Voices from the Field Blog: Rhode Island First State in Nation to Pass Homeless Bill of Rights

by Darby Penney
October 23, 2014

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Homelessness and Housing contributing writer Darby Penney highlights a landmark piece of legislation to provide comprehensive protections against discrimination for individuals and families experiencing homelessness and to educate the public about the reality of life for the most vulnerable people.

In 2012, Rhode Island became the first state in the U.S. to pass a Homeless Bill of Rights, thanks to the leadership of the Rhode Island Homeless Advocacy Project (RIHAP), an organization led by people who have experienced homelessness or are currently experiencing homelessness. Founded by the late John Joyce, who drafted the original bill, RIHAP worked in collaboration with allies in the state legislature, the Rhode Island Coalition for the Homeless (RICH), the state chapter of the American Civil Liberties Union (ACLU), the Interfaith Coalition Against Poverty, and other community organizations to pass the legislation on June 20, 2012. The bill prohibits discrimination based on housing status, stating, “No person’s rights, privileges, or access to public services may be denied or abridged solely because he or she is homeless. Such a person shall be granted the same rights and privileges as any other resident of this state” (Homeless Bill of Rights, R.I. Gen. Laws Ann. §34-37.1-2, 2012).

While the language may sound deceptively simple, the ramifications are far-reaching, according to Jim Ryczek, Executive Director of the Rhode Island Coalition for the Homeless. “The bill is both an educational tool to raise awareness of the ways in which people experiencing homelessness have been discriminated against and a legal tool to enforce people’s rights,” he said. In the tradition of civil rights legislation generally, the goal of the bill was to stop discriminatory practices against a vulnerable group of individuals by ending discriminatory behavior. The intent of the legislation was not to single out any specific group engaging in discriminatory practices, but rather to provide comprehensive protections against discrimination for individuals and families experiencing homelessness within all areas of the public sector.

The campaign for passage of the bill also served as a way to educate legislators and the public about the reality of life for people experiencing homelessness. “Working in partnership with RIHAP members, we developed flyers and talking points for advocates to use in lobbying their legislators and speaking to the press,” Ryczek said. “We focused on explaining that people were asking for equal rights, not ‘special rights.’ In our lobbying and conversations with the media, we highlighted the experiences of discrimination faced by individuals in our community. We all learned much more about what it feels like to experience homelessness in Rhode Island,” Ryczek explained.“ Much of that knowledge is uncomfortable to sit with and unsavory to acknowledge.”

Other jurisdictions have since passed homeless bills of rights, including the states of Connecticut and Illinois in 2013. Illinois’ bill contained language similar to Rhode Island’s, focusing on ensuring that persons who are homeless have the same rights and privileges as all other residents, including the right to use public spaces such as sidewalks, parks, and transportation; equal treatment by government agencies, including the right to vote; and a right to confidentiality and reasonable expectation of personal property (Sheffield, 2013). Connecticut’s law is similar, but also explicitly prohibits “harassment or intimidation from law enforcement officers” (An Act Concerning A Homeless Person’s Bill of Rights, 2013 Conn. Pub. Acts 13-251).

According to the National Coalition for the Homeless (NCH), legislation establishing homeless bills of rights is currently being considered in California, Delaware, Minnesota, Missouri, Oregon, Puerto Rico, Tennessee, and Vermont, as well as in the cities of Baltimore, Maryland, and Madison, Wisconsin. The need for such protective legislation is made more urgent by legislation in localities across the country that effectively criminalize people who are experiencing homelessness by targeting them for their lack of housing and not for their behavior, according to NCH. This includes laws that prohibit feeding people in public places; sleeping in cars, tents, or public spaces; or panhandling.

In Rhode Island, one of the arguments made by opponents of the Homeless Bill of Rights was that it would unleash a flood of lawsuits. This has not happened, according to Jim Ryczek of the Rhode Island Coalition for the Homeless (RICH). In fact, not a single action has been brought under the provisions of the law to date, and RICH encourages Rhode Islanders who feel they have been discriminated against to consider filing a claim. Ryczek offers the following advice to advocates in other jurisdictions: “The laws are important because we currently have no other recourse in our fight to stop discrimination against people experiencing homelessness. Even if few lawsuits are brought, it is vital that these laws are in place to keep the issue visible.”

For more information on organizing to enact a homeless bill of rights in your state or locality, visit the Rhode Island Coalition for the Homeless website at http://www.rihomeless.org/Resources/HomelessBillofRights/tabid/273/Default.aspx

Western Regional Advocacy Project’s Homeless Bill of Rights Campaign site at http://wraphome.org/work/civil-rights-campaign and the Homeless Civil Rights forum of the National Coalition for the Homeless at http://nationalhomeless.org/campaigns/bill-of-right/

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

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Voices from the Field Blog: Living in her Buick During Law School—Remembering Mimi Kravitz

by Darby Penney
September 22, 2014

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Homeless and Housing Resource Network contributing writer Darby Penney reflects on the life and legacy of a colleague, and how the emergence of Supported Education helps people with psychiatric disabilities meet their goals of higher education.

Recently, while working on a proposal, I did some reading about Supported Education (SEd), a type of program that assists people with psychiatric disabilities in their pursuit of higher education. SEd is a psychiatric rehabilitation intervention that first emerged in the 1980s, along with work at the Boston University (BU) Center for Psychiatric Rehabilitation to develop supported employment (SE) programs. While SE demonstrated success in helping people with psychiatric disabilities choose, get, and keep jobs, many of those jobs were part-time and low-paying, and did not generally lead to real careers that provided enough income for people to become and remain independent (Anthony, 2011). These findings led BU staff to look at the educational needs of people with psychiatric disabilities—in addition to their more immediate employment needs—because of the documented connection between higher educational levels and increased income. This work resulted in the creation of Supported Education as a unique, person-centered approach to supporting people with psychiatric disabilities who wanted to embark on or continue interrupted college careers (Rogers et al., 2010).

My recent encounter with the history and philosophy of Supported Education led me to reflect on the life of my late colleague Miriam (Mimi) Kravitz, who was homeless during much of her undergraduate career and could certainly have benefitted from SEd. Mimi helped found and served as Executive Director of INCUBE, a ground breaking peer-run program in New York City that helped people with psychiatric disabilities develop their own businesses. This began in the late 1980s, a time when many mental health programs still acted as if those of us with psychiatric histories were unemployable. INCUBE was a quirky, incredibly innovative program that served as a nurturing, protective environment for fledgling entrepreneurs who were overcoming challenges related to inpatient hospitalization, drug or alcohol problems, and homelessness.

But in the years before she became the Executive Director of INCUBE, Mimi was, in her own words, “…sick and helpless, and almost alone in New York. As a film and television student at New York University, I ended up sleeping in Union Square… After that, I lost touch with my family and became a child of the system. The experience of Union Square… left me with neurological damage. Hospitalized in the seventies, large doses of Thorazine and anti-psychotics were used. Now, I thank God that people are recognizing that trauma is not psychosis. I was in the system for seven years. I had nine psychiatric hospitalizations… I intermittently lived in welfare hotels and adult foster care.” Mimi goes on to explain that, for much of her early life, the possibility of going to college seemed like a fantasy. “For me, most of my life was spent suffering from isolation and fear. As a small child, I could hear music and voices, which made it difficult for me to learn to read and write” (Kravitz, 1998).

Despite these experiences, Mimi eventually worked her way through college and received a degree in Business Management. Perhaps even more impressive, she later attended and graduated from Brooklyn Law School while she was homeless and living in her Buick in the law school parking lot. I vividly recall an image of Mimi from Peter Stastny’s 1995 film Nerve, in which she described the process of protecting herself, figuring out how to meet her basic needs, and focusing on her studies, knowing that, for her, it would be the way out of poverty, life as a mental patient, and homelessness. A large, exuberant woman with red curls and a hearty laugh, Mimi demonstrated in the film how she made inventive use of a large cape that she wore throughout her law school career. Sometimes it served as a tent-like shelter, sometimes as a changing room, other times as a hiding place, and sometimes just as protection from the winter chill. When I first saw the film almost 20 years ago, I remember feeling that this was a perfect demonstration of the grit, courage, inventiveness, and imagination that allowed Mimi to persevere though many types of hardships and emerge with a law degree that helped lift her out of homelessness.

So, in celebration of Mimi’s life and legacy, I’d like to call attention to the hope and possibilities that programs like Supported Education can offer people who find themselves in circumstances similar to those that Mimi faced in the 1970s and ’80s. People experiencing homelessness today are capable of the kinds of accomplishments that her life exemplifies, and the homelessness services network can help connect people to innovative services like Supported Education that can help them meet their own goals.

For more information on Supported Education, see SAMHSA’s downloadable Supported Education toolkit at http://store.samhsa.gov/product/Supported-Education-Evidence-Based-Practices-EBP-Kit/SMA11-4654CD-ROM.

References
Anthony, W. A. (2011). Upping the ante. Psychiatric Rehabilitation Journal, 34(3), 175-176.

Kravitz, M. (1998). Legal actions. New York City Voices, fall 1998. Available at http://www.nycvoices.org/article_46.php.

Rogers, E. S., Kash-MacDonald, M., Bruker, D., & Maru, M. (2010). Systematic review of Supported Education literature, 1989 – 2009. Boston, MA: Boston University, Sargent College, Center for Psychiatric Rehabilitation. Available at http://www.bu.edu/drrk/research-syntheses/psychiatric-disabilities/supported-education/.

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

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Voices from the Field Blog: Promoting Recovery in Homeless Services

by Darby Penney
August 20, 2014

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Homeless and Housing Resource Network contributing writer Darby Penney interviewed Gloria Dickerson, Recovery Specialist at the Center for Social Innovation, on meaningful involvement of people who are current or former service users in the development, implementation, and evaluation of policies in homeless services.

“Recovery doesn’t have an endpoint,” says Gloria Dickerson, Recovery Specialist at the Center for Social Innovation, “it’s an ongoing journey. There’s never a time when you feel like you’ve finally arrived. You spend your life recovering. The good part is that this forces you to develop skills that allow you to keep moving forward in a spirit of hope. Because for me, no matter what, even though there are setbacks, hope is what recovery is all about.” As someone in recovery from trauma, mental illness, physical health problems, and homelessness, Dickerson has a lifetime of lived experience to support her belief in the healing power of hope.

She has also written about concrete actions that can be taken to integrate recovery-focused principles and practices into the homeless assistance network. There is a need for a recovery orientation when serving individuals experiencing homelessness, Dickerson and her co-authors found, because these individuals often face complex, multi-faceted challenges: “Recovery from homelessness overlaps significantly with the process of recovery from mental illness, substance use, and/or traumatic stress… This overlap suggests a significant opportunity for the homeless assistance network to learn from the research, practices, and policies used to promote and implement recovery-oriented care in the areas of mental health, addiction, and trauma care” (Gillis, Dickerson, & Hanson, 2010).

The first step to adapting recovery principles and practices to homeless services is to understand how this concept has been articulated by different systems and to find the commonalities. In 2012, SAMHSA, released a working definition of recovery that did just this, bringing together a variety of stakeholders from the mental health and addictions fields to craft a shared vision that 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” (SAMHSA 2012). The working definition is further elaborated through ten guiding principles, the first of which is hope, which is viewed as the “catalyst of the recovery process.”

Dickerson believes that homeless service providers can fan the flames of hope by recognizing that people using services “need to direct and be in charge of our own recovery. Providers need to let clients know what they are doing right, because success breeds success. When you see me succeeding, tell me, encourage me!” Providers also need to recognize the extent to which the people they serve have experienced trauma, both prior to and because of their homelessness, Dickerson believes. “Being trauma-informed is not an add-on,” she says. “Trauma is at the heart of most clients’ experience and its effects need to be recognized; the resilience that people have developed in the face of trauma needs to be honored.”

Another way the homeless service network can promote recovery is to offer low-demand service models like Housing First, which view housing as a basic human right, not as a reward for being compliant with treatment. These models do not tie housing to other services, take a harm-reduction approach, and do not put conditions on retaining housing that go beyond what would be required of any tenant in the general housing market. This model has been found to be effective in promoting recovery. A recent study showed that people experiencing homelessness and co-occurring mental health and substance abuse diagnoses who were served in Housing First programs had significantly lower rates of substance use than people who received traditional “treatment first” services, and were more likely to remain housed (Padgett et al. 2011).

Consumer integration—the meaningful involvement of people who are current or former service users—in the development, implementation, and evaluation of policies and services is another vital part of creating a recovery culture, according to advocates Laura Prescott and Leah Harris (2007). Providers must ensure that consumers are seen as equal and valued partners in the change process and that their input is taken seriously if organizations are to successfully incorporate recovery principles into every aspect of their operations. Through this process, everyone—staff and people receiving services alike—work through the complicated, messy, but ultimately rewarding and ongoing process of figuring out how to make recovery real on a daily basis. “I have a lot of hope for the future of recovery-oriented services,” says Dickerson. “It helps people take joy in their work when they can walk with people on their recovery journey. It’s a process, and sometimes it’s slow, but the relationship of hope and recovery is vital.”

More information on SAMHSA’s working definition of recovery and its ten guiding principles of recovery is available at http://store.samhsa.gov/product/SAMHSA-s-Working-Definition-of-Recovery/PEP12-RECDEF.

References
Gillis, L., Dickerson, G., & Hanson, J. (2010). Recovery and homeless services: New directions for the field. Open Health Services and Policy Journal, 3, 71-79.

Padgett, D.K., Stanhope, V., Henwood, B.F., & Stefancic, A. (2011). Substance use outcomes among homeless clients with serious mental illness: Comparing Housing First with treatment first programs. Community Mental Health Journal, 47(2), 227-232.

Prescott, L., & Harris, L. (2007). Moving Forward, Together: Integrating Consumers as Colleagues in Homeless Service Design, Delivery and Evaluation. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.

SAMHSA's Working Definition of Recovery. (2012). Rockville, MD: Publication #PEP12-RECDEF. Substance Abuse and Mental Health Services Administration.

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

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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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Voices from the Field Blog: Holding Spaces for Care – Trauma-Informed Approaches

by Darby Penney
June 20, 2014

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Homeless and Housing Resource Network contributing writer Darby Penney reflects on the moving testimony of a formerly homeless mother who received trauma-informed services through a SAMHSA treatment for the homeless grant in Albany, the Addiction and Recovery Center for Hope (ARCH) program.

More than 60 local health and human service providers, researchers, government officials, and community members came together in Albany, NY, on June 10, 2014, for a roundtable discussion exploring how findings of the SHIFT study (Service and Housing Interventions for Families in Transition) can be used to change policies and practices to help reduce family homelessness.

The study found that homeless mothers are a highly traumatized and under-served group; 93 percent of participants had a history of trauma, with 81 percent having experienced multiple traumatic events. About half the women met diagnostic criteria for post-traumatic stress disorder (PTSD) at the beginning of the study. The majority met criteria for major depression, and most were survivors of interpersonal violence by family, intimate partners, or other known perpetrators. Their children were also negatively impacted by their mothers’ trauma histories, with 41 percent having physical and/or emotional difficulties at baseline (Hayes et al., 2013).

The SHIFT study, funded by the Wilson Foundation, was conducted in the upstate New York cities of Albany, Syracuse, Rochester, and Buffalo by the National Center on Family Homelessness (NCFH). It identified mothers in emergency shelter, transitional housing, and permanent supportive housing programs and interviewed them three times over a 30-month period. 

The results of this study are consistent with those of an earlier study of factors involved in family homelessness (Bassuk et al., 1997), according to Carmela DeCandia of NCFH. What is new, she said, is the study’s conclusion that unresolved trauma issues—as indicated by severity of symptoms of PTSD—and low self-esteem were the only predictors of continuing residential instability at 30 months into the study.
 
These findings illustrate the critical need for agencies that serve homeless families to learn about trauma and its impact, along with implementing trauma-informed approaches to service provision. This conclusion was emphasized by the moving testimony of a formerly homeless mother who received trauma-informed services through the ARCH program. After multiple episodes of homelessness, which resulted from struggles with her own emotional distress and her daughter’s suicide attempts, Maria, a single mother, entered the ARCH program. Talking with ARCH staff, she realized for the first time that what she experienced as a child was abuse and that she is a survivor of trauma. Maria and her children moved into a supported apartment program, and with ARCH’s trauma-informed supportive services, she has been able to return to the workforce.

While some in the audience were familiar with the idea of trauma-informed approaches (formerly referred to as trauma-informed care), it was apparently a new concept for most of those who participated in the roundtable. A recent review of the literature found that while trauma-informed care offers a coherent framework for providing homelessness services, the concept remains unclear for many providers and the mechanisms for creating trauma-informed organizational and systems change is not well understood in this field (Hopper et al., 2010).

SAMHSA defines trauma-informed approaches as follows: A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; it responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings; and it seeks to actively resist re-traumatization.

Homeless service providers—as well as other human services agencies—can request training and technical assistance on trauma-informed approaches to become a trauma-informed organization and to provide trauma-informed peer support, as well as related issues, through SAMHSA’s National Center for Trauma-Informed Care (NCTIC).

For more information on technical assistance from NCTIC, contact Pam Rainer at prainer@ahpnet.com. To access the SHIFT study, please navigate to this link: http://www.air.org/sites/default/files/SHIFT_Service_and_Housing_Interventions_for_Families_in_Transition_
final_report.pdf

References
Bassuk, E. L., Buckner, J. C., Weinreb, L. F., Browne, A., Bassuk, S. S., Dawson, R., & Perloff, J. N. (1997). Homelessness in female-headed families: Childhood and adult risk and protective factors. American Journal of Public Health, 87(2), 241-248.

Hayes, M., Zonneville, M., & Bassuk, E.  (2013). The SHIFT Study: Final Report. Needham MA:  The National Center on Family Homelessness.

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.

Interested in being an HRC Guest Blogger? E-mail 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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Voices From the Field Blog: Alcohol Management: Reducing seizures, falls, and brain injury among alcohol dependent people

by Livia Davis
March 25, 2014

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Homeless and Housing Resource contributing writer Livia Davis details the work of Downtown Emergency Service Center (DESC) in Seattle, Washington in implementing Alcohol Management as a harm reduction strategy and the need for research to determine if Alcohol Management results in better health outcomes, improved safety, and less victimization.

To limit potentially life-threatening effects of alcohol withdrawal, including seizures, hallucinations, falls resulting in head trauma or broken bones, and victimization due to acute intoxication, Downtown Emergency Service Center (DESC) in Seattle, Washington decided to implement Alcohol Management as a harm reduction strategy for eligible residents in their 1811 Eastlake supportive housing facility that serves “formally homeless men and women with chronic alcohol addiction.” Alcohol Management is offered to residents who are at risk of harm during periods of alcohol withdrawal or other dangerous behavior associated with their alcohol use. Not without controversy in the local community, DESC is committed to improving the quality of life for program participants, increasing their housing stability, and reducing the harm of alcohol withdrawal. Currently, about 16 out of 75 residents at 1811 participate in Alcohol Management indicating it's not an intervention best suited for everybody. At the Housing First Partners Conference in Chicago held on March 13, 2014, DESC explained how Alcohol Management works.

Using Motivational Interviewing, staff members first approach potential program candidates to facilitate the completion of a client’s alcohol intake goals. Questions are asked to develop an agreement for each participant, including: Do you drink more in the morning to stave off withdrawals? How many drinks do you need to avoid feeling sick? How long between drinks do you begin to go into withdrawal? What is your goal? Do you want to cut back? Based on responses, an individual alcohol management plan is developed and signed by the participant and DESC.

The plan details the dosage of alcohol to be administered by staff at certain intervals. For example, the plan may detail 2 beers at 8 a.m., 12 noon, 4 p.m., and 8 p.m. every day. At the agreed-upon times, the Alcohol Management participant then proceeds to the staff desk and is given the agreed-upon amount of beer.

To implement Alcohol Management, a number of processes and infrastructure and training need to be developed or be in place. Clients need to have a steady income source and a payee. Program funds are not used to purchase alcohol, and both the participant and their payee agree to provide needed funds according to the alcohol-purchasing schedule. Purchasing, storing, and dispensing alcohol dosages also require a number of processes and safeguards that 1811 Eastlake has developed over the last seven years, including locked cabinets, training of staff, and dosage tracking charts.

DESC collects anecdotal data on outcomes from the Alcohol Management program and reports the following:

  1. Increases stability: The chaos of binging and withdrawing occurs less often and provides participants with a sense of stability and control they have not experienced in a long time. This increased stability is often associated with the development of new goals, including changing long standing drinking patterns;
  2. Allows for intervention in case of alcohol withdrawal: With dosage tracking documentation sheets (e.g., if a participant misses his/her dosage for 24 hours) staff will go and check to be sure that the person is not experiencing harmful effects due to withdrawal;
  3. Fosters engagement: Regular conversations can be maintained that increase awareness and stimulate articulation of goals, and allows for engagement around alcohol use to be a centerpiece of ongoing treatment planning;
  4. Slows health decline: Alcohol management is not a magic bullet but getting less intoxicated means more engagement with health providers to address chronic and acute health need;
  5. Likelihood of a decrease in alcohol use over time for some participants. While often not the inital goal, a number of residents participating in alcohol management have cut back or even stopped drinking altogether; and 
  6. Risk of loss of independence: Some participants get dependent on staff through structured alcohol dosage, and DESC recognizes that loss of independence is not necessarily a positive outcome, although has seen the same participants rediscover abilities to better integrate with community members or service providers through the stability afforded by participating in alcohol management.

DESC staff discussed the need for research to determine if Alcohol Management results in better health outcomes such as improved safety (e.g., fewer falls and reduction of instances of brain injury) and less victimization.

For additional information, please click on www.DESC.org or contact
Noah Fay at NFay@DESC.org or Hector Herrera at HHerrera@DESC.org.
 
Sources for this article include: www.DESC.org and the Housing First Partnership Conference workshop on March 13, 2014: Alcohol Management: A Practical Harm Reduction Intervention conducted by Noah Fay and Hector Herrera from DESC.

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Voices From the Field: Walking In Daylight

by Steven Samra
February 27, 2014

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Homeless and Housing Resource contributing writer Steven Samra opens up about his mental health recovery journey and from his perspective what peers need to help into support others who are experiencing acute symptoms overcome ostracism, shame, and misinformation.

I “aged out” of the mental health system at 17, after having spent much of my adolescence under the influence and control of the amphetamine Dexedrine, which was used to treat Attention Deficit Disorder for “hyperactive” children in the days before Ritalin and Adderall. For the following 23 years, I wandered from job to job, relationship to relationship, and street drug to street drug, trying to calm the anxiety and the uncontrollable need to move, talk, think, and do something—anything. I suffered classic hypomania symptoms of bipolar disorder throughout my adult life, and eventually gravitated towards those drugs to help me slow down the noise and activity in my mind and body. 

Throughout those decades, the idea of experiencing a mental health condition never really occurred to me. After all, I had been “cured” back in the 70’s, and there was no way I was “crazy”; I was just “high energy,” which frankly served me quite well until I would “overamp” and make inappropriate decisions due to my inability to gauge and tailor/control my own behavior and responses effectively.

Worse, even if I would have been self-aware that I was experiencing a mental health condition, I would have never told anyone because being branded with a “mental illness” brought with it almost certain scorn, ridicule, ostracism, and blatant discrimination from those in my immediate circle and the larger community. It wasn’t until I entered counseling and a Methadone maintenance program in early 2000 that I began to understand there was something underlying my compulsion to use, a need to self-medicate symptoms of my mental health challenges away. 

Fast forward 15 years later and today I am in the final stages of a medically supervised withdrawal from Methadone, but more importantly, I am acutely aware that I suffer from some mental health challenges, exacerbated by trauma experienced as a youth and the repeated retraumatization—accompanied by “collateral” trauma—of decisions and behaviors related to a life spent in addiction. 

Today, I wear the scars of my addiction and underlying mental health conditions on my sleeve. I do so because when I was open to and seeking treatment, I didn’t ask the service deliverer I approached whether they were “addiction” or “mental health.”  I asked, “can you help me figure out what is going on inside?” Unfortunately, what I found was that very few were able to work with me on both fronts and that treatment delineation, to a large extent, continues in provider organizations today. Strides have been made, to be sure, but we as providers, as people in recovery, and as people needing the support of both groups, are still seemingly light years from effective and complimentary dual treatment options. Worse, the discrimination, ignorance, and fear of those experiencing a “mental illness” are still rampant in our communities and show little sign of abating anytime soon.

To help combat this, I and many others now talk openly, freely, and regularly about our “co-occurring” disorder and work daily to raise awareness, reduce discrimination, and promote mental health because with mental health comes not just recovery from the condition, but a liberating freedom, self-esteem, and genuine self-worth as well. We stand as a testament, along with millions of others—colleagues, friends, and peers—that recovery from both addiction and mental health challenges is not only possible, but to be expected. 

From my perspective, what my peers need to do to help support those who are both in recovery and experiencing acute symptoms is simple:

  • Provide easy to understand information that helps us identify and understand what’s happening to us as we endure our mental health challenges;
  • Offer real treatment and “return to life” options that are tailored to—and driven by—our complex needs and conditions; and
  • Suggest opportunities to join our larger community without fear of discrimination, verbal and/or physical abuse, and/or marginalization.

We are making progress every day, and the more we share about our lived experience and our journey into recovery, the more we raise awareness, smash stereotypes, and reduce the ignorance associated with mental health issues. Make no mistake; however, we still have a very long road to travel, and it will be up to us to walk in the daylight along this path so that others are unafraid—and in fact, empowered—to join us.

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Voices From the Field Blog: Will You Still Be Mine?

by Rachael Kenney
January 27, 2014

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Homeless and Housing Resource Network contributing writer Rachael Kenney illuminates the challenges that couples experiencing homelessness face in forming connections with others as well as redefining intimacy in their daily lives.

Mark: “Well, if you had three wishes, what would they be?”
Paul: “House. Job. Baby.”

Watch a few of Mark Horvath’s videos about couples and it immediately becomes clear: Couples that are homeless have a similar desire for intimacy as couples who aren’t homeless. Not just physical intimacy, but emotional intimacy; a sense of closeness and emotional warmth. But so many of the ways that we build intimacy aren’t accessible while homeless. There is no kitchen in which to cook for one another, no TV to cuddle in front of, and no place to come home to together.

Paul, and his girlfriend Katie met when they were both already living on the street in London. Like many young folks on the street, they were not in school and could not secure employment, so they built intimacy by spending all of their time together, searching for resources, panhandling, and just waiting for tomorrow. One might suggest that these relationships are dangerous, that the young people glamorize homelessness and getting into relationships will just perpetuate the situation. There is some truth to this claim, as couples have more difficulty getting off the street because they often disregard housing options that won’t allow them to stay together. But dating while living on the street can also have a positive impact. For Katie, homelessness and her relationship with Paul contributed to her sobriety.

Others, like Edward and Anita, were married for twenty-two years before they became homeless. It appears that their strong foundation is what carries them through episodes of homelessness. And then there are Maria and Neville:

Maria: “[I’d wish for] a cheap little car so I can get around, and a wheelchair. Actually, a wheelchair is my priority.”
Neville: “And each other.”
Maria: “And each other. We’ve been married for four months, been together for five years. And I’ve never been happier in the sense of a relationship.”

Even with the stressors of being homeless together, these people value their relationships and work hard to maintain them. Their relationships remind them that they are valuable and worthy. They are important in at least one other person’s life.

When night falls, these three couples can be found “sleeping rough,” or on the street. Some of the reasons they do this are the same reasons that single people avoid shelters: theft, violence, and strict rules. But couples also sleep outside because most shelters can’t accommodate couples, even same-sex couples, in the same sleeping quarters. Sleeping rough may be a way to hang on to a sense of normalcy. Regardless of whether or not they are physically intimate during this time together, it gives them the opportunity to build emotional intimacy. And as they close their eyes and drift off into sleep, they can almost believe that they are holding one another in bed in their own home. And that the light from the stars and the streetlights is filtering in through the windows, rather than directly down on them from above.

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Limitless Potential

by Valerie Gold
December 20, 2013

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Homeless and Housing Resource Network contributing writer Valerie Gold recounts the experience joining a team of runners from Back On My Feet, an organization that uses running to help people experiencing homelessness change the way they see themselves and to achieve real change. 

So much of the work to address homelessness involves waiting: waiting for people’s names to rise to the top of various lists, waiting for apartments to pass inspection, waiting for replacement documents, approvals, or funds. Waiting, and its accompanying frustrations, contribute to the sense of powerlessness and hopelessness endured by many people experiencing homelessness.

As 2014 begins, Back On My Feet (BOMF) is not waiting, but instead is racing forward with its mission to use running to help people experiencing homelessness to realize their own power and to achieve real change. With the addition of two new chapters in the last twelve months, BOMF now operates running teams based in homeless shelters in eleven cities across the country. Nearly 400 individuals experiencing homelessness are running with these teams each month. Eighty-two percent report that their health is good or excellent, and 94 percent describe themselves as hopeful about their futures. And so far, 46 percent of BOMF runners have obtained employment, housing, or both.

The Monday before Thanksgiving, I joined the team of BOMF runners who live at the New England Shelter for Homeless Veterans for a pre-dawn run. The team assembled at 5:20 a.m. in the lobby of the shelter. The runners were easy to spot, bundled up in BOMF tracksuits and shod in bright new running shoes. As we waited for a few volunteers (referred to as "nonresident team members") to arrive, Eric,* a tall and friendly vet with an easy laugh, described the 5K race in South Boston that he had run the day before through a fierce wind and temperatures well below freezing. This was his first race, he said, and he almost stopped several times, but was urged on by Kathleen, BOMF’s Program Coordinator, who ran with him the entire way to set his pace and make sure that he achieved his goal of completing the event.

Once everyone arrived, we moved outside, formed a circle, did some jumping jacks to warm up, and then put our arms around one another and recited the Serenity Prayer. And then we were off. I settled in to run next to Joe, an elegantly-coiffed runner with a white goatee whose pace accelerated as the stars faded and the moon slowly set, until I nearly collapsed from trying to keep up with him. The physical suffering was worth it, as Joe was a great conversationalist, expounding upon the concepts of self-efficacy and mental toughness as I gasped and groaned and otherwise generally displayed my lack of any toughness – mental or otherwise. When I finally gave up and waved Joe on, I was immediately joined by a group of women from the Common Ground Team. One of them had her arm in a sling, and all of them shivered cheerfully as they introduced themselves and told me how long they had been on the team. I had no idea which of them were people experiencing homelessness and which of them were nonresident team members. This is part of what works about BOMF– by building teams of runners instead of groups of givers and recipients of support, of assistance, of anything but fellowship and mutual encouragement and accountability, BOMF makes it possible for people who have experienced terrible things, including great isolation, to resocialize and reconnect with others, while building or rebuilding key aspects of their identities: as athletes, teammates, morning people, or just plain survivors. At the same time, nonresident runners have the opportunity to connect in a meaningful and immediately rewarding way with people with whom they might otherwise never be engaged.

After my run, I followed the Boston BOMF staff back to the offices that they occupy, courtesy of Comcast. Victor, Kathleen, and Allison, all fearsomely fit, energetic, and passionate about their work, described their goals for doubling the number of BOMF runners in Boston, and for maximizing the positive impact of their program through strategic partnerships with homeless service providers and individualized supports for runners. They shared challenges, ranging from the easily addressed (advising a new team member that he should relieve himself before leaving the shelter as opposed to doing so mid-run in front of his teammates) to the more complex, like the heightened risk of substance abuse relapse, arrest, or other crisis occurring during the weeks between Thanksgiving and New Year’s Day. Running alone won’t eliminate this risk, of course, but it can help, and the accountability and sense of belonging that comes from being on a team provides further protection. As Victor, the Boston Executive Director, shared his plans for "over programming" with movie nights, dinners, and races during this period, his investment in the safety and success of each team member was clear.

BOMF is more than a novel idea or a promising practice. It is a reminder that the people we work with in outreach programs and homeless shelters have limitless potential for healing and growth. Running is a great way to tap into this potential. It changes a person from the inside out, and provides a daily demonstration of the lesson so eloquently articulated within BOMF’s vision statement: If we keep moving forward, we arrive someplace different, we arrive stronger and often as better versions of ourselves.

Of course, running is not the only way to move forward or fulfill potential. As 2014 begins, I challenge myself and my colleagues to stop waiting and take inspiration from BOMF to search for new and better ways to be reminded of the tremendous power that each of us holds within.

*Permission was granted by all of the individuals identified in this piece to share first names.

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Category: General | Guest Entry