on Drug Abuse encouraged increasing the availability of treatments such as buprenorphine. This medication was approved by the Food and Drug Administration (FDA) in 2002 for treatment of opioid addiction. In layman’s terms, buprenorphine is a semi-synthetic opioid that activates receptors (part of the system that sends chemical signals throughout the brain) to some degree, but blocks other opioids, such as heroin or oxycodone. (For a detailed illustration of how buprenorphine works, click here.)

Buprenorphine is one of a few medications used in what is commonly known as opioid replacement therapy, but more accurately referred to as opioid agonist medication-assisted treatment (OA-MAT). Other medications approved for use in OA-MAT include methadone and naltrexone. Despite demonstrated effectiveness, OA-MAT has been traditionally difficult to secure. Until passage of the Drug Addiction Treatment Act (DATA) of 2000, buprenorphine and methadone were dispensed only within the context of a federally licensed Opioid Treatment Program (OTP), mostly located in large cities. DATA 2000 allowed qualified physicians to treat opioid addiction outside of an OTPiii.

This change in treatment provision increased potential OA-MAT treatment capacity, but according to a study published earlier this year, that capacity still falls short of treatment need. In their findings, researchers from the FDA, the CDC, and the Substance Abuse and Mental Health Services Administration (SAMHSA), estimate a gap between treatment need and capacity of up to 1.4 million people. They note, “. . . far more patients are in need of treatment than can currently access it.” 

Recent events suggest that additional help for people struggling with opioids, particularly those at risk for overdosing, is on its way. Last year, the FDA approved a hand-held auto-injector (sold as “Evzio”) that can be used by family members and other caregivers to administer naloxone. Recognized more easily by its brand name Narcan, this medication has been used for over 40 years by first responders and hospital staff to counteract opioid overdose. It does this by replacing other opioids that that may be bound to the receptor and blocking others from binding. When administered in a timely fashion, it reverses the respiratory depression, sedation, and hypotension brought on by the opioidiv. In other words, it allows individuals who have overdosed to breathe normally, to “wake up.”

Many leading health organizations have endorsed the use of naloxone. SAMHSA issued an Opioid Overdose Prevention Toolkit, which includes ensuring “ready access to naloxone” as a strategy for preventing overdose deaths. The American Medical Association, American Public Health Association, the United Nations Office on Drugs and Crime, and World Health Organization all support the availability of naloxone to caregivers and families.

The call for access to naloxone by laypersons is growing, and the Massachusetts Department of Public Health has been quick to respond.  It piloted the Opioid Overdose Prevention and Reversal Project, which trains people who use opioids, their families, and their friends on preventing and recognizing an opioid overdose.  To respond to an overdose, participants learn about calling 9-1-1, performing rescue breathing, and administering naloxone via nasal spray.

Many other communities are following suit. At least 40 states and the District of Columbia have made it easier for lay administrators to use naloxone without fear of legal repercussions and many states have passed “Good Samaritan” laws that empower bystanders to seek help in the case of an overdosev.  The Harm Reduction Coalition (HRC) distributes free naloxone kits to people in San Francisco who are at risk of overdose. It is one of over 600 local, community-based opioid overdose prevention programs in the U.S. that provide naloxone to laypeople.

Naloxone has been credited with saving tens of thousands of lives, but it is not a cure-all. Health officials have detected “repeaters” who have been saved from overdose more than once, underscoring the need to treat the true problem: addiction. For Timothy Purington, Director of Prevention Services at Tapestry Health in Western Massachusetts, the current demand for Narcan reflects a new way of thinking:  “. . . people are valuing the lives of opiate addicts, which is not something that I've seen before. I think that attitudes are changingvi."  Recognizing addiction as a chronic disease in need of management, rather than as a sign of moral failure or lack of self-discipline, reduces the discrimination associated with drug use. For a population already experiencing the negative attitudes associated with homelessness, this relief can truly be both life-saving and life-changing.

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

i. National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. (2011). Policy impact: Prescription painkiller overdoses. Atlanta, GA: Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/drugoverdose/pdf/policyimpact-prescriptionpainkillerod-a.pdf

ii. National Institute on Drug Abuse. (2014, May 14). America’s addiction to opioids: Heroin and prescription drug abuse. Presented by Nora D. Volkow, M.D. at the Senate Caucus on International Narcotics Control. Retrieved from http://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2014/americas-addiction-to-opioids-heroin-prescription-drug-abuse#_ftn3

iii. Jones, C., Campopiano, M., Baldwin, G., & McCance-Katz, E. (2015). National and state treatment need and capacity for opioid agonist medication-assisted treatment. American Journal of Public Health. e-View Ahead of Print. doi: 10.2105/AJPH.2015.302664

iv. RxList: The Internet Drug Index. (2015). Narcan. Retrieved from http://www.rxlist.com/narcan-drug/clinical-pharmacology.htm

v. Davis, C., Chang, S., and Carr, D. (2015). Legal interventions to reduce overdose mortality: Naloxone access and overdose Good Samaritan laws. St. Paul, MN: The Network for Public Health Law. Retrieved from https://www.networkforphl.org/_asset/qz5pvn/naloxone-_FINAL.pdf

vi. Williams, M. (2014, April 10). Q&A with Liz Whynott and Tim Purington of Tapestry Health on needle exchange, Narcan, and stigma. Mass Live. Retrieved from http://www.masslive.com/news/index.ssf/2014/04/qa_with_tapestry_health_on_drug_addiction.html

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Voices from the Field Blog: Toward a Meaningful Life

by Kay Peavey
August 25, 2015

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Homeless and Housing Resource Network Contributing Writer Kay S. Peavey describes reintegration: what it means, who it involves, and how it’s being fostered in a major new initiative.

Reintegration: what does it mean? According to the dictionary, its most common definition is “restoration to a unified state,” but other denotations of the word are used in certain fields, such as psychiatry and psychology. Similarly, the most common result of an Internet search of “reintegration” involves veterans returning to civilian life, but there are many other applications: to adult and juvenile offenders and victims, to individuals experiencing schizophrenia, to human trafficking targets.

As disparate as these populations may seem, they all face the process of returning to meaningful lives as whole contributing members of their communities. This daunting task is made more manageable by services and supports that are tailored to the needs of a particular population. For example, increasing awareness of the difficulties that veterans face has prompted both government and not-for-profit agencies to develop more programs that help them reintegrate into civilian life.

Other populations appear less frequently in the public eye. Discussion of the reintegration of women is often limited to the context of domestic violence. According to a policy brief from the Colorado Coalition for the Homeless, violence is the principal cause of women’s homelessness. But other circumstances can make women equally as vulnerable, equally in need of supports and services that facilitate reintegration.

One study on reintegration focused on women with histories of substance use disorders. It describes how “U.S. policy tends to view substance abuse as a moral weakness and to stress punishment,” which has included withholding access to housing and social support. Participants of the study corroborated that inadequate housing posed a significant barrier to their recovery. The author recommends “radical changes in the approach to women with substance abuse problems, providing support and a path to a pro-social lifestyle that includes normal responsibilities.”

ProMedica recently accepted this challenge. With the support of the Substance Abuse and Mental Health Services Administration, it will collaborate with its affiliate Harbor Behavioral Health to open a residential treatment center for women who have limited access to quality healthcare services.  In addition to offering treatment for substance use disorders, the center will work to ensure successful community reintegration for the women who participate. (To access the press release announcing this major initiative, click here.)

Specifically targeting pregnant and postpartum women, the program intends to decrease the impact of the opioid epidemic in Northwest Ohio.  Babies born to women who use opioids during pregnancy may be subject to neonatal abstinence syndrome, which can lead to seizures, respiratory problems, feeding difficulties, low birth weight, and death. While officials stress the goal of improving birth outcomes, their vision also includes improving family functioning through education.  Revisiting the findings of the study mentioned above, “relationships with children” ranked in the top three most often mentioned responses to the question of “What helped in your healing and recovery?” The women in the study shared that being able to provide for their families and serving as role models were motivators for recovery.

Helping women fulfill these parental responsibilities contributes to their sense of participation in normal social roles, which has been shown to contribute positively to recovery. That “normal social role” may be as parent or as some other whole contributing member of the community, such as the veteran who successfully applies his military skills to civilian employment. It may be a person with schizophrenia relearning basic social and life skills after a psychotic break or an individual re-joining a community upon release from incarceration. Regardless of the role, the outcome is restoration to a unified state, which is the very definition of reintegration.

VanDeMark, N. (2007). Policy on reintegration of women with histories of substance abuse: A mixed methods study of predictors of relapse and facilitators of recovery. Substance Abuse Treatment, Prevention, and Policy, 2 28), 2. doi:10.1186/1747-597X-2-28

National Institute on Drug Abuse. (December 2012). What are the unique needs of pregnant women with substance use disorders? Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition).


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

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Voices from the Field Blog: Recovery Both Big and Small

by Katie Volk
July 15, 2015

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Homeless and Housing Resource Network contributing writer Katherine Volk reflects on conversations with staff at a community-based organization about re-imagining the notion of recovery.

My colleagues and I think a lot about recovery. How to define it. How to instill it as a value in organizations. Often, when I’m visiting a community organization, the conversation about recovery turns to mental health diagnoses and addiction treatment. Recently, though, I was having a conversation with staff at a small community-based organization that drove home to me that recovery is so much more. Working with families experiencing homelessness, the staff described to me dislocation and loss, regaining a sense of self, discovering new ways of being.

On my drive home, my mind wandered to the families with whom I’ve worked, the kids I’ve played with in shelter playrooms, their mothers and fathers. I remember our conversations and begin to re-imagine them in terms of recovery.

“I’m recovering from the strange smells in the shelter,” says a seven-year old.

“I'm recovering from the shame of putting my children to sleep in our car, rather than in bunk beds in our apartment,” says a dad. 

“I’m recovering from an abusive relationship, but more than that, I’m recovering from the realization that I didn’t know relationships could be any other way,” says a mom.

I then imagine these same conversations evolving into a reflection about what people now know.

“I remember the point in my recovery where my sleep patterns became normal. I slept soundly for the first time in years. Maybe ever.”

“Today, I invited a friend to my house to play.”

“I cook dinner for my family and realized that for awhile, I was too depressed to eat with them. Now I do–and it tastes so good.”

“Today I came home to MY place. I snuggled with my cat and read the newspaper.”

In other words, recovery is about the big things–kicking an addiction to heroin, climbing out of depression, finding a healthy way to move forward after terrible violence–and also about the seemingly small ones. The simple moments. The small gestures. Recovery, too, is coming to terms with things that we still want to learn. “Humans of New York,” a story-telling art project made popular through social media, recently posted a quote from a young woman who captures this idea so well.

She says, “I think I need to learn discipline. I don’t think I ever learned it when I was young. I had one of those typical inner city stories. My mom was addicted to drugs so I had no bedtime. No wake-up time. No chores to do. Those sound like simple things but they aren’t. I’ve seen a lot of people in college who are able to work really hard at something even if they aren’t very interested in the subject, and I think that’s because they learned discipline.”

The Substance Abuse and Mental Health Administration (SAMHSA) defines recovery as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” Recovery happens in four dimensions: health, home, purpose, and community. My hope is that we help one another find these things–big and small; grand and simple; what we know to be true and what we still would like to discover.

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

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Voices from the Field Blog: Mental Health Awareness: Here and Now

by Kay Peavey
June 19, 2015

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Homeless and Housing Resource Network Contributing Writer Kay S. Peavey describes exciting mental health awareness initiatives currently underway in the United States and how these efforts can help improve our interaction with people who are experiencing homelessness.

In the early evening, a man wanders slowly along a downtown residential street in a medium-sized city in upstate New York. He is wearing layers of tattered clothes, despite the summer heat. As he shuffles along, he softly mumbles to himself, occasionally yelling out incoherently. Onlookers are uncomfortable, tightening their circles of friends to avoid the possibility of contact with him; they are afraid, grabbing the hands of their children to pull them away from him; they are cruel, taunting the man. Of the dozens of people the man passes, only one acknowledges his obvious distress: an outreach worker slowly approaches the man, providing reassurance and offering assistance.

This scene played out in the mid-1980s, during a time when the “homeless crisis” forced communities to recognize homelessness as a societal problem. By the end of the decade, public awareness of homelessness had gained some traction. In 1986, Hands Across America—an attempt to create a human chain from coast to coast—was organized to raise funds to fight homelessness. A year later, the Stewart B. McKinney Homeless Assistance Act was passed. Later renamed the McKinney-Vento Homeless Assistance Act, it was the first major federal legislative response to homelessness.

Title VI of the McKinney-Vento Act provides for mental health services for individuals experiencing homelessness, and the need for such services is great. As many as 30 percent of individuals experiencing chronic homelessness have mental health conditions (SAMHSA, 2011); however, lacking ties to supports that traditionally lead individuals to get help (families, friends, primary care physicians), people experiencing homelessness may not be receiving the care they need. Addressing disparities in care of mental illnesses is a topic recently championed by Chirlane McCray, First Lady of New York City. At a conference in January of this year, she candidly shared her own family’s experience with mental illness before describing plans for a comprehensive review of mental health issues in New York City that will help address disparities.

This willingness to share, to stop looking the other way, is a key message of a major nationwide initiative encouraging everyone to be more open and honest about mental health. Emerging from the White House National Conference on Mental Health held in 2013, the Campaign to Change Direction encourages people to recognize the five signs of emotional suffering as a first step in getting help for oneself or for loved ones and acquaintances. In the official launch of the campaign, First Lady of the United States Michelle Obama said, “It’s time to tell everyone dealing with a mental health issue that they are not alone.”

In her remarks, Mrs. Obama specifically mentions Mental Health First Aid (MHFA) as a tool that can be used to help someone who might be experiencing a mental health issue. MHFA was developed in Australia in 2001 and piloted in the United States seven years later under the coordination of the National Council for Behavioral Health, the Maryland Department of Health and Mental Hygiene, and the Missouri Department of Mental Health.

MHFA is the help offered to a person developing a mental health problem or experiencing a mental health crisis until appropriate treatment and support are received or until the crisis resolves. Participants of the training learn how to assess for risk, listen to and reassure the person in crisis, and encourage professional help and other support (Mental Health Association of Maryland, Missouri Department of Mental Health, & National Council for Behavioral Health, 2013). The training is beneficial to everyone in a community: hospital staff, Rotary Club members, law enforcement, employers, professional associations, faith communities, friends and families, Neighborhood Watch participants, school personnel, etc. Anyone working with individuals who are experiencing homelessness—outreach workers, case managers, shelter staff, food pantry volunteers—can benefit from the enhanced understanding of mental health offered by this training.

Research has demonstrated that MHFA is effective in a myriad of ways, not the least of which is reducing overall social distance toward individuals with mental illness (National Council for Behavioral Health, undated). Making connections is particularly important for a population living with the double burden of both homelessness and mental illness.

Awareness and education can dispel the mistrust and fear that lead to people tightening their circles, grabbing their children’s hands, taunting—actions that should not have occurred 30 years ago and should not be occurring today. All of us—not just one person out of dozens—need to know when and how to offer assistance. Commenting on recent efforts to change the way mental health is viewed in this country, Mrs. Obama urges, “It’s up to us to show compassion, to reach out, to connect, to help folks find the hope and the support they need.”

Mental Health Association of Maryland, Missouri Department of Mental Health, & National Council for Behavioral Health. (2013). Mental Health First Aid USA, Revised First Edition. Lutherville, MD: Mental Health Association of Maryland.

National Council for Behavioral Health. (Undated). Mental Health First Aid: Frequently Asked Questions. Retrieved from http://www.mentalhealthfirstaid.org/cs/faq/

Substance Abuse and Mental Health Services Administration (SAMHSA). (2011, July). Current statistics on the prevalence and characteristics of people experiencing homelessness in the United States. Retrieved from http://homeless.samhsa.gov/ResourceFiles/hrc_factsheet.pdf

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

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Voices from the Field Blog: Women's Addiction Services Leadership Institute

by Darby Penney
June 19, 2015

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Homeless and Housing Resource Network contributing writer Darby Penney explores how SAMHSA’s Women’s Addiction Services Leadership Institute (WASLI) supports leadership development including the expansion of housing programs in women’s behavioral health services.

“Leadership is a skill that can be learned,” said Deborah (Deb) Werner, senior program manager at Advocates for Human Potential, Inc. and director of the Women’s Addiction Services Leadership Institute (WASLI). “It’s not something you’re born knowing how to do. Everyone can be a leader, no matter what your role in your organization. And it is especially important to focus on building leadership in women’s services, to ensure that gender-responsive approaches are available to women with substance abuse and co-occurring disorders,” she said.

WASLI is a unique national program sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) that participants have described as “life-transforming.” Established in 2009, it is an intensive six-month program that is currently working with its fourth class of trainees, who are selected through a competitive national application process.  WASLI has its roots in the Partners for Recovery-Addiction Technology Transfer Center Leadership Institute, and is customized to meet the specific needs of those working in women’s services. Recognizing that there are many effective, evidence-based programs and policies that address the specific behavioral health needs of women and families, but are still not available to most women, SAMHSA instituted WASLI to address the need to bring these practices to scale. The goals of the program are to develop and improve participants’ leadership skills; create a network of the next generation of leaders in women’s behavioral health services; and to establish a model of women’s leadership training.

The program offers an individualized learning experience that begins with a leadership assessment that helps each trainee identify her strengths and challenges. Participants are assisted in developing a Leadership Enhancement Action Plan (LEAP), which they implement with the support of a personal coach with whom they have regularly scheduled meetings. The WASLI program also includes a four-day, face-to-face immersion training, a monthly webinar/teleconference series on current trends in women’s behavioral health issues, and a three-day Enhancement Training. The program concludes with a graduation webinar, after which graduates are welcomed into the Alumni Network, which offers ongoing learning opportunities and mutual leadership support. Some graduates go on to become WASLI coaches.

As an integral part of their leadership development, each participant takes on the planning, development, and implementation of a service project in her locality. “The purpose of these projects is to give the participants the opportunity to stretch their skills and reach beyond their past accomplishments, with the support of their coach and the network,” Werner explained. “Women find this both challenging and empowering.”

Several WASLI participants have taken on service projects related to housing and homelessness. Lori Criss, a member of the 2011 class, is associate director of The Ohio Council of Behavioral Health & Family Services Providers, and founder and principal advisor to Ohio Recovery Housing. Her project was entitled Furthering an Intentional Community of Recovery for Women and Families. “The skills and relationships that I developed through WASLI prepared me to foster momentum for a new statewide initiative for recovery housing in Ohio,“ Criss said.  "I was able to build relationships with Ohio’s administration and legislature and develop a broad coalition invested in creating opportunities for housing choice and promoting quality recovery housing in every community in Ohio.” 

In 2013, the Ohio Council published an environmental scan of recovery housing in the state, which led to passage of legislation in 2014 that defined recovery housing, requires its inclusion in every local behavioral health continuum of care, and provided an initial investment of $10 million to jumpstart development of recovery housing in 43 communities,” she said. Ohio Recovery Housing, a non-profit for individuals and organizations operating quality recovery housing, was incorporated in 2014 as Ohio’s affiliate of the National Alliance for Recovery Residences. This progress helped spur a national conversation about housing choice for people with substance use disorders. “My ability to help drive the recovery housing initiative forward in Ohio and to play a key role in the national housing choice dialogue is a direct byproduct of the investment made in me through the Women’s Addiction Services Leadership Institute,” Criss said.

In Mesa, Arizona, 2011 WASLI graduate Kimberly Craig’s project, Expanding Safe and Affordable Housing for Women with Co-occurring Disorders and their Families, aimed to expand affordable housing choices for women with substance abuse disorders and their families by acquiring abandoned properties in blighted, high-crime areas.  The strategy of targeting abandoned properties proved to be an incentive for the City of Mesa to help fund the project.  “We were successful, and have purchased three fourplex units,” said Craig, Vice-President, Women’s & Children’s Programs, Center for Hope, Community Bridges, Inc. “This benefits the women and their families by providing them with long-term, safe and secure housing where they can maintain custody of their children while attending treatment services, and where they can continue to strengthen recovery and life skills that will allow them to maintain recovery and wellness of the entire family.” 

Becca Crowell, executive director of the Nexus Recovery Center in Dallas, Texas, was a 2009 WASLI graduate. The goal of her service project was to add transitional housing to her agency’s continuum of care for women of low income who use substances as well as their children. State behavioral health funds are distributed locally through a highly managed system of care, which often results in very short residential stays. Nexus found that many women had no place to go when they left residential treatment, which made it difficult to successfully transition to outpatient care.  During her WASLI program, Crowell researched approaches to affordable housing, developed a business plan, identified funding opportunities, and completed a Housing and Urban Development (HUD) application. Today, Nexus offers 35 apartment units funded through HUD, primarily two and three bedroom units for families.  They have also secured 15 vouchers for apartments through the Dallas Housing Authority for their clients.

“WASLI’s strengths-based, mutually supportive approach was instrumental in helping these leaders develop the skills, knowledge, and confidence to succeed with these projects,” said Werner. “These successes show that the women who come to WASLI are ready to reach for the next level of achievement to benefit women’s behavioral health services.”

For more information on The Women’s Addiction Services Leadership Institute (WASLI), go to http://www.samhsa.gov/women-children-families/trainings/wasli.

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

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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.”

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: Consistency and Community-Based Mentoring for the Most Vulnerable Children

by Darby Penney
April 14, 2015

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Homeless and Housing Resource Network contributing writer Darby Penney discusses the work of Adoption & Foster Care Mentoring in Boston and how it provides whole-person supportive services that help to put foster children on a path to self-sufficient adulthood.

Young people who leave foster care—often at the age of 18 with little support and few skills—are at risk for a host of negative outcomes, including homelessness. “By age 26, 36 percent of young people who ‘aged out’ of foster care have experienced homelessness, according to the University of Chicago’s Chapin Center,” said Colby Swettberg, executive director of Adoption & Foster Care (AFC) Mentoring in Boston. “Prevention is key. At AFC, we offer long-term mentoring, life skills training, and matched financial savings for youth in foster care that prepare them to be self-sufficient in adulthood and avoid negative outcomes like homelessness.”

The Chapin Center conducted a longitudinal study of the adult functioning of former foster youth that estimated 25,000 to 30,000 young people leave foster care annually at age 18 (21 in some states), and that these young people face enormous challenges in achieving housing stability (Dworsky, Napolitano, & Courtney, 2013). Factors that increased the risk of homelessness include having run away while in foster care, being male, having been physically or sexually abused, instability in foster care placement, or having symptoms of mental health disorders. Factors that helped prevent homelessness included extending foster care to age 21, access to transitional housing programs for youth, helping youth build financial stability before they leave foster care, and training and support to develop the skills to live independently.

AFC Mentoring exists to provide just these types of supports to young people aging out of foster care. It is the only mentoring program in Massachusetts that focuses exclusively on youth in foster care. Jean Rhodes, Ph.D., Director of the Center for Evidence-Based Mentoring, calls AFC Mentoring, “the pre-eminent mentoring program serving foster youth in the country.”

The program pays particular attention to the most disadvantaged of foster children; for example, those who have lost contact with their families of origin or the child who is the only one left in the group home with nowhere to go on Thanksgiving. AFC’s mission is to provide whole-person support to these vulnerable young people through a trio of integrated supportive services that prepare them to transition to adulthood: mentoring relationships, intensive case supports, and financially incentivized life skills training.

At the heart of AFC’s services is a community-based mentoring program that matches adult volunteers with kids in foster care. “We have a very rigorous screening and training program for volunteers. Consistency is vital for these kids, so we require mentors to spend at least eight hours a month with their mentee, and we ask for a minimum of a one-year commitment,” said Swettberg. “This is so important, because the mentor may be the only adult who has ever shown an interest in the child who was not paid to do so. These kids desperately need a sense of belonging. Our mentors have a terrific impact on their mentees. While the average length of a volunteer commitment in mentoring programs is about nine months, our average is 55 months. Our mentors and mentees develop strong relationships, and we have evidence that this makes a lasting difference in kids’ lives.”

AFC’s program staff includes masters-level social workers who provide intensive support to both mentees and mentors. “These folks are skilled clinicians and are the glue that holds our mentoring matches together,” said Swettberg. “They are there for the kids when they are facing hard times, and they are also there for the mentors if the relationship with the mentee is going through a difficult phase. They also act as resource brokers with local human service agencies, linking kids to services like vocational training or housing.”

The third piece of AFC’s trio of supportive services is a life skills training program called AFC Leaders, which prepares young people aged 16 and older with the concrete skills they will need to transition from foster care to adulthood. When young people in foster care turn 18, in most states, they are considered adults and they abruptly lose their eligibility for foster care. Being completely on one’s own would be difficult for any 18-year-old, even one from the most supportive family, and young people who have experienced the kind of trauma, displacement, and loss that are common among foster children are in an even more vulnerable position.

AFC’s life skills program works to prepare young people for this eventuality, helping them become self-sufficient, but not alone. Mentors stay connected to young people after they age out of foster care, and AFC puts no age limit or time limit on young people’s involvement with their services.

Not only does the AFC Leaders program teach young adults concrete skills like nutrition and healthy cooking, preparing a resume, finding affordable housing, and identifying career goals, it pays them to learn these skills. In addition, the program matches all the funds the young people earn, so they have a nest egg when they leave foster care. Young people use their savings for things like college tuition, rent, textbooks, laptops, and clothing for job interviews.

“We hope that young people are referred to us early, so we have time to work with them, connect them with caring mentors, and give them access to skills training,” said Swettberg. “Unfortunately, the reality is we sometimes get referrals just as young adults are about to age out of the system and, at that point, their needs are very acute and the stakes are extremely high. By starting our programs earlier, we hope that kids will develop the relationships, resiliency, and skills they need to thrive as adults.”

“It’s important to realize that this is a very solvable problem—a problem we can get our arms around,” she continued. “We know who these kids are, foster youth are tracked by the state, and we know what services and supports kids need to transition successfully to adulthood. But when we don’t intervene early with caring support, the problem gets more difficult to solve and more expensive to solve. We can put foster youth on a path to healthy, self-sufficient adulthood if we can make sure they get what they need early on and we offer them consistent support over time.”


Dworsky, A., Napolitano, L., & Courtney, M. (2013). Homelessness during the transition from foster care to adulthood. American Journal of Public Health, 103(S2), S318-S323.

For more information on the innovative programs offered by Adoption & Foster Care Mentoring (AFC), visit their website at http://afcmentoring.org/.

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

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Voices from the Field Blog: Circumstances & Hope

by Darby Penney
March 16, 2015

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Homeless and Housing Resource Network Contributing Writer Darby Penney writes about how Glenn Schaefer turned his struggle with homelessness and depression into a book with a message of hope and empowerment for people experiencing homelessness. Schaefer emerged from these circumstances heartened by the kindness of strangers.

Almost overnight, after Glenn T. Schaefer was laid off from a good-paying job selling radio advertising, his life came crashing down around him. He lost the new home for which he could no longer afford the mortgage payments, as well as his new car. His wife left him. He became homeless. The friends who had been there during the good times now kept their distance. He found himself despondent, with suicidal feelings, and admitted himself to a psychiatric unit for the first–but not the last–time. 

This episode began a long, halting, but ultimately successful comeback journey from homelessness and depression that Schaefer chronicles in his recent book, Oh! You’re One of Those People...: A Whimsical Two Year Journey of Depression, Desperation, and Detainment (Dog Ear Press, 2014). “Many people don’t realize how easy it is to become homeless,” he said. “A lost job, a broken relationship—it can just cascade. And suddenly the losses pile up, and you find yourself on someone’s couch, in a shelter, or on the street.”

Why would one describe such a difficult experience as “whimsical?” Schaefer says he wasn’t being ironic in his choice of words; he kept looking for the bright spots during the hard times. But another reason, he says, in retrospect, is that perhaps he took a self-deprecating, darkly humorous tone as a way to cover the pain he experienced during the two years he spent homeless. 

After he lost his job, home, and family, Schaefer returned to his hometown to stay with his mother. This arrangement didn’t work out, and he found himself down and out among the people he had grown up with in his hometown. In some ways, he says, it might have been easier being homeless in the anonymity of a big city. It was hard to have people he had known as a youngster look down on him or pity him.

The book’s title comes from a painful episode. During the time he was homeless, Schaefer often slept in temporary shelters in his hometown, sleeping in a different host church every night. One Sunday, he attended the morning service at the Methodist church, sitting in a back pew, trying not to stand out in the crowd. During the service, the pastor asked congregants to turn and greet their neighbors. The woman in front of him turned to shake his hand, smiling, and then a guarded look came over her face. “I recognize you, don’t I?” she asked. “You’re one of those people who stay in the basement.” 

Recognizing that it might be easier to start over in a place where no one knew him, Schaefer made his way to North Carolina, where he eventually found a part-time job and a temporary place to stay. But after a while, he “ran out of bridges to burn,” and felt like he needed to make a fresh start. In desperation, he called an old friend and said, “I just can’t do this anymore.” His friend sent him a train ticket to Memphis and took him in. “I was tired of carrying everything I owned in a gym bag and sleeping on park benches,” he said. “I was ready to work to get my life back.”

He had done some writing during his media career, and he started making notes about his experiences with homelessness and depression. At first, he had no plans to write a book: “It was just ‘bar napkin therapy’ for me at the beginning,” Schaefer said. It helped him sort things out, he says, and he kept writing in fits and starts.  But eventually it was the compassion shown by strangers that motivated him to keep writing.

Schaefer points out that while some people he encountered reacted like the disapproving woman in the church, other people—total strangers—were incredibly kind. The day before Christmas Eve, he was standing in line at Kmart to pick up his blood pressure medication and found that he did not have enough money to pay for it. He walked away, but the pharmacist called him back; someone behind him in line had covered the cost of his prescription. Another night, he was wandering aimlessly in a snowstorm and was rescued by a registered nurse just coming off her shift. Her compassion helped him resolve to write down the stories of what he has learned from this difficult part of his life.

The message he wants to send through his book is simple, Schaefer says. “I want people who are homeless to understand that it is not hopeless. Most people need someone to tell them that they won’t give up on them, that they are a decent person, and that they can turn their life around. It helped me when people treated me that way, and it can help others.”

Glenn Schaefer’s book, Oh! You’re One of Those People...: A Whimsical Two Year Journey of Depression, Desperation, and Detainment, is available for purchase at Amazon.com or at Barnes & Noble.

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

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