Voices from the Field Blog: Taking Action on Opioid Addiction

by Kay Peavey
September 16, 2015

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Voices from the Field Blog: Toward a Meaningful Life

by Kay Peavey
August 25, 2015

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

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

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

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

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

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

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

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

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

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


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

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Voices from the Field Blog: Recovery Both Big and Small

by Katie Volk
July 15, 2015

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

by Kay Peavey
June 19, 2015

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

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

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

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

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

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

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

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

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

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

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

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

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

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

by Darby Penney
June 19, 2015

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

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

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

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

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

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

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

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

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

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

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

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

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

by Darby Penney
May 18, 2015

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Voices from the Field Blog: Consistency and Community-Based Mentoring for the Most Vulnerable Children

by Darby Penney
April 14, 2015

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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Voices from the Field Blog: Circumstances & Hope

by Darby Penney
March 16, 2015

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

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

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

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

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

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

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

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

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

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

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

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

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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.”


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/

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

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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.  

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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