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May/June 2013 Issue

Reducing Homelessness in Veterans With Mental Illness
By Kate Jackson
Social Work Today
Vol. 13 No. 3 P. 8

Homelessness affects approximately 140,000 veterans annually, according to Dennis P. Culhane, PhD, director of research at the National Center on Homelessness Among Veterans for the VA and the Dana and Andrew Stone Professor of Social Policy at the University of Pennsylvania. On any given night, he adds, roughly 60,000 veterans are without a home.

But these numbers are on track for a positive downward slide after having already fallen dramatically in the past six years. While not all agree it’s attainable, experts concede significant progress has been made toward a goal set by Eric K. Shinseki, secretary of the VA, to eradicate veteran homelessness by 2015. An array of housing programs, dedicated outreach, a housing-first approach, and homeless-specific services provided by the VA are hammering away at the statistics, Culhane says.

But for many veterans, mental health issues, including those related to PTSD, substance abuse, depression, anxiety, and other disorders are the obstacles to finding and keeping secure housing—in addition to a lack of affordable options and social and economic disadvantage.

Vicious Cycles
Mental health issues complicate and contribute to the problem of homelessness in multiple ways. “They often result in the inability to acquire the skills, supports, and opportunities for economic advancement, for housing, or good family and social relationships,” says Gary Shaheen, MPA, director of employment policy at the Syracuse University Institute for Veterans and Military Families. All of this, he says, “can shut down a person’s ability to cope and hope.”

Culhane says people with severe mental illness who do not have disabilities related to military service typically live on a fixed income of roughly $640 per month and can’t afford housing in the private market. Added to that, he says, a mental health crisis also may cause people to lose housing, perhaps by creating problems with landlords or family members, or as a result of extended hospitalizations that prevent them from making the rent.

Mental health issues not only contribute to homelessness but also may be consequences of it, says Keith Armstrong, LCSW, a clinical professor in the department of psychiatry at the University of California, San Francisco (UCSF) and coauthor of Courage After Fire: Coping Strategies for Troops Returning From Iraq and Afghanistan and Their Families. Some veterans, he notes, have no significant mental health issues until, and as a result of, becoming homeless. Sometimes, it is both.

He poses, for example, a scenario of a veteran with psychological problems consistent with a diagnosis of PTSD who may not be able to take care of the basics in life, such as paying bills. He may use what money he has on gambling, drugs, or alcohol—avoidant coping strategies to protect himself from the memories of his war experience. The combination of substance abuse and trauma exposure, Armstrong says, can lead to homelessness, and once homeless, the vet may become depressed, and a cascade of psychological problems can occur.

The mental illness piece of this tangled puzzle may be treated with medication, Shaheen notes. “That can be important, especially for removing the pain and suffering that comes with the symptoms,” particularly those exacerbated by trauma and loss of friends and fellow vets during combat. But, he says, “We need other nonclinical and personal wellness-based strategies to treat the root causes and engage individuals back into a program of recovery and rehabilitation.”

One of the major obstacles to seeking help for the mental health issues that contributes to homelessness is stigma, according to Shaheen. Issues of military identity and culture as well as fear of discrimination may stand in the way of veterans seeking available help or being receptive to outreach efforts.

Compounding the problem, Shaheen says, is the cyclical nature of mental illness and its treatment. “You just don’t take care of it like a cold. You deal with it, and it can come back. So what might prevent a veteran from admitting or seeking treatment could be fear of loss of a job, and that’s why veteran peer support can be so effective in providing motivation to seek help.”

All branches of the military and the VA, Shaheen observes, have been trying to turn that around by supporting the idea that having a mental illness is not a sign of weakness. The VA, for it’s part, “is doing a lot of outreach, a lot of messaging to returning soldiers that there’s nothing negative about seeking mental health treatment, that they needn’t suffer in silence alone,” Culhane says. Still, according to Shaheen, “There are tremendous forces that run counter to an individual’s comfort with being disclosed.”

Among the solutions targeting these problems, in addition to dispelling the shadow of stigma, is the Housing First model, along with bold federal initiatives that integrate social services to address mental health issues.

Housing First Model
Traditionally, individuals with substance abuse or mental health issues received temporary residential treatment followed by housing. Experts and agencies agree that the Housing First model, adopted by the US Interagency Council on Homelessness, the VA, and the Department of Housing and Urban Development (HUD), which provides individualized treatment after putting veterans in homes, offers homeless veterans—particularly those with mental health issues—the best chance to get off the street and stay off.

“You get them into a home first,” Shaheen explains, “to set the groundwork and build trustful relationships with service coordinators and housing specialists, and provide a context for getting the treatment and support they need.”

To keep the housing, they need to manage the mental health issues that had contributed to homelessness or lost opportunities. “It’s not that they’re getting the housing on the condition that they accept treatment. Housing First gets them a place to live and then supplies those supports that vets realize they need if they want to keep their home,” Shaheen explains. “Housing First works well with an attentive case management model, with the use of community treatment teams and trust- and support-building relationships.”

“We require our VA medical centers to enroll the chronically homeless into permanent supportive housing programs, Section 8 voucher programs, and case management regardless of whether they’re clean and sober or in treatment. We’re not trying to make them better before we get them into housing; that’s putting the cart before the horse,” Culhane notes. “The research has been fairly robust in showing that getting people into housing is the critical first step into getting them engaged in recovery.”

Meeting the Goal
According to Shaheen, “The VA has been doing a very good job through its Supportive Services for Veterans and Families Initiative” to address the problem. The new program has earmarked $300 million in grants for the fiscal year 2013-2014 funding cycles to consumer cooperatives and private nonprofit organizations that provide services to help stabilize housing for very-low-income veterans. Culhane says the aim is to get 100,000 veterans out of shelters and back into housing, help them pay for first and last months’ rent plus security deposits and moving expenses, assist them with the housing search, mediate conflicts and debt issues with family members, and connect individuals with sources of treatment.

Armstrong says, “The VA is doing a tremendous job of actually outreaching to veterans by creating [the] Supportive Housing [HUD-VASH] program and doing all it can to bring people in.” Congress has authorized 60,000 vouchers that the HUD-VASH program is providing to homeless veterans to supplement rental payments, and the VA is contributing the case management services and the treatment teams to help people get into the units and hold onto them, Culhane adds.

The Missing Piece
While the VA has worked hard to get veterans off the streets, it can’t and shouldn’t carry the lion’s share of the burden, according to Armstrong. Years ago, he observes, combating homelessness was the job of local communities, but the VA stepped up to shoulder the effort.

“That’s wonderful,” he says, “except it may end up allowing the communities to relinquish their responsibility for helping.” He explains that the solution is the VA plus the community, and there must be more community partnerships that send the message that our veterans are everyone’s responsibility—the nonprofit organizations located downtown, the businesses, and “the places where people step over homeless vets.”

Shaheen agrees that the solution is multilayered. It requires not only employers willing to hire vets transitioning out of homelessness and businesses downtown partnering to help but also cooperation among all the helping parties. “The best approach involves an integrated model of treatment and support. The social worker, peer support people, clinicians, employment staff, and housing specialists all need an equal voice in that model and to be trained in understanding how systems and services intersect and how employment best practices are delivered,” he says.

Shaheen adds that since unemployment and underemployment is one of the root causes of homelessness, a Housing First strategy also should be accompanied by a “work fast” strategy. “Both are essential in ending and preventing veteran homelessness,” he says.

Armstrong observes that it’s often the case “that when somebody steps forward, a lot of other people step backward. But we all need to step forward, whether it’s social workers or others, and be part of the solution.”

— Kate Jackson is an editor and freelance writer based in Milford, PA. She has written for Social Work Today on topics such as grief and loss, mental health, compassion fatigue, and the emotional aspects of illness.