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

by Darby Penney
May 18, 2015

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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Voices from the Field Blog: 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.”

References

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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Voices from the Field Blog: The Human Connection

by Darby Penney
February 17, 2015

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Homeless and Housing Resource Network Contributing Writer Darby Penney writes about New York City’s Hetrick-Martin Institute (HMI) which has focused for more than 35 years on meeting the needs of lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth. Through human connection and cultural activities, HMI makes a difference in the lives of young people, many of whom became homeless after being rejected by their families of origin.

At 3:15 pm every weekday, Annalee Fannan opens the pantry at New York City’s Hetrick-Martin Institute (HMI), and offers up donated clothing, toiletries, and snacks to the lesbian, gay, bisexual, transgender, and questioning (LGBTQ) young people who participate in HMI’s lifesaving services and programs. About 80 percent of these youth are experiencing homelessness or marginally housed, and they can take advantage of the pantry’s showers and laundry facilities, too, and stay for a hot meal at dinnertime. Fannan, the pantry coordinator for HMI’s Homeless Youth Services, gets to know members’ tastes and sense of style, and may put aside certain clothing that matches their personalities, like high-end stylish shoes and gloves. This human connection, as well as the material assistance, makes a difference in the often chaotic lives of the young people, many of whom became homeless after being rejected by their families of origin when they came out as LGBTQ. Others aged out of foster care or ran away from situations where they felt unsafe, only to end up on the streets, with a different set of urgent safety concerns.

“While it’s hard to get an accurate count, some agencies estimate that there are between 3,000 and 5,000 unsheltered youth between the ages of 12 and 24 in New York City annually,” said Fannan. “Yet there are only 250 beds in youth shelters across the city. There are a few emergency housing programs specifically for LGBTQ youth, like those offered by the Ali Forney Center, where people can stay for up to 30 days, and there are some transitional living programs, where people can stay for a year. But these resources aren’t nearly enough. And LGBTQ youth may have difficulties at shelters that do not understand their specific needs and problems. The youth we serve have limited options: many are couch-surfing, staying sporadically with friends, or sleeping on trains. We know of youth who have gotten married or gotten pregnant in hopes of finding better housing. Others use survival sex to find a place to stay, whether for the night or longer.”

While the situation in New York City is critical, the extent of homelessness among youth across the nation—particularly LGBTQ youth—is alarming. There are between 1.6 and 2.8 million young people experiencing homelessness in the United States, according to a report by the Center for American Progress, and a disproportionate number of these identify as LGBTQ: about 40 percent, compared to a rate of 5-10 percent among the general population (Quintana, Rosenthal, & Krehely, 2010). These young people tend to become homeless at very young ages: on average, gay and lesbian youth become homeless in New York City at 14.4 years of age, and transgender youth at 13.5 years. A 2012 national study of services provided to LGBTQ youth experiencing homelessness confirmed these statistics (Durso & Gates, 2012). In addition, 43 percent of youth surveyed said they became homeless when their parents forced them out of the home because of their sexual orientation or gender identity; 32 percent reported being physically, emotionally, and/or sexually abused at home.

It is not surprising, then, that LGBTQ youth experiencing homelessness have very high rates of mental health and substance use problems, violent victimization, suicidal acts, and engage in a range of HIV risk behaviors (Keuroghlian, Shtasel, & Bassuk, 2014). It is important to note that LGBTQ youth are not a homogenous population, and different subgroups have varying needs that must be understood and addressed. As Keuroghian and colleagues (2014) point out, there is a public policy vacuum when it comes to this population: “…an explicitly articulated federal health policy agenda does not yet exist to address homelessness among LGBT youth in the United States.” The Center for American Progress recommends, as a start, that discrimination against these youth should be overtly banned in all federal programs and agencies (Quintana et al., 2010).

Hetrick-Martin Institute is the nation’s oldest and largest LGBTQ youth-serving organization, and has focused for more than 35 years on meeting the needs of at-risk LGBTQ youth in New York City and beyond. For example, HMI’s newest initiative, the Center for LGBTQ Youth Advocacy and Capacity Building, advocates on behalf of LGBTQ youth by influencing policy on local, national, and international levels, while helping to build the capacity of decision-makers, individuals, and institutions that serve this marginalized population. HMI is also the founder and host agency for the Harvey Milk High School, a small, fully accredited public high school run by the New York City Department of Education for at-risk LGBTQ students who were unable to safely complete their education in traditional public high schools. HMI’s Homeless Youth Services offers a comprehensive set of direct services and referrals for youth aged 13 to 24 in an LGBTQ-friendly environment. While HMI does not provide housing, it refers youth to emergency, transitional, and permanent housing providers, and offers an array of supports. The Health and Housing staff, for example, do street outreach at the parks, piers, and other places where LGBTQ youth experiencing homelessness gravitate, working to develop trusting relationships with young people to encourage them to use HMI services.

These services include an after-school program that offers arts and cultural activities, such as dance, film, photography, painting, and theater, which are very popular with members. Tryouts for a production of West Side Story were scheduled the day Fannan and I spoke, and HMI regularly hosts vogueing and ballroom events, which serve as both an outreach tool and entertainment. In addition, HMI’s after-school program (which is open to youth whether or not they are attending school), offers health and human services such as mental health and substance abuse counseling, HIV testing, job readiness and career exploration, and housing referral.

Housing and homeless service providers need training on cultural competency that is specific to LGBTQ youth, Fannan believes. Too many providers— including foster care agencies, housing providers, and behavioral health organizations—are not familiar with the varieties of LGBTQ youth cultures, and this can interfere with serving these young people appropriately. “Providers need to meet these youth where they are,” Fannan said. “There’s a need for more harm reduction programs and staff who understand the lives of these young people.”

References

Durso, L.E., & Gates, G.J. (2012). Serving our youth: Findings from a national survey of service providers working with lesbian, gay, bisexual, and transgender youth who are homeless or at risk of becoming homeless. Los Angeles: The Williams Institute with True Colors Fund and The Palette Fund.

Keuroghlian, A. S., Shtasel, D., & Bassuk, E. L. (2014). Out on the street: A public health and policy agenda for lesbian, gay, bisexual, and transgender youth who are homeless. American Journal of Orthopsychiatry, 84(1), 66.

Quintana, N.S., Rosenthal, J., & Krehely, J. (2010). On the streets: The federal response to gay and transgendered homeless youth. Washington, D.C.: Center for American Progress. Available at: https://cdn.americanprogress.org/wp-content/uploads/issues/2010/06/pdf/lgbtyouthhomelessness.pdf

For more information about Hetrick-Martin Institute, visit http://www.hmi.org/


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Voices from the Field Blog: Planning Low-Demand Housing for People Living with HIV/AIDS and Experiencing Homelessness

by Darby Penney
January 21, 2015

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Homeless and Housing Resource Network contributing writer Darby Penney describes how the Damien Center in Albany, New York is rebuilding after a devastating fire, expanding its services to include low-demand housing for people living with HIV/AIDS who are experiencing homelessness.

When the Albany (New York) Damien Center, a grassroots support program for people living with HIV/AIDS, lost its building to fire in August 2013, no one envisioned that a vital new service for its members might someday be born out of the ashes. Staff and members struggled to rebuild the sense of safety and community that the Damien Center had provided since 1990, hastily setting up temporary operations in the First Lutheran Church. For months, everyone was in shock, working to slowly replace what was lost and attempting to reconnect with members, many of whom stayed away after the fire damaged the only place where they felt safe. As a new board member, I was in shock, too, trying to provide practical help, but not yet quite clear how I could be most useful.

Months passed with no settlement from the insurance company. While extremely grateful for the church’s hospitality, Executive Director Perry Junjulas felt like the organization was in a holding pattern, unable to plan for the future. Staff, members, volunteers, and board members were traumatized by the many losses, and the strain took a toll on everyone. It was a trying time for our community.

Amidst this uncertainty, Tracy Neitzel, a visionary leader in homeless services in New York’s Capital District, began a conversation with Junjulas about the possibility of branching out to provide low-demand permanent supportive housing for people living with HIV/AIDS. Junjulas was well aware of the desperate need for stable housing among Damien Center members, about 40 percent of whom are homeless or precariously housed. However with no experience administering housing programs, initially this idea seemed like a stretch. But Neitzel, recently retired after 22 years as executive director of Joseph’s House and Shelter in Troy, New York, was persistent and encouraging. A pioneer in harm reduction and Housing First approaches to homelessness, she noted that the Damien Center’s practice of accepting members as they are, without imposing extensive rules, was in sync with low-demand housing models for people experiencing homelessness.

Junjulas, too, recognized the commonality in the approaches and became intrigued by the possibility of redefining the organization’s mission to include housing. “There is a big need for this approach to housing for our members. They struggle with lots of challenges beyond HIV/AIDS, like poverty, mental health, and substance abuse disorders,” he said. “There are other local housing programs for people with HIV/AIDS, but they impose strict rules that many of our members are incapable of meeting, because their lives are often in chaos. Many members are trauma survivors, and these kinds of rules kick up their trauma responses.”

The turning point came when Neitzel arranged for Damien Center board members to tour Hill Street Inn, a low-demand permanent supportive housing program for people unable to deal with rule-bound housing. The building—funded by state and federal money and designed by architect Owen Neitzel, Tracy’s husband—offers 18 studio apartments and two one-bedroom apartments for couples. “We believe in no rules without reasons,” Neitzel said, “and all of our rules are safety-based. People don’t need to be sober to live here; people can smoke in their own apartments, just like anyone else. We find that people often make changes in their behavior when they know it improves their chances of keeping their apartments, because having their own place is very important to them. But we don’t ask people to adhere to rules except those that ensure everyone’s safety.”

The tour opened board members’ eyes to new opportunities. Talking with tenants at the Inn, we saw first-hand the dramatic effect that having a safe place to call one’s own had on people with long histories of homelessness who had trouble with arbitrary rules. We also learned about the intersection of HIV/AIDS and homelessness. The numbers of people living with HIV/AIDS who move into Joseph’s House supported housing is disproportionally high, without any outreach or active recruitment.

As the National AIDS Housing Coalition (NAHC) points out, people experiencing homelessness have higher rates of HIV infection than the population at large, and people living with HIV/AIDS are at greater risk of homelessness than the population at large. NAHC has also demonstrated that “housing assistance is a powerful and cost-effective way to improve HIV health outcomes and prevent new infections” (National AIDS Housing Coalition, 2013).

With the board energized and committed to the new vision, plans moved fast. The insurance company settled and a new property, located close to Albany Medical Center, the regional HIV/AIDS treatment center, is under contract to be purchased. The Damien Center proposes to build a new center there, designed by architect Owen Neitzel, which will include its agency headquarters and program space, as well as 20 units of low-demand permanent supportive housing to serve 22 people living with HIV/AIDS.

New York State’s Homeless Housing and Assistance Program (HHAP) has funds available for capital construction costs. Tracy Neitzel helped the Damien Center prepare and submit a HHAP grant in the fall of 2014; a decision on this grant is expected soon. Beyond capital costs, the major concern is how operating costs will be sustained. The Damien Center will have access to some housing subsidies for eligible people, which recently became available after other local programs closed. Without such subsidies, the monthly rent would not be affordable for people who rely on disability benefits.

Meanwhile, Junjulas has cultivated relationships with neighbors, civic groups, and politicians to educate them about the need for and benefits of the proposed housing project. These efforts have been successful in building strong community backing, including the support of the neighborhood association and Common Council members. The zoning board approved the project, and groundbreaking is anticipated in the spring of 2015. When the program opens, hopefully in spring 2016, it will be the only Housing First model available in Albany for people living with HIV/AIDS.  

References:
National AIDS Housing Coalition (2013). Housing is HIV Prevention & Care (fact sheet). Available at http://nationalaidshousing.org/PDF/FactSheet.pdf

More information about the Albany Damien Center is available at http://www.albanydamiencenter.org/

More information about Joseph’s House and Shelter is available at http://www.josephshousetroy.org/

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

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Voices from the Field Blog: Child Homelessness: A National Crisis

by Darby Penney
December 11, 2014

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Homelessness and Housing contributing writer Darby Penney interviews Ellen Bassuk, primary author of America’s Youngest Outcasts: A Report Card on Child Homelessness, on the expanding crisis of family and child homelessness. Between 2012 and 2013, the rate of homelessness among children rose by eight percent nationally. Yet most states’ efforts are not sufficient to address the crisis.

“Family and child homelessness is a crisis and it is not getting the attention it deserves,” said Ellen Bassuk, M.D., primary author of America’s Youngest Outcasts: A Report Card on Child Homelessness. The report was released in November 2014 by The National Center on Family Homelessness at American Institutes for Research. Between 2012 and 2013, the rate of homelessness among children rose by eight percent nationally. “That means that 1 in 30 American children—2.5 million—were homeless in 2013,” Dr. Bassuk, founder and former president of The National Center on Family Homelessness, said. “These are historically high rates. In 1988, families accounted for about one percent of people experiencing homelessness; now, it’s about 36 percent.” The report rates each state and the District of Columbia on four dimensions: extent of child homelessness, child well-being, risk for child homelessness, and state policy and planning efforts. As the report shows, the number of children who experience homelessness continues to climb sharply, yet most states’ efforts are not sufficient to address the crisis.

The typical family experiencing homelessness in 2013, according to the report, consists of an African-American mother under the age of 27 with two small children; 51 percent of children who experience homelessness are under the age of six. Domestic violence, sexual abuse, and other types of interpersonal violence are widespread among this group of women; 90 percent have experienced severe trauma. “This young mother is likely to be relatively uneducated and has little opportunity to earn a living wage that could support her family,” said Dr. Bassuk. “And because she is low-income and has young children, she needs but can’t afford, childcare to hold a job. Add to this picture alarming rates of domestic violence, and this woman is behind the eight ball—and so are her kids.”

While progress has been made in recent years in reducing chronic homelessness among veterans and other single adults, Dr. Bassuk said the opposite is true for families. Policymakers tend to under count families experiencing homelessness because the U.S. Department of Housing and Urban Development (HUD) does not count precariously housed or doubled-up families, only those living on the street or in shelters. In addition, programs designed for families experiencing homelessness tend to focus on the needs of the mother and pay less attention to the critical needs of the children. While becoming homeless is potentially traumatizing for people of any age, it is important to recognize that, when young children experience trauma, there is a relatively short window in their developmental process to address the trauma before it becomes a serious problem that affects them as adults.

“We know from the Adverse Childhood Experiences study that childhood trauma has lifelong negative effects on physical and mental health,” said Dr. Bassuk. “These children are typically facing multiple adverse events before they even enter school. Two-thirds of homeless mothers have a history of domestic violence; one-third of them are actively fleeing domestic violence when they become homeless.”

The type of shelters available to families contributes to the destabilizing trauma experienced by children, according to Dr. Bassuk. Family shelters are often large, older houses where the entire family stays in one room. There is no privacy or safe place for children to play, and boys over the age of 12 are often not permitted. If families do not quickly find permanent housing and are forced to remain in the shelter system, 40 to 50 percent of them will break up within five years, with children being sent to live with relatives or placed in foster care, Dr. Bassuk noted. These children face almost insurmountable obstacles as they become adults and are often trapped in a cycle of poverty, ill health, and significant social disadvantages.

To compound the barriers these families face, it is very difficult—if not impossible—for them to become stably housed without access to subsidized housing, according to Dr. Bassuk. Yet the amount of subsidized housing available has actually gone down at the same time that the need has skyrocketed.

“Family homelessness is exploding because the demographics of the family have changed,” Dr. Bassuk said. “There’s a rise in female-headed households and poverty, an expansion of the low-wage economy, lack of affordable housing, increased levels of violence against women, and cuts in human service programs. Family homelessness consolidates all of our society’s gender issues in one place.”

So what can and should be done to deal with this expanding national crisis? “One thing we know is that housing is essentia,l but not sufficient to make a difference for these families,” Dr. Bassuk said. “We not only need housing, but we also need services for these kids and moms, and we need services for them in the shelters and afterwards.” While some advocates believe that children who experience homelessness should use mainstream mental health and support services, Dr. Bassuk said that does not work. It is unrealistic, she believes, to expect stressed-out homeless families to navigate the fragmented human service system to try to get help for their traumatized children at the same time they are trying to find stable housing and employment. “Six months to a year in a shelter without supportive services is a very long time in the life of a toddler,” Dr. Bassuk said. “These kids need services now!”

Resources:

America’s Youngest Outcasts: A Report Card on Child Homelessness. (2014). Waltham, MA: The National Center on Family Homelessness at American Institutes for Research. Available at: http://www.homelesschildrenamerica.org/.

A summary fact sheet of the report’s findings is available at http://new.homelesschildrenamerica.org/mediadocs/275.pdf.

State rankings are available at http://new.homelesschildrenamerica.org/mediadocs/276.pdf.

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Voices from the Field Blog: Winter Weather Preparations for Those Living Unsheltered

by Darby Penney
November 14, 2014

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Homelessness and Housing contributing writer Darby Penney discusses the onset of winter weather and what many cities have instituted in response to tragic deaths from hypothermia and other cold-related conditions to temporarily enhance access to shelter when the temperature falls.

Living on the street can be daunting and dangerous at any time of the year, but in many parts of the country, the onset of winter weather can quickly make this a potentially lethal circumstance. In response to tragic deaths from hypothermia and other cold-related conditions, many cities have instituted Code Blue programs to temporarily enhance access to shelter when the temperature falls.

In New York City, for instance, the Department of Homeless Services initiates Code Blue when the temperature falls to 32 degrees or lower, or if there are sustained winds or periods of intense snowfall. While a Code Blue is in effect, twice the usual number of street outreach vans are deployed to help locate people in need and offer them rides to shelter, assess them for medical needs, and provide warm clothing and food. In addition, people may access any of the agency's shelters and drop-in centers without going through the usual intake process. Many cities have similar programs, although the instigating weather conditions, rules, and available services vary from place to place.

But some people do not live in places with Code Blue programs, or, for a variety of reasons, may choose not to come into shelter. In some localities, people who are under the influence are not welcome to enter shelters, even during emergency weather conditions. But across the country, homelessness service providers, volunteers, and generous citizens have come up with ways to help unsheltered people survive frigid temperatures.

In Buffalo, New York, volunteers Jesse and Kristen Dixon recently founded the Code Blue Relief Mission in October 2014 to collect and distribute blankets, coats, sleeping bags, and other winter gear to people living outside. The Dixons formerly volunteered with an organization that served a similar mission but closed down last year. Realizing that people experiencing homelessness in Buffalo would otherwise go without this service this winter, the couple rallied friends, family members, and community volunteers to make sure these needed supplies are collected and distributed. Inspired by his father, a Vietnam veteran, Jesse Dixon started volunteering in order to help veterans experiencing homelessness and felt that direct outreach to individuals living on the streets of Buffalo was the best way he and his family could help. Code Blue Relief Mission has a drop-off point at a parking garage near the stadium during every Buffalo Bills home game, which brings in much-needed clothing and gear. They also solicit donations from citizens, churches, and other organizations. The group collaborates with local homeless service providers, as well as volunteers, to locate people experiencing homelessness who could benefit from their services, and they distribute the donated supplies to people living on the streets, underpasses, and other outdoor locations during evenings and weekends. Kristen Dixon said, "For me, it's very personal; it warms my heart to be able to help somebody. Basically, you hand somebody a blanket and you might be changing their lives. You don't know their story or what they've been through, but you know at that moment you were able to help them."

Chris Krager, Executive Director of Samaritan House, a homeless shelter and transitional housing program in Kalispell, Montana, also believes in encouraging local people to reach out and offer to help their neighbors who are homeless during the winter. Samaritan House, located in Montana’s remote Flathead Valley, hosts a blog, Homeless in the Flathead, which mixes inspirational reflections, the stories of people who have experienced homelessness, and requests for specific items to be donated. “Every year around this time, I post an article on the blog asking people to be neighborly, to look out for their neighbors who are homeless and cold and to help them out,” said Krager. “If people feel uncomfortable approaching a homeless person, I ask them to let me know where I can find the person, and I’ll go talk to them myself.” He also knows from experience where many of the established camps are, and drops by to offer people access to Samaritan House. It helps to bring presents, he said, noting that he always brings a blanket, a coat, some socks, or similar items when trying to establish a rapport with an individual.

During the winter, Samaritan House uses roll-away beds to help accommodate more guests than usual, going from 62 beds to 99 beds, and is still within the fire code occupancy limits. Some people are reluctant to come in during the cold, Krager said, because they currently use drugs and alcohol (Samaritan House cannot accommodate people who are actively using). For people who remain outdoors in the Montana winter, said Krager, “what’s most important are just common sense things: warm gear like boots, coats, socks, hats, and gloves.” Offering these items to people in a spirit of genuine empathy, he believes, is a way anyone can “look out for their neighbor and help them out in a neighborly way.”

Samaritan House’s blog, Homeless in the Flatland, can be found at http://homelessintheflathead.blogspot.com/

Code Blue Relief Mission has a Facebook page: https://www.facebook.com/pages/Code-Blue-Relief-Mission/801651253229259

Information about the New York City Department of Homeless Services’ Code Blue program is at http://www.nyc.gov/html/dhs/html/communications/code-blue2014.shtml

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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/

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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/.

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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.

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