end homelessness

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1 HELPING PEOPLE The Role of Psychologists and Recommendations to Advance Research, Training, Without Practice, and Policy Homes Report of the APA Presidential Task Force on Psychology’s Contribution to End Homelessness James H. Bray, PhD APA President 2009

2 HELPING PEOPLE The Role of Psychologists and Recommendations to Advance Research, Training, Without Practice, and Policy Homes Task Force Members Report of the APA Presidential James H. Bray, PhD Task Force on Psychology’s APA President, 2009 Baylor College of Medicine Contribution to End Homelessness Norweeta G. Milburn, PhD, Chair Semel Institute for Neuroscience and Human Behavior University of California, Los Angeles Beryl Ann Cowan, JD, PhD Children’s Hospital Neighborhood Partnership Boston, MA Seymour Z. Gross, PhD Hennepin County Mental Health Center Minneapolis, MN Allison N. Ponce, PhD Yale University School of Medicine Joseph Schumacher, PhD University of Alabama at Birmingham Paul Anderson Toro, PhD Wayne State University APA Office on Socioeconomic Status Keyona King-Tsikata Antoinette “Toni” Alvano Krysta N. Jones

3 Helping People Without Homes The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Report of the APA Presidential Task Force on Psychology’s Contribution to End Homelessness Available online at http://www.apa.org/pi/ses/resources/publications/end- homelessness.aspx Suggested bibliographic reference: American Psychological Association, Presidential Task Force on Psychology’s Contribution to End Homelessness. (2010). Helping people without homes: The role of psychologists and recommendations to advance Retrieved from http://www.apa.org/ research, training, practice, and policy. pi/ses/resources/publications/end-homelessness.aspx Copyright © 2010 by the American Psychological Association. This material may be reproduced in whole or in part without fees or permission provided that acknowledgment is given to the American Psychological Association. This material may not be reprinted, translated, or distributed electronically without prior permission in writing from the publisher. For permission, contact APA, Rights and Permissions, 750 First Street, NE, Washington, DC 20002-4242. APA reports synthesize current psychological knowledge in a given area and may offer recommendations for future action. They do not constitute APA policy or commit APA to the activities described therein. This report was received by APA Council of Representatives at its February 2010 meeting. APA Editorial and Design Group Deborah Farrell, Editor David Spears, Designer Helping People Without Homes The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy

4 Contents iv Acknowledgments Executive Summary 1 Introduction 5 Purpose 5 Background 5 Historical Context 6 Definitions and the Prevalence of Homelessness 7 Definitions 7 The Prevalence of Homelessness 7 Key Subgroups 10 Adults 10 Families With Children 11 Unaccompanied Adolescents 12 Variations Across Nations 12 Psychosocial Factors Associated With Entering and Exiting Homelessness 13 The Heterogeneity of Homelessness 13 13 Poverty Substance Abuse 14 Mental Illness 15 Physical Health Problems and Illness 17 Child Welfare Involvement Including Foster Care 17 Incarcerated and Institutionalized Populations 19 Resilience, Social Support, and Resources 21 The Role of Psychologists in Ending Homelessness 24 Theoretical Models 24 Conceptualization of the Survey 26 Remediation of Homelessness 29 Interventions for Homelessness 29 Clinical Applications With Homeless People 33 Prevention of Homelessness 34 Policy 36 Recommendations to Advance Research, Training, Practice, and Policy 36 Research 36 Training 36 Practice 37 Advocacy 37 38 References Helping People Without Homes iii The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy

5 Acknowledgments We would like to express appreciation to the following individuals, who shared their expertise and provided input as this report was being developed: Margot Ackermann, PhD, Homeward, Richmond, VA Elizabeth Arnold, PhD, Wakeforest University Peggy Bailey, Corporation for Supportive Housing John Buckner, PhD, Children’s Hospital Boston Dennis Culhane, PhD, University of Pennsylvania Barbara Duffield, National Association for the Education of Homeless Children and Youth Peter Fraenkel, PhD, City College of New York Jennifer Frey, PhD, On Our Own of Maryland, Inc. Daniel Herman, PhD, Columbia University Charlene Le Fauve, PhD, Substance Abuse and Mental Health Services Administration Suzanne Wenzel, PhD, University of Southern California We also appreciate the expertise and input provided during the development of the report by the following boards and committees of APA: the Board for the Advancement of Psychology in the Public Interest; the Board of Scientific Affairs; the Committee on Aging; the Committee on Children, Youth, and Families; and the Committee on Ethnic Minority Affairs. Helping People Without Homes iv The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy

6 Executive Summary The Prevalence of Homelessness Purpose The 2009 Presidential Task Force on Psychology’s The task force adopted an inclusive definition of Contribution to End Homelessness was commissioned by homelessness: Homelessness exists when people James H. Bray, PhD, during his tenure as president of the lack safe, stable, and appropriate places to American Psychological Association (APA). The mission live. Sheltered and unsheltered people are of the task force was to identify and address psychosocial factors and conditions associated with homelessness and to homeless. People living doubled up or in define the role of psychologists in ending homelessness. overcrowded living situations or motels because of inadequate economic resources are Introduction included in this definition, as are those living Each year between 2–3 three million people in the United in tents or other temporary enclosures. States experience an episode of homelessness (Caton et al., 2005). The psychological and physical impact of The episodic and transient nature of homelessness makes it homelessness is a matter of public health concern (Schnazer, difficult to estimate its prevalence accurately. In this report, Dominguez, Shrout, & Caton, 2007). Psychologists as the task force used prevalence data contained in the U.S. clinicians, researchers, educators, and advocates must expand Department of Housing and Urban Development’s (HUD; and redouble their efforts to end homelessness. 2009a) assessment of homelessness report to Congress and the U.S. Conference of Mayors’ (2009) report on hunger Historical Context and homelessness. HUD reported that 1.6 million people Beginning in the 1980s, a large body of research on were without homes in 2008, but this is likely to be an homelessness began to emerge, spearheaded by researchers underestimate of the number of people living without and policy analysts from a number of disciplines, including homes. In the United States, the overall population of people psychology (Buckner, 2008; J. M. Jones, Levine, & living without homes can be divided into several subgroups, Rosenberg, 1991; Kertesz, Crouch, Milby, Cusimano, & including individual adults; families with children; and Schumacher, 2009; Shinn & Weitzman, 1990). This report, unaccompanied youth who have left home, run away, or while not all-inclusive, is derived from the body of research “aged out” of foster care placements. on homelessness, as well as from clinical practice that has developed over the past 25 years and that continues to develop. Helping People Without Homes 1 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy

7 Psychosocial Factors Associated With The Role of Psychologists in Ending Entering and Exiting Homelessness Homelessness Among those living without homes are people of all ages, Models that describe how people become homeless include races, ethnicities, cultural backgrounds, sexual orientation, micro- and macro-level perspectives. Promising theoretical and immigration status. Homelessness occurs when a models that demonstrate how psychology can better address cascade of economic and interpersonal factors converge in homelessness include the (Goodman, Saxe, trauma model & Harvey, 1991), the risk amplification model the lives of people marginalized in society. When compared (Whitbeck & Hoyt, 1999), and the with the general population, people living without homes (Toro, Trickett, Wall, ecological model & Salem, 1991). To document psychologists’ current views have poorer physical health, including higher rates of tuberculosis, hypertension, asthma, diabetes, and HIV/ and activities related to homelessness, the task force designed AIDS (Zlotnick & Zerger, 2008), as well as higher rates and conducted a Web-based survey through the APA Public Interest Directorate in coordination with the APA’s of medical hospitalizations (Kushel, Vittinghoff, & Haas, 2001). Although poor people with alcohol or substance Center for Workforce Studies. While the survey suggests dependence and/or mental illness are clearly at greater that psychologists are significantly involved in a wide range of activities in relation to people who are homeless, the risk for becoming homeless and face additional barriers to exiting homelessness, the majority are not involved time they spend on these activities is relatively short. Other in alcohol or substance abuse or suffering from mental findings related to working with subgroups, barriers, and disorders. The remediation of homelessness involves attitudes are presented in this report. addressing the risk factors that contribute to homelessness as Remediation of Homelessness well as advocating for structural changes, such as increased low-income and supportive housing. As researchers, Efforts to remediate homelessness address individual factors, clinicians, and advocates, psychologists can contribute to prevention measures, and public policy. The task force preventing homelessness and, where it occurs, intervening to reviewed efforts to remediate homelessness at the individual expedite a return to stable housing. level, including providing housing and a range of supportive services, such as addiction treatment, mental health A strong association exists between child welfare agency services, medical treatment, intensive case management, involvement and homelessness. The pathway between assertive community treatment, critical time intervention, foster care and adult homelessness is complex. History and ecologically based family therapy. The following areas of incarceration is associated with a significantly higher meant to characterize the clinical relationship between the likelihood of being homeless (Burt, Aron, Lee, & Valente, psychologist and people experiencing homelessness are also 2001), and former prisoners are at increased risk for discussed: building trusting relationships, working as part of recidivism when homelessness is involved (Metraux a team, assisting with welfare benefits, self-care, hands-on & Culhane, 2004). There is also a strong link between treatment, and detecting other conditions. homelessness and hospitalization. Many argue that deinstitutionalization is directly responsible for the problem Although existing literature devotes considerable attention of homelessness and for the people who have serious mental to treatment-oriented approaches for dealing with the social illness; however, lack of comprehensive services—especially problem of homelessness, psychologists, other researchers, supportive housing—likely has a greater impact. Finally, and policymakers have only recently begun to consider ways much research and discussion focus on the negative to prevent homelessness from occurring in the first place mental health outcomes associated with homelessness, (Burt, Pearson, & Montgomery, 2007; Haber & Toro, 2004; despite evidence indicating that many people without Lindblom, 1996; Shinn & Baumohl, 1999; Toro, Dworsky, housing function quite well (Buckner, 2008; Cowan, 2007; & Fowler, 2007; Toro, Lombardo, & Yapchai, 2003). These Haber & Toro, 2004; Masten & Sesma, 1999). By also strategies are discussed in this report. Finally, the report understanding protective factors, including social support attempts to explain the significant variation in rates of that fosters resilience among adults, adolescents, and families homelessness across developed and underdeveloped nations living without homes, psychologists can develop targeted in order to assist in identifying and tackling the root causes prevention and intervention models. of homelessness around the globe. Helping People Without Homes 2 Executive Summary The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy

8 of such training should include better understanding of Recommendations psychosocial factors associated with both the entrance In their roles as clinicians, researchers, and educators, into and exit from homelessness. Educational program psychologists have unique contributions to make to the content should strive to dispel stigma associated with remediation of homelessness. The task force endorses homelessness as well as with pervasive mental illness and the following research, training, practice, and advocacy to promote strength-based approaches to working with recommendations as vehicles by which the discipline of marginalized populations. psychology can contribute to ending homelessness under the leadership of the American Psychological Association. Practice In accordance with APA guidelines that encourage research psychologists to provide clinical and other services to To further address the causes, course, prevention, and marginalized and underserved people, the task force remediation of homelessness, social science researchers are recommends that psychologists: encouraged to: • Provide strength-based clinical and assessment services to • Direct research efforts toward prevention of homelessness populations who are homeless or at risk of homelessness, in marginalized and vulnerable populations. including families involved with child welfare agencies, Design and disseminate evidenced-based interventions for • children in foster care placements, unaccompanied work with those currently experiencing homelessness. youth, persons experiencing alcohol or illegal substance dependence, and persons of all ages identified with • Engage in program evaluation with a focus on pervasive and/or chronic mental illness. mechanisms that support rapid return to permanent housing and methods for sustaining housing in vulnerable • Maximize the use of clinical and assessment services by populations. providing them in accessible settings and at times that reflect the needs of the populations served. Conduct research on service utilization among chronically • and pervasively mentally ill populations at risk for • Create meaningful collaborations between psychologists, homelessness. social workers, case managers, nurses, physicians, teachers, and schools to best serve the multifaceted needs of • Investigate methods to promote resilience in at-risk individuals at risk of homelessness or those who currently populations, including children and youth. are without stable housing. training advocacy To enhance the ability of psychologists to work effectively To prevent an increase in homelessness, to better address the with populations at risk of homelessness or currently living needs of those currently without housing, and to promote without homes, the following education and training are the rapid exit from homelessness where it currently exists, recommended: psychologists are encouraged to advocate at the state, local, Incorporate into graduate school curricula theoretical • and federal levels as follows: and applied perspectives of working with diverse and Advocate for legislation that would fund supportive • underserved populations at risk for homelessness. housing as well as safe low-income housing in urban, • Develop practicum and internship placements that allow suburban, and rural areas. trainees opportunities to work with at-risk populations Advocate for legislation that would provide a range of • including sheltered families and adults, children in foster needed services, including mental health services to at-risk care placements, unaccompanied youth, individuals with families, unaccompanied youth, and children and adults chronic mental illness, and persons with substance and with disabilities. alcohol dependence. • Advocate for funding for targeted counseling services, • Create continuing education programs that encourage education and job training opportunities for youths in psychologists to engage in work with populations foster care, and transitional services for those returning to experiencing homelessness. home placement and/or communities. Enlist psychologists to offer appropriate mental health • education programs to service providers, charitable groups, community volunteers, and the public at large. The focus Helping People Without Homes 3 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Executive Summary

9 Advocate for an increase in substance abuse and alcohol • treatment programs, including services that promote the strengthening of families. • Advocate for health care coverage for those without homes and those at risk of losing stable or permanent housing. Advocate for education and job training and after-school • and day care programs to support poor families. Advocate for debt forgiveness programs for psychologists • and others engaged in research on the prevention or amelioration of homelessness. Advocate on an individual basis for persons in need of • services, including low-income housing, supplemental income, food, and benefits. Helping People Without Homes 4 Executive Summary The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy

10 Introduction factors associated with entering and exiting homelessness; Purpose presenting the results and implications of a survey about the The 2009 Presidential Task Force on Psychology’s role of psychologists in ending homelessness; identifying Contribution to End Homelessness was commissioned how homelessness can be remediated through prevention, by James H. Bray, PhD, during his tenure as president intervention, practice, and policy; and recommending how of the American Psychological Association (APA). The psychology can advance training, research, practice, and creation of the task force reflects Dr. Bray’s understanding policy to end homelessness. of the unique role of psychologists as both researchers and practitioners in working with people living without housing Background and the potential for the profession to improve outcomes Each year between 2–3 million people in the United States in this vulnerable population. The mission of the task force experience an episode of homelessness (Caton et al., 2005). was to identify and address psychosocial While predominantly concentrated in factors and conditions associated Homelessness is tied to economic urban areas, homelessness also occurs with homelessness and to explore the instability and an insufficient supply in suburban and rural locations across multifaceted role of psychologists in of affordable low-income housing. the country and affects people across ending homelessness. the life span, from newborns to the In addition, the task force was to provide recommendations elderly (U.S. Conference of Mayors, 2009). For most people, on how APA can advance the association’s mission statement homelessness is a relatively short experience and one that in three specific areas: does not recur (Culhane, Metraux, Park, Schretzman, & Valente, 2007). Yet for approximately 10%, homelessness is • The role of psychologists in providing clinical services to long term and/or cyclical. marginalized people, including those living without homes. Great diversity—in age, gender, race, ethnicity, and sexual • Remediation of homelessness through prevention and orientation—exists among populations living without homes. intervention research. Overly represented among such populations are ethnic • The advancement of training, research, practice, and and racial minorities. Homelessness is tied to economic policy efforts associated with homelessness within the instability and an insufficient supply of affordable low- field and in the community at large. income housing. A significant majority of people who This report addresses these three areas by providing a lose housing are extremely poor. The economic downturn historical background for understanding homelessness beginning in 2007 resulted in a new surge of family and current knowledge about the conceptualization and homelessness as more advantaged people lost their homes prevalence of homelessness; describing the psychosocial Helping People Without Homes 5 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Executive Summary

11 “bums,” “panhandlers,” and “street people.” Unfortunately, because of job layoffs, high unemployment, and lost savings derisive terms have persisted in common parlance over the (U.S. Conference of Mayors, 2009). years, contributing to the continued marginalization of The psychological and physical impact of homelessness is a people living without stable housing (Toro & McDonnell, matter of public health concern (Krieger & Higgins, 2002; 1992). Many today still refer to people without homes as Schnazer et al., 2007; M. Y. Smith et al., 2000). Many people “the homeless,” a monolithic and stigmatizing classification who lose housing have preexisting chronic health conditions that is dehumanizing (Milburn, Ayala, Rice, Batterham, & (Schnazer et al., 2007). For some, living in shelters or on the Rotheram-Borus, 2006; Phelan et al., 1997). street exacerbates underlying conditions and vulnerabilities Beginning in the 1980s, a large body of research on (Schnazer et al., 2007; Wilson, 2005). Children living homelessness began to emerge, spearheaded by researchers without homes lose opportunities for consistency and a and policy analysts from a number of disciplines, including sense of place that nurture healthy development; as a result, psychology (Buckner, 2008; J. M. Jones et al., 1991; Kertesz they are apt to suffer long-lasting academic and emotional et al., 2009; Shinn & Weitzman, 1990). Over the past repercussions (Cowan, 2007; Donahue & Tuber, 1995). 25 years, social and behavioral science, as well as medical Adults and children without homes often lack access to research, has grown and taken a more nuanced approach to health care treatment (Kushel et al., 2001). In addition, understanding homelessness. Scholarly attention has focused homelessness carries a stigma that diminishes self-esteem on investigating subgroups of the homeless population, for many (Phelan, Link, Moore, & Steuve, 1997). The including families, adolescents, and persistently mentally human cost of homelessness erodes health and potential ill people. A robust literature has identified risk factors (Herman, Susser, Streuing, & Link, 1997; Koegel, Melamid, that contribute to homelessness and protective factors that & Burnam, 1995). Psychologists as clinicians, researchers, may deter it (Buck, Toro, & Ramos, 2004; Buckner, 2008; educators, and advocates must expand and redouble their Culhane et al., 2007). Research has also begun to explore the efforts to end homelessness. interface of homelessness with mental and physical illnesses, Historical Context such as substance abuse, HIV/AIDS, and co-occurring disorders (M. Y. Smith et al., 2000). Models for interventions Homelessness is not a new phenomenon. Throughout with homeless populations have also been reported (Fraenkel, American history, especially during times of economic 2006). This report, while not all-inclusive, is derived from decline and uncertainty, individuals and families have the body of research on homelessness, as well as from clinical lived without stable or appropriate housing (Rossi, 1989). practice that has developed over the past 25 years and that The scholarly investigation of homelessness is likewise continues to develop. well established (for a more complete historical review, see Milburn & Watts, 1985); accounts of homelessness can be found in both historical and literary works (e.g., Clemens, 1917). Sociological and anthropological studies of homelessness began in the United States and Great Britain in the early 1900s (N. Anderson, 1923) and continued through the Great Depression (Caplow, 1940; Cross & Cross, 1937; Culver, 1933; Locke, 1935; Outland, 1939) and into the late 1960s (Bahr, 1969; Bogue, 1963; Levinson, 1957, 1963). Conceptualizations of homelessness, as well as the nomenclature given to those without homes, have shifted over the years. During the Great Depression, those without housing were referred to as “tramps,” “vagrants,” and “migrant laborers.” In the 1950s and 1960s, people without housing were widely depicted as chronically alcoholic men who lived on “skid row.” With the deinstitutionalization movement of the 1970s, people who were seriously and persistently mentally ill became equated with homelessness (Arce, Tadlock, Vergare, & Shapiro, 1983; Ball & Havassy, 1984). Such people were often described as “bag ladies,” Helping People Without Homes 6 Introduction The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy

12 Definitions and the Prevalence of Homelessness circumstances, those in temporary institutional settings who Definitions lacked prior stable housing, unaccompanied youths, and Defining homelessness is not without controversy. victims of domestic violence. Disagreement among policymakers, government officials, While these two laws and others underscore living social scientists, and advocates exists over conditions that conditions that are commensurate with homelessness, many constitute homelessness, and by extension, who “is” or “is statutes and policies are not as inclusive. For example, many not” considered to be homeless (Toro & Warren, 1999). incarcerated adults and juveniles, children in foster care Such debates have far-reaching implications. For example, placements, and indigent patients admitted to psychiatric narrow definitions of homelessness may preclude people and other hospital settings lack stable housing in the having access to housing subsidies and vouchers, emergency community, yet by statute, these people do not meet the shelter and/or transitional housing programs, and specific criteria for homelessness (Toro & Warren, 1999). People social service programs. While consistent statutory who are discharged or released early from institutional definitions of homelessness have not been adopted, federal, settings and are not protected by statute may be at risk of state, and local laws identify ranges of criteria that create a imminent homelessness or of resorting to living on the definitional construct of homelessness. streets (Kushel, Hahn, Evans, Bangsberg, & Moss, 2005). A particularly inclusive federal definition of homelessness For purposes of this report, we adopted an inclusive is contained in the McKinney-Vento Education Act of definition of homelessness. Homelessness exists when people 1986 (see http://uscode.house.gov/download/pls/42C119. lack safe, stable, and appropriate places to live. Sheltered ), a law that entitles children to remain in local public txt and unsheltered people are homeless. People living doubled schools despite their loss of housing. Children and families up or in overcrowded living situations or motels because of are considered to be living without homes if they stay in any inadequate economic resources are included in this definition, setting unintended for human habitation or doubled up with as are those living in tents or other temporary enclosures. relatives or friends. Unaccompanied youths, including those Gender, age, disability, or other personal characteristics are who run away (e.g., leave home without parental permission), not included in this definition of homelessness. are afforded protection under the McKinney-Vento Act. Other federal statutes have not considered adults living in The Prevalence of Homelessness motels or with friends or relatives as being homeless. More recently, the Homeless Emergency Assistance and Rapid Many people live without housing for relatively brief periods Transition to Housing (HEARTH) Act of 2009 expanded (Caton et al., 2005; Culhane et al., 2007). During such the definition of homelessness to include those at imminent episodes, people are dispersed across geographical locations risk of losing housing due to eviction under specific economic among emergency shelters, transitional housing programs, Helping People Without Homes 7 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Introduction

13 These deficiencies in data collection are also reported by motels, stations, abandoned buildings, and the streets. U.S. HUD (2009a). Moreover, this model assumes that all or Others live in their cars, in campgrounds, under highways, most people living without housing use services, which is not in tunnels, and in other places that are hard to locate. necessarily accurate. The fact that many people are turned Many people live doubled up in temporary situations with away from services—or do not seek them—would suggest friends and relatives. The episodic and transient nature of that prevalence counts based on this method underestimate homelessness makes it difficult to conduct research on it or true numbers of people living without homes. ascertain accurate estimates of its prevalence. In fact, much of the literature depicts experiences of chronic homelessness Advocates for populations of homeless people regard data rather than the experiences of the majority of people who are lifetime prevalence of as more accurate than point-in-time newly or briefly without homes (Caton et al., 2005; Milburn, or period prevalence data. Politicians and policymakers Rotheram-Borus, Rice, Mallett, & Rosenthal, 2006) are more apt to accept data that may underestimate prevalence. For purposes of this report, we used prevalence The actual prevalence of homelessness is a matter of 2008 Annual Homeless data contained in the U.S. HUD’s controversy among politicians, advocates, and social Assessment Report to Congress , released in July 2009. Although scientists. Methods used for collecting data related to we cite data contained in this government report, we believe prevalence in this population underlie the debate. Two that the prevalence of current homelessness is probably point-in- predominant methods are used to collect data: higher. These data were collected prior to the downturn in and time counts . Point-in-time period prevalence counts the economy and do not account for the many people who counts are “snapshots” of homelessness, currently collected have sought but were denied services over the past year. The on one identified night in January (U.S. HUD, 2009a). In data are also more likely to capture the addition, populations of people without experiences of people who are homeless homes are counted across geographical Much of the literature depicts for longer periods. We encourage research locations. Such locations include shelters, experiences of chronic homelessness that distinguishes the experiences of those transitional housing programs, and well- rather than the experiences of the who are newly homeless from those who known places where people without majority of people who are newly or are experiencing chronic homelessness. homes may congregate, such as railroad briefly without homes. Better understanding of the experiences stations and parks. Not counted on such that precipitate homelessness is key to evenings are people living doubled up in prevention efforts. Research on strategies that support rapid the homes of others, living in their cars, or those dispersed in rehousing is also needed. unknown or hard-to-find locations. On the basis of a point-in-time estimate, the U.S. HUD Link et al. (1995) and others disputed the accuracy of point- report (2009a) noted the following regarding one night in in-time counts because many people are not in locations January 2008: where they can legitimately be included. This perspective would appear to be supported by the report of the U.S. • There were 664,414 sheltered and unsheltered people in Conference of Mayors (2009) on hunger and homelessness. the United States. This report found that across 27 U.S. cities, shelters were • 58% of such people were in shelters or transitional full, and people seeking beds and other services were turned programs; 42% were unsheltered. away (see U.S. HUD, 2009b). Similar accounts have been published in numerous national and local media outlets. It is 62% of all homeless people at that point in time were • highly conceivable that such people would not be included individuals; 38% were part of a family unit. in the point-in-time counts, and thus estimates of prevalence • 50% of the total adult population on that evening were through this method are too low. unsheltered; 27% of the families accounted for were The other method for counting people without homes—the unsheltered. period prevalence model—relies on the collective reporting • 30% of the people counted at this point in time met by a range of providers of homeless-related services over a criteria for being chronically homeless. 12-month period. Data are gathered from soup kitchens, shelters, transitional facilities, and other programs. This Although these data reflect people living in diverse locations model provides a more comprehensive count of homelessness, in the United States, 50% of the people counted were but it is not complete. Critics of this method note concentrated in five states: California, New York, Florida, inconsistency in data collection between and within agencies Texas, and Michigan (U.S. HUD, 2009a). and the failure to include all service providers as reporters. Helping People Without Homes 8 Definitions and the Prevalence of Homelessness The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy

14 March) of 2009. It indicated a significant rise in the number One-year estimates of homelessness were also reported of families with dependent children seeking shelter. These by HUD (2009a) in its one-year report. These data were data are commensurate with findings reported by the U.S. collected predominantly from shelter and transitional Conference of Mayors (2009). housing programs. During the period of October 2007 through September 2008, approximately 1.6 million people Data reported by the U.S. Conference of Mayors (2009) used shelters or transitional housing programs. Of this provided indicators of economic conditions that are total population, 68%, or 1,092,600, were individuals, while associated with increases in homelessness. Of the 27 cities 516,700 were members of a family unit. In total, HUD participating in the survey, 76% reported increased demands reported that 159,142 families were sheltered during this for shelter. Seven cities reported double-digit increases in one-year period. The number of sheltered families rose 9% in family homelessness. Eighty-two percent of cities reported 2008; the number of individuals remained stable. These data having to make adjustments in shelter accommodations do not contain information on people living doubled up or in to address the vast increase in demand for beds. Sixty-two other locations. These data also did not include information percent of cities reported that shelters allowed people to on unaccompanied youth. sleep on floors, cots, chairs, and in hallways. Fifty-two percent of cities reported that people seeking shelter were Adults using shelter beds were overwhelmingly male, routinely turned away because the shelters were filled to African American, and older than 30 years of age. Forty capacity. Eleven cities reported that a limited number of percent of sheltered adults were reported to have a disability. motel vouchers were given to people because there were no Thirteen percent of sheltered adults were veterans. Forty vacancies in shelters (U.S. Conference of Mayors, 2009). percent of sheltered males ranged in age from 31 to 50 years. The average sheltered family was headed by a female As part of its surveys, the U.S. Conference of Mayors also and comprised two to three members. Females not seeking gathers data from cities about the causes of homelessness. shelter as part of a household were significantly older than The four main reasons reported in 2009 for family those with families. Fifty percent of sheltered children homelessness were lack of affordable housing (74%), poverty were younger than 5 years of age. Most shelter services (52%), unemployment (44%), and domestic violence (44%). were provided in cities, with 32% of services accessed in Individuals reported lack of affordable housing, substance suburban and rural areas. These data are compelling in that abuse, and unemployment (U.S. Conference of Mayors, the U.S. Conference of Mayors’ (2009) report on hunger and 2009). Increased need was also reflected in an overall increase homelessness noted a sharp increase in family homelessness, in request for food assistance (26%) by many people who particularly in suburban areas. considered themselves “middle class” (U.S. Conference of Mayors, 2009). These data reflect the experiences of people Forty percent of all people seeking emergency shelter came identified as being without homes. Unaccounted for are from another shelter or residential program. Another 40% those people of all ages whose needs remain invisible but sought shelter after living in a home, either their own or nonetheless real. that of a relative or friend. One fifth of all people were most recently housed in an institutional setting such as a hospital, prison, or motel. Emergency shelter stays during the 2008 period tended to be short, with 60% of people staying in particular settings for one month or less. The average period in transitional housing was 6 months, with 20% of people staying more than a year. Lengths of stays in shelters varied according to geographical location, opportunities for alternate housing, and the characteristics of people needing shelter. Longitudinal studies of homelessness describe patterns of shelter stays associated with demographic factors (Bassuk et al., 1997; Caton et al., 2005; Koegel et al., 1995; Stein & Gelberg, 1995). In response to the economic downturn and expected changes in the prevalence of people living without housing, HUD to track relevant changes Pulse Report (2009b) published a in the populations of people without homes. This report provided limited data for the first quarter ( January through Helping People Without Homes 9 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Definitions and the Prevalence of Homelessness

15 Key Subgroups n the United States, the overall population of people including divorce, separation, and domestic violence can I underlie homelessness (Lehman et al., 2007). Prior to living without homes can be divided into several losing housing, most adults live with others, particularly in subgroups: family settings (Caton et al., 2005). Personal factors such as • Individual adults significant substance abuse and/or alcoholism, mental illness, Families with children • and criminal histories diminish opportunities to obtain employment or other income and may also contribute to • Unaccompanied youth who have left home, run away, or homelessness (Caton et al., 2005). aged out of foster care placements Adults living without housing are characterized by the We recognize that there are many diverse groups, each of fact that they are unaccompanied by minor children in which has subgroups, with particular characteristics and a household or family arrangement. Most adults live in needs. Heterogeneity exists within and between subgroups, shelters, transitional housing, on the streets, or in settings and professionals working with homeless people are urged not intended for habitation. Others may be temporarily to undergo diversity training and develop multicultural living doubled up with friends or family members (U.S. competence. Although there are both distinct and Conference of Mayors, 2009). A majority of sheltered adults overlapping service needs between subgroups, discussion without homes are men (68%), yet the number of women in of each subgroup is separate. Prevention, intervention, and this population is growing (Lehman et al., 2007; U.S. HUD, research with populations of people living without housing 2009a). Veterans constitute 13% of all sheltered adults (U.S. must focus on the context in which homelessness exists. HUD, 2009b). Adults The adult population of people living without homes has also grown older (Shinn et al., 2007). The aging of the adult Among adults of all ages, housing loss is inextricably tied homeless population is linked to several factors, including to structural factors including economic instability and a the overall aging of the U.S. population, a majority of whom lack of affordable housing (Zlotnick, Robertson, & Lahiff, live on fixed incomes. Subsidized housing for elders is 1999). Homelessness may occur following eviction, job loss, limited, and current harsh economic conditions have resulted relocation, and in some instances, natural disasters such as in the loss of employment, savings, and pension benefits. hurricanes, earthquakes, and fires (Lehman, Kass, Drake, Personal factors, such as a rise in substance abuse and mental & Nichols, 2007). Rising rates of unemployment, layoffs, illness among elderly people, may also contribute to the loss and foreclosures unseen since the Great Depression of of housing in this age group (Crane et al., 2005; Deitz & the 1930s explain the increase in homelessness in the past Wright, 2005). year (U.S. Conference of Mayors, 2009). Family upheaval Helping People Without Homes 10 Key Subgroups The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy

16 children without homes are under age 5 (U.S. Conference Research has shown that characteristics of homeless adults of Mayors, 2009). Although young children are overly vary depending on age (Hahn, Kushel, Bangsberg, Riley, represented among those without homes, growing numbers & Moss, 2006). For example, homeless single women are of families have school-aged and adolescent children as well. older on average than homeless unhoused women with Data concerning the numbers and ages of children in this children. Within the adult population, age is often associated population may be skewed. When seeking emergency shelter with personal factors such as substance abuse or mental admission, parents often do not report their children who are illness (Caton et al., 2005). In addition to the provision of living elsewhere with relatives and friends (Cowan, 2007). appropriate affordable or subsidized housing, social services As a result of shelter regulations that bar children over a designed for adult populations must take into account age as certain age, especially boys and adolescents of both genders, well as personal factors. many older children are not included in census studies. Among adults who are without housing, the vast majority Finally, as discussed in greater detail elsewhere in this are only homeless on a short-term basis (Caton et al., report, the interface between homelessness and child welfare 2005; Kuhn & Culhane, 1998). Studies report varying involvement results in many children being separated from average lengths of shelter stays, but it is widely agreed parents and the placed in foster care. These children tend not that only 10% of the adult population meet criteria for to be reported in census studies of homelessness. chronic homelessness (Caton et al., 2005). Individuals with A robust literature has investigated families that are disabilities, including pervasive mental illness, are more homeless in comparison with those that are housed likely to be chronically homeless, due in large part to a lack (Buckner, 2008). While significant differences can be of appropriate services and housing that match their needs. found in comparisons of families without homes and those Certain demographic characteristics are associated with in the general population, few differences exist between shorter periods of homelessness, including being younger, extremely poor families with housing and those without having a history of employment, and having opportunities housing (Culhane et al., 2007; Huntington, Buckner, & for rehousing with friends and family as opposed to relying Bassuk, 2008). Families that lose housing tend to have even on housing vouchers. Length of homelessness has not been fewer economic resources and more extensive histories of linked to other demographic characteristics such as gender, residential instability and relocation. race or ethnicity, educational attainment, veteran status, or marital history (Caton et al., 2005). Extremely poor families, when compared with those that are less poor, experience cumulative stressors including high For many homeless adults, rapid rehousing in the community rates of exposures to physical and sexual abuse, substance should be a priority. A number of adults need supportive and alcohol abuse, domestic and other interpersonal violence, services in the community, including job training, mental and family destabilization (Anooshian, 2005; Attar, Guerra, health care, and/or substance abuse treatment in conjunction & Tolan, 1994; Bassuk, 1993). Chronic medical conditions with their exit from homelessness. A distinct but important and untreated emotional and behavioral disturbances exist at minority are best served by supportive housing programs that higher rates among poor families than among those in the incorporate case management and other services in varying general population (Bassuk et al., 1997; Graham-Bermann, degrees at residential locations. The immediate identification Coupet, Egler, Mattis, & Banyard, 1996; Weinreb, Buckner, of the housing, employment, and other service needs Williams, & Nicholson, 2006). Poor families also are more of adults when they first enter homelessness is a critical likely to live in unsafe neighborhoods, often in conditions component of work with this population. Psychologists that are unhealthy as well as dangerous (Garbarino, 2001). can participate in such endeavors through psychological assessment and referral when appropriate, as members of Homelessness itself is a significant stressor for families. case management teams, and as advocates for programs that Many families double up with relatives and friends prior to promote rapid rehousing and supportive services. seeking shelter. Negotiating a maze of bureaucratic agencies, sometimes daily, for housing and food is exhausting for Families With Children family members of all ages. Dislocation from possessions, Families with children are the fastest growing segment neighborhoods, and important attachment figures, such of the homeless population (U.S. Conference of Mayors, as extended family members and friends, is destabilizing 2009). The majority of families without homes are headed for children and adults alike (Cowan, 2007). Families by relatively young and poorly educated single mothers who lose privacy when they enter shelters and are required to are either underemployed or not working (Aratani, 2009; adhere to new rules and regulations, which can upset family Friedman, Meschede, & Hayes, 2003). Fifty percent of hierarchies (Friedman, 2000). Many children without homes Helping People Without Homes 11 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Key Subgroups

17 are often victims of assault and robberies. Living on the have greater numbers of school absences than their housed streets can amplify maladaptive behaviors (Tyler, Hoyt, peers, compromising their academic achievement as well as Whitbeck, & Cauce, 2001; Whitbeck & Hoyt, 1999). their school adjustment and self-esteem (Masten, Miliotis, Because they lack legitimate sources of income, some youths Graham-Bermann, Ramirez, & Neeman, 1993). engage in behaviors such as sex work that place them at Typical lengths of stays in family shelters vary, in large greater risk for harm. Involvement in high-risk behaviors part due to structural factors such as inadequate supplies of and substance abuse increases exposure to HIV/AIDS as low-income or subsidized housing. In most communities, well as other sexually transmitted diseases (Cauce et al., there are long waiting lists for Section 9 housing and 2000; DeRosa, Montgomery, Hyde, Iverson, & Kipke, 2001). limited vouchers. Some communities have arcane rules and As with other subgroups, distinctions exist between requirements that obstruct families in their efforts to be adolescents who newly enter homelessness and those who rapidly re-housed (Bosman, 2009). Larger families tend to are without homes for longer periods or on a more cyclical have longer shelter stays due to a dearth of subsidized units basis (Milburn et al., 2006; Tompsett et al., 2009). Most that can accommodate more than a few people. research in this area has focused on those who meet criteria Psychologists working with populations of families without for chronic homelessness (Milburn et al., 2006; Whitbeck homes have opportunities to provide assessment and & Hoyt, 1999). Better understanding of the experiences of therapeutic services where needed. Strength-based group those entering homelessness is needed, as are strategies for interventions for families experiencing homelessness have rapid rehousing. Prevention and intervention work with shown promising results (Fraenkel, 2006; Gerwitz, 2007). adolescents who are experiencing homelessness must reflect Many families in shelter settings have experienced trauma, their age and developmental needs (Haber & Toro, 2004; and mental health interventions and trauma-focused Masten et al., 2004). interventions are needed (Health Care for the Homeless Clinicians’ Network, 2003). Shelter settings need to incorporate strategies that are trauma sensitive. Psychologists can provide mental health services to individuals and groups in shelter settings and elsewhere, but their services are also invaluable in terms of the training and support they can offer Variations Across Nations to shelter providers and staff working with the unique needs The rate of homelessness varies among developed of this population. nations, with the United States, the United Kingdom, and Canada having some of the highest rates (lifetime Unaccompanied Adolescents prevalence of 6–8% for literal homelessness), and other Adolescents living on the streets, in abandoned buildings, nations (e.g., France and Germany) having much lower stations, and other uninhabitable places, as well as in shelters rates (lifetime prevalence of 2–3%) (Toro et al., 2007; are a unique subpopulation of those living without homes Toro, Bokszczanin, & Ornelas, 2008). Explaining (Tompsett, Fowler, & Toro, 2009). Approximately 7.6% of the significant variation in rates of homelessness can 12–20-year-old youths spend at least one night per year in a assist in identifying and tackling the root causes of shelter facility (Ringwalt, Greene, Robertson, & McFeeters, homelessness across developed nations. For example, 1998). Although poverty contributes to homelessness in Shinn (2007) and Toro et al. (2007, 2008) suggested this population, causes of adolescent homelessness vary. that the breadth and efficiency of health and human One strong predictor is family conflict (Milburn et al., services across nations could help explain the variation in 2006). Some adolescents leave home because of abuse or rates. Germany and France, for example, have a strong victimization, while others who are gay, lesbian, bisexual, or array of such services, including a “guaranteed minimum transgendered may be told to leave when they express their income,” readily available national health care, and sexual orientation (Cochran, Stewart, Ginzler, & Cauce, generous unemployment benefits (Helvie & Kuntsmann, 2002). Other adolescents have aged out of foster care or 1999; Tompsett et al., 2003). Other factors posited to juvenile justice placements and have no home or community explain higher rates of homelessness include strong to which to return (Haber & Toro, 2004). With few job skills capitalist and individualist national tendencies, intense and limited income, adolescents experiencing homelessness immigration, an uneven distribution of wealth, and weak can rarely obtain safe and affordable housing. Youths living family and other social ties (Adams, 1986; Shinn, 2007; without homes are at great risk for victimization (Wenzel, Tompsett et al., 2003; Toro et al., 2007, 2008). Hambarsoomiam, D’Amico, Ellison, & Tucker, 2006) and Helping People Without Homes 12 Key Subgroups The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy

18 Psychosocial Factors Associated With Entering and Exiting Homelessness housing among blue-collar workers and the middle class The Heterogeneity of Homelessness (Aratani, 2009), the overwhelming majority of people who Among those living without homes are people of all ages, experienced homelessness were extremely poor (Burt et al., races, ethnicities, cultural backgrounds, sexual orientation, 1999). Over the past year, the number of people seeking and immigration status. Diversity also exists in the food and shelter has risen exponentially (U.S. Conference behavioral characteristics of people living without homes. For of Mayors, 2009). Nonetheless, among people seeking example, although poor people with substance abuse and/ emergency shelter for the first time, most fell well below or mental illness are clearly at risk for becoming homeless nationally established indicators of poverty (U.S. Conference and face additional barriers in exiting homelessness, the of Mayors, 2008). majority of people who are experiencing homelessness are Discrimination against racial and ethnic minority not substance abusers or mentally ill. And while some people populations long embedded in American society has resulted without homes conform to stereotypes of being isolated from in the overrepresentation of people of color, particularly family and friends, most are in regular contact with family African Americans, poor people, members. Stereotypes are dangerous, and Stereotypes are dangerous, and for and correspondingly, people who are for every psychosocial factor discussed experiencing homelessness (Barbell in this report, there is wide variation. every psychosocial factor discussed in & Freundlich, 2001; Bassuk et al., A discussion of psychosocial factors this report, there is wide variation. 1997; Burt et al., 1999). According to associated with either entering or exiting recent estimates, African Americans constitute 42% of the homelessness must take into account the multidimensional population of people living without homes, Caucasians 39%, heterogeneity of these populations. Psychologists working Latinos 13%, Native Americans 4%, and Asians 2% (U.S. with individuals and groups must be vigilant in exercising Conference of Mayors, 2008). multicultural sensitivity and recognizing the strengths and unique characteristics of all people. Economic instability is pervasive in the lives of poor people, who are most vulnerable to job layoffs, unemployment, Poverty evictions, property and personal crimes, and the long-lasting Homelessness occurs when a cascade of economic and devastation of natural disasters (Aratani, 2009). Insufficient interpersonal factors converge in the lives of marginalized food, nutrition, and associated health conditions are more people. In most cases, income, earned or otherwise, is common among poor adults and children (Alaimo, Olson, inadequate either to secure or maintain affordable housing Frongillo, & Breitel, 2001). Chronic health problems, as well (Shinn et al., 1998). Until 2008, when widespread economic as inaccessibility to medical and dental care, increase school instability resulted in a significant increase in the loss of absences and limit employment. Inadequate education and Helping People Without Homes 13 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Key Subgroups

19 expand low-income housing stock and increase supportive high dropout rates quash opportunities to earn incomes housing for disabled people are critical. Additionally, sufficient to meet rising costs of food, transportation, and community-based job training and affordable day and child care. Against a backdrop of increasing costs and targeted social services are key. For many individuals and limited assets, poor people compete for affordable housing families, services that foster the creation of community and (Rafferty & Shinn, 1991). family supports ease the transition from being homeless to Structural and psychosocial factors combine to heighten being re-housed (Burt et al., 2007). When needed, access the risk of homelessness (D. G. Anderson & Rayens, 2004; to mental health services and substance abuse treatment Buckner, 2008; Webb, Culhane, Metraux, Robbins, & is critical to support individuals and maintain families in Culhane, 2003; Wilson, 2005). American housing policies housing (D. G. Anderson & Raynes, 2004; Wilson, 2005). have not adequately addressed the needs The remediation of homelessness involves of poor and disabled people. Among the The remediation of homelessness focusing on the risk factors that contribute most obvious structural deficiency is the involves focusing on the risk to homelessness as well as advocating well-documented imbalance between factors that contribute to for structural changes, such as increased the demand for low-income, affordable low-income and supportive housing. As homelessness as well as advocating housing and its limited availability (Bassuk researchers, clinicians, and advocates, for structural changes, such et al., 1997). This disparity between psychologists can contribute to preventing demand and supply—linked to failure as increased low-income and homelessness and, where it occurs, to create new affordable housing stock, supportive housing. intervening to expedite rehousing. gentrification, discriminatory housing practices and zoning laws, condemnation Substance Abuse of unsafe or substandard housing, and foreclosures of National and international surveys of psychiatric morbidity buildings containing otherwise affordable rental units— assessing drug, alcohol, and tobacco usage helped define disproportionately burdens poor people (Aratani, 2009; and differentiate substance abuse and dependence and Lehmann et al., 2007). Community-based supportive other psychological morbidity among populations of people housing programs for people with disabilities are also few. At with and without homes. Lehman and Cordray’s (1993) the same time, high unemployment rates; the post–welfare meta-analysis of 16 epidemiological studies of populations reform restriction of TANF (Temporary Assistance for of people experiencing homelessness in the United States Needy Families) benefits to some families in need of income was performed to provide more precise estimates for the subsidy; limitations in supplemental security income (SSI) prevalence of alcohol, drug, and mental health disorders disability payments; and the continually rising costs of food from previous research providing a wide range of estimates. and other necessary items sink those who are already poor Weighted estimates were 28% for current alcohol disorder into even greater poverty (Aratani, 2009; Bassuk et al., 1997; and 10% for current drug use disorder. Huntington, Buckner, & Bassuk, 2008). Farrell and colleagues (1998) assessed substance misuse Among populations of poor people, some are at greater and psychiatric comorbidity among populations of people risk of homelessness than others (Aratani, 2009; Bassuk et experiencing homelessness by summarizing results from al., 1997; Lehman et al., 2007; Van den Bree et al., 2009). three surveys: a national household survey, a survey People with pervasive mental illness are less able to obtain of institutional residents with psychiatric disorders, lucrative or steady employment and, in the absence of and a national homeless survey. The household survey supportive housing, are more likely to be without homes. included over 10,000 households; the institutional survey Other psychosocial risks for homelessness have been well interviewed 755 people; and the homeless survey of hostels, documented in a robust literature: childhood maltreatment, night shelters, day centers, and private-sector leased including sexual and physical abuse; intimate partner or other accommodations included 1,061 people. This research types of victimization; substance abuse; dysfunctional family reviewed patterns of nicotine, alcohol, and other drug use patterns; and out-of-home placement during childhood in the different samples and examined interactions with (Caton et al., 2005; Herman et al., 1997; Koegel et al., 1995; other psychiatric comorbidity. The authors reported that Stein & Gelberg, 1995). A particularly sobering predictor of substance-related disorders were some of the most common adult homelessness is lack of stable housing as a child. mental disorders within the community, with 5% of the The exit from homelessness depends on addressing the household sample, 7% of the institutional sample, and over multiplicity of factors that contribute to the loss of housing. 21% of the sample of those without homes recorded as In accordance with new federal housing policies, efforts to Helping People Without Homes 14 Psychosocial Factors Associated With Entering and Exiting Homelessness The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy

20 homeless person. Despite this, a complex relationship does alcohol dependent. Rates of tobacco, alcohol, and other drug exist between homelessness and mental illness. use and dependence, which were dramatically higher in the sample of people without homes than in either of the other Both structural and individual factors contribute to two samples, were significantly associated with higher rates homelessness among people with mental illness and poor of psychological morbidity. mental health, including lack of safe, affordable housing, as well as potentially disabling behavioral health issues Bassuk, Buckner, Perloff, and Bassuk (1998), however, (O’Hara, 2007). While mental illness may lead to problems found that the difference in substance use disorders between that result in homelessness, it does not appear to be a those who were housed and those who were not housed sufficient risk factor on its own, based on comparisons of disappeared when income was controlled in an unmatched people who are homeless with mental illness and (a) those case-control design of low-income mothers. While the without mental illness and (b) those housed with mental prevalence of substance use and other trauma-related illness (Sullivan, Burnam, Koegel, & Hollenberg, 2000). The disorders among poor women was higher than that among symptoms associated with mental illness and substance use women in the general population (as compared with women disorders may not only contribute to a person’s vulnerability in the National Comorbidity Study), this research suggests for homelessness but may also be exacerbated by the that substance abuse may be more a result of poverty than experience of homelessness (O’Hara, 2007). simply of being labeled homeless. According to the Substance Abuse and Mental Health Future research needs to account for such intervening Services Administration (2003), lack of resources and variables, and future service planning should take into fragmented, antiquated mental health service systems account any disparities of prevalence of substance use and exacerbate the problem of homelessness for people with other psychiatric disorders in different subsections of the mental health problems. Homeless people with serious population. The rates of substance abuse among people who mental illness find it more challenging to become housed on are homeless are significant but do not seem to justify the their own and are at greater risk of chronic homelessness (U.S. drug-using stigma aligned with people who are homeless. In HUD, 2001). Between 150,000 and 200,000 people with fact, practicing psychologists and researchers may be able to disabilities, including mental illness, identify resilience and protective factors Psychologists can play a role in screening, experience chronic homelessness. in the majority who are not using drugs to reduce the length and negative assessment, treatment, and research of Meta-analysis of 16 epidemiological consequences of homelessness as it substance abuse and how it relates on studies of people in the United States relates to drug and alcohol abuse. without homes revealed the prevalence entering and exiting homelessness. of mental disorders for any Axis I Finally, youths who are homeless disorder to be 43%; for a severe Axis I disorder, 18%; and for have also been found to exhibit high rates of substance-use a lifetime severe Axis I disorder, 32% (Lehman & Cordray, disorders, including alcohol abuse or dependence and drug 1993). More recent estimates of mental disorders among abuse or dependence (Rotheram-Borus, 1993). Psychologists people living without homes range up to over 40% (Burt, can play a role in screening, assessment, treatment, and 2001; Fazel, Khosla, Doll, & Geddes, 2008), with a wide research of substance abuse and how it relates to entering variety of symptoms of mental disorders and diagnosed and exiting homelessness. mental illnesses present, including schizophrenia and other Mental Illness psychoses, mood and anxiety symptoms, paranoia, and obsessive compulsive symptoms and disorders including While rates of mental illness among people who are posttraumatic stress disorder (PTSD) (Connolly, Cobb- homeless in the United States are generally higher than in Richardson, & Ball, 2008; Olfson, Mechanic, Hansell, Boyer, the general population (twice the rate found for the general & Walkup, 1999). population, according to the Bassuk et al., 1998, study), most people who are homeless are not suffering from a mental As many as one third of people without homes in the United disorder (only 18% met criteria for current severe mental States, Australia, Great Britain, and Canada report having disorder in Lehman & Cordray’s, 1993, meta-analysis). experienced psychiatric hospitalization (Ducq, Guesdon, & Roelandt, 1997). Rates that might be expected among the Furthermore, Bassuk et al.’s (1996, 1998) research even failed general population reported from the National Comorbidity to find significant differences in mental disorders between Study (Kessler et al., 1994) estimated that nearly 50% of housed and not-housed mothers when controlling for income, challenging the common stereotype of the mentally disturbed Helping People Without Homes 15 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Psychosocial Factors Associated With Entering and Exiting Homelessness

21 chronic) and aggression; 43% reported having attempted respondents reported at least one lifetime mental disorder, suicide (Klee & Reid, 1998). and close to 30% reported at least one 12-month disorder. The risk of mental health problems may be particularly Life on the streets and in shelters is stressful and often high among adolescents living on the streets, who tend associated with victimization (Kushel, Evans, Perry, to experience more stressful events and exhibit more Robertson, & Moss, 2003) and subsequent mental psychological symptoms than do youths without homes health problems. Women who experience homelessness who have not spent time on the streets (Robertson & Toro, are at particular risk for victimization (Wenzel, Tucker, 1999; Whitbeck & Hoyt, 1999). Behavioral problems, Hambarsoomian, & Elliot, 2006). Up to 39% of homeless such as conduct or oppositional defiant disorder, may be women experience PTSD as a result of their encounters even more prevalent than mental health problems (Cauce with violence, which is three times more common than for et al., 2000; McCaskill et al., 1998; Toro & Goldstein, women in general. Experiencing nonphysical victimization, 2000). Adolescents without homes who perceive a need for such as being threatened with a weapon or theft of property, mental health services may not know where to go or which is associated with higher levels of depressive symptoms, services to access (Solorio, Milburn, Anderson, Trifskin, & and physical victimization is related to lower levels of Rodriguez, 2006). perceived safety. Consequently, perceived safety partially mediates depressive symptoms in this group (Perron, The problem of mental illness and poor mental health Alexander-Eitzman, Gillespie, & Pollio, 2008). In one study, among the homeless population affects all strata of the homelessness has also been associated with suicide among homeless—children and adults. The mental health of veterans with diminished social and environmental support children who are homeless is an area of special concern. (Lambert & Fowler, 1997). Not all children without homes experience mental health symptoms; however, the lack of predictability and More women than men who are homeless experience mental consistency in their lives makes it harder to meet their illness (Marshall, 1996). The National Center on Family psychological and developmental needs. These children Homelessness (see Buckner, Beardslee, & Bassuk, 2004) can have high rates of mental health problems (Karim, reported that 47% of homeless women meet the criteria Tischler, Gregory, & Vostanis, 2006), and compared with for a diagnosis of major depressive disorder—twice the their housed peers, these children are reported to experience rate of women in general. Women living in shelters have more disruptive behavioral disorders (Yu, North, LaVesser, a significantly increased risk of depression, and homeless Osborne, & Spitznagel, 2008). women who are on the streets rather than in shelters are 12 times at greater risk of mental health problems and three The high rates of co-occurrence of mental illness and times more likely to have fair or poor physical health and homelessness must be addressed. First, distinguishing more sexual partners than other women (Nyamathi, Leake, between those with and without severe mental illness & Gelberg, 2000; Rayburn et al., 2005). Not all homeless may be particularly important. Assertive community women are alike, however; Bassuk et al. (1996) reported on treatment offered significant advantages over standard case mental health and other characteristics associated specifically management models in reducing homelessness and symptom with mothers who are homeless. E. M. Smith and North severity in homeless people with severe mental illness (1994) studied 300 homeless women (90% of whom were (Coldwell & Bender, 2007). mothers) and concluded that mothers with their children Second, the President’s New Freedom Commission on may benefit more from increased social services. Mental Health (2003) made clear the need to address the At-risk youths living without homes also have problems public mental health system’s delivery of service to people with mental health, including mood disorders, suicide without homes and with mental illness. This population attempts, and PTSD (Cauce et al., 2000; McCaskill, Toro, is more likely to use hospitals than regular outpatient care & Wolfe, 1998; Powers, Eckenrode, & Jaklitsch, 1990; Rew, (North & Smith, 1993), which is not only more expensive Thomas, Horner, Resnick, & Beuhring, 2001; Rotheram- but results in fragmented service and less attention paid to Borus, 1993). PTSD affects as many as one third of ongoing mental health needs. adolescents without homes (Whitbeck, Hoyt, Johnson, & Finally, Shinn and Gillespie (1994) argued that although Chen, 2007), as does the co-occurrence of depression and substance abuse and mental illness contribute to anxiety symptoms with PTSD (Gwadz, Nish, Leonard, & homelessness, the primary cause is the lack of low-income Strauss, 2007). Among 14–25-year-old youths experiencing housing. Access to this housing is even more difficult for homelessness, 82% reported psychological symptoms people who are mentally ill and/or have substance abuse including depression and anxiety (sometimes severe and Helping People Without Homes 16 Psychosocial Factors Associated With Entering and Exiting Homelessness The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy

22 HIV/AIDS prevention efforts are effective for some problems. People with substance and other mental disorders subgroups, including drug addicts and adolescents living experience even greater barriers to accessible housing without homes (Schumacher et al., 2003; Rotheram-Borus than their counterparts: income deficits (low levels of et al., 2003). New research suggests that protective factors social security disability), stigma, and need for community as well as risk factors may explain high-risk sexual practices, wraparound services. Psychologists can play an important such as multiple sexual partners and unprotected sex, role not only in identifying and treating mental disorders among homeless adolescents (Tevendale, Lightfoot, & among those who are experiencing homelessness but also Slocum, 2009). in helping to reduce homelessness by providing the needed support to assist individuals in adapting to the community. Access to care and the utilization of services are important issues for people with physical health problems and illnesses, Physical Health Problems and Illness including those living without homes. While considerable Considerable attention has been given to physical health attention has been given to physical health problems and problems among people without homes (McMurray-Avila, illness in such populations, the accessibility of health care and Gelberg, & Breakey, 1999; Zlotnick & Zerger, 2008). When barriers to care are underinvestigated and not well understood compared with the general population, people without (McMurray-Avila et al., 1999). Psychologists working homes have poorer physical health, including higher rates of with populations living without homes must not ignore tuberculosis, hypertension, asthma, diabetes, and HIV/AIDS their health problems. Ways in which psychologists can (Zlotnick & Zerger, 2008), as well as higher rates of medical contribute to better health outcomes among people without hospitalizations (Kushel et al., 2001). Poor physical health homes include teaming with local Health Care for the is associated with poverty in general but seems to be more Homeless organizations; assisting in the development and pronounced among those who are without homes. Recent implementation of behavioral interventions for engagement studies document the prevalence of traumatic brain injury in treatment and adherence to it; investigating psychological in adults without homes in Canada, where men are more factors linked to health care utilization; and collaborating likely than women to report such histories. Studies with with and training other providers in stigma reduction and in smaller samples in the United States show similar findings ways to improve healthy behaviors through strength-based (LaVecchia, 2006; MacReady, 2009). Veterans without approaches that enhance motivation and reduce stigma. homes are more likely than nonveteran adults to experience recent traumatic brain injuries. Child Welfare Involvement Including Foster Care Poor physical health is related to gender, age, and ethnicity among people without homes and also varies across the key A strong association exists between child welfare agency subgroups (Munoz, Pandero, Santos, & Quiroga, 2005). involvement and homelessness. This association is best For example, homeless European American women have depicted by the intersection of three pathways: more health problems and less access to health services • Families without homes are more likely than those that than their counterparts (Arangua, Andersen, & Gelberg, are housed to have their children removed and placed 2005). Sexually transmitted diseases including HIV/AIDS in the foster care system (Bassuk et al., 1997). By some are prevalent among some subgroups of people without estimates, up to 30% of children in the foster care system homes. Age, gender, and ethnicity are linked to such HIV/ have parents who are living without homes (Harburger & AIDS risk behaviors as injection drug use and high-risk White, 2004). sexual practices (Song et al., 1999). HIV/AIDS, like other • A significant number of children who exit foster care, chronic diseases, is associated with poverty and is particularly either by running away from placements (Nesmith, problematic for some adolescents living on the streets and in 2006) or aging out upon turning 18, are likely to end up shelters (Gillies, Tolley, & Wolstenholme, 1996; Rotheram- without stable homes and resort to living on the streets or Borus, Koopman, & Ehrhardt, 1991; Rotheram-Borus et elsewhere (Mason et al., 2003). al., 2003). Sexually experienced adolescents out of home for longer periods engage in more HIV/AIDS–related high-risk Severing bonds between parents and children, including • behaviors (Milburn et al., 2006). High-risk sexual practices through foster care placement, is a strong predictor of such as unprotected survival sex increase HIV/AIDS risk homelessness and emotional dysfunction across the life for gay, lesbian, and bisexual youths living without homes span (Choca et al., 2004; Cowal, Shinn, Weitzman, (Cochran et al., 2002; Gangamma, Slesnick, Toviessi, & Stojanovic, & Labay, 2002; Herman et al., 1997; Koegel et Serovich, 2008). al., 1995; Rosenfeld et al., 1997). Helping People Without Homes 17 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Psychosocial Factors Associated With Entering and Exiting Homelessness

23 The events and circumstances leading up to the loss of Families at greatest risk of child welfare involvement are housing are fraught with great stress. With the loss of those headed by relatively young single mothers with more housing, parents, often accompanied by their children, than one school-aged or adolescent child (Park, Metraux, must negotiate a web of bureaucracies to meet everyday Brodbar, & Culhane, 2004). Other factors contributing to needs for shelter and food. Once sheltered, families are child welfare involvement are parental histories of domestic subjected to new and unfamiliar rules and rituals, displacing violence, incarceration, hospitalization, and substance abuse the autonomy of parents and establishing new hierarchies (Bassuk et al., 1997). Among families without homes and (Friedman, 2000). These changes in family structure and seeking shelter, the risk of welfare involvement is especially the challenges of living with numerous strangers can be heightened. In some instances, child welfare authorities destabilizing for adults and children (Cowan, 2007; Fraenkel, are involved with families prior to their loss of housing 2006; Friedman, 2000). Parents and children alike may (McChesney, 1995). Families may have “open” cases of child react to the cumulative stressors of homelessness with abuse or neglect that follow them once a loss of housing increased dysfunction, including explosive behaviors or other occurs (Park et al., 2004). maladaptive coping styles. Families that are newly without housing may come to the Precarious family circumstances that contribute to the loss attention of child welfare authorities because of structural of housing, including domestic violence, substance abuse, factors intrinsic to shelter systems. For example, certain and parental mental illness, in some cases legitimately shelters that restrict adolescents or male children over a raise concern about children’s well-being and create the certain age facilitate the breakup of families. In light of such need for welfare agency involvement (Health Care for restrictions, some parents attempt to place their children the Homeless Clinicians’ Network, 2003; Kittinger et al., with relatives or friends, while others are forced to resort to 2000). Suboptimal parenting practices often associated child welfare agencies rather than place children in foster with substance abuse and mental illness may result in child care (Cowan, 2007). abuse or neglect (Bassuk et al., 1997; Kittinger et al., 2000). When children are placed informally with relatives or friends, Parenting styles that include harsh physical punishment, a breakdown in arrangements may also lead to formalized neglect, or emotional abuse may be observed by residents and foster care placement (Cowal et al., 2002; Park et al., 2004). shelter staff, resulting in a mandated report to child welfare Even in those states that disallow restrictions on children agencies (Harburger & White, 2004) entering shelters, high rates of parent–child separations Foster care placement has long been associated with poor continue (Cowal et al., 2002). Significant numbers of mental health outcomes (Choca et al., 2004; Landsverk children are also forced into foster care placement by parental & Garland, 1999; Mason et al., 2003; Rosenfeld et al., entry into substance abuse treatment, jail, or a psychiatric 1997). While many children entering foster care have institution (Kittinger, Nair, & Shuler, 2000). preexisting mental health conditions, a robust literature The very fact of living in shelter environments places suggests that severing the parent–child bond, moving families under greater scrutiny and can lead to the filing children among multiple placements, and poor reunification of child protection reports with child welfare agencies planning jeopardize children’s mental health during critical (Friedman, 2000; Friedman et al., 2003). Child welfare developmental periods, often with life-long consequences authorities in many states remove significant numbers of (Nesmith, 2006; Rosenfeld et al., 1997). children from their parents simply because they lost their In the absence of other indicators, child welfare agencies homes. In these instances, agencies often make incorrect should not equate the loss of housing with neglect determinations that the inability to provide stable housing (Harburger & White, 2004). To the extent is equivalent to neglect (Harburger & Using child welfare budgets possible, caseworkers must attempt to White, 2004). Reunification under such to strengthen families in keep families intact. Parenting programs, circumstances is tied to parental ability to communities is a more practical outpatient counseling services for family find suitable housing, a Herculean feat in members in need, and enrollment in housing markets with high demand and and inexpensive proposition than prosocial community activities provide few options for low-income or subsidized foster care placements. important supports to families. Substance housing. The structural deficiencies of the abuse programs that provide placements for children as well American housing market punish parents and children for as their parents may have beneficial and long-lasting positive the lack of affordable housing and causes inordinate stress effects. Using child welfare budgets to strengthen families in for family members (Harburger & White, 2004; Park et al., communities is a more practical and inexpensive proposition 2004). Helping People Without Homes 18 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Psychosocial Factors Associated With Entering and Exiting Homelessness

24 act of foster care the ongoing imP than foster care placements. In addition to providing direct services to families, psychologists can advocate for the The pathway between foster care and adult homelessness funding of comprehensive programs that support families is complex. Foster care placement is a strong predictor and prevent homelessness. of homelessness in adulthood (Herman et al., 1997). A significant number of children in foster care have mental the exit from foster care illnesses that require treatment (Landsverk & Garland, 1999; Many children in foster care placements were neglected and Rosenfeld et al., 1997). Children in foster care placements harmed in their homes prior to entry into often do not receive the mental health care (Kittinger et al., 2000). Once removed, Foster care placement treatment that is needed and may continue to children must negotiate the disruption exhibit emotional and behavioral disturbances is a strong predictor of of contact with family members and into adulthood (Barbell & Freundlich, 2001; homelessness in adulthood. disconnection from home environments while Landsverk & Garland, 1999; Rosenfeld et al., learning to adapt to the requirements of their 1997). Continuing maladaptive behaviors may be associated foster homes. Not all foster parents are equally well trained with pervasive mental illness. In addition, inadequate or suited to the task of parenting children who are enduring community supportive services may lead to homelessness. huge psychological loss. The cyclical removal of children The severing of bonds with parents, siblings, and other wherein one foster placement is replaced with another important caregivers can have long-term destabilizing effects recreates trauma, loss, and disconnection. Foster children and affect functioning. Social and community supports may have difficulty forming attachments, which may lead to may be more difficult to create for people displaced during maladaptive behaviors, including running away. their formative years. Psychologists must use their clinical Children at highest risk of running away from foster care skills to treat children in foster care who have experienced placements are those who were older when first placed, cumulative trauma (van der Kolk, 1987). Psychologists had multiple placements, and on whom little caseworker can also provide in-service training to foster parents and resources were expended (Courtney, Piliavin, Grogan-Kaylor, caseworkers to enhance positive experiences of children in & Nesmith, 1999; Nesmith, 2006). Additional risk factors care. Collaboration with other mental health professionals for running away include limited contact with the family of to create strength-based services for youths returning to origin, authoritarian foster parents, gender identity issues, communities following foster care placement is necessary. and a prior history of elopement (Nesmith, 2006). Children Advocacy for the creation of job training and appropriate who run away from foster care placements are likely to be housing opportunities for this population is key. difficult to place in alternate settings and ultimately may end up living on the streets (Nesmith, 2006). Incarcerated and Institutionalized Populations Parents with children in foster care placements often do not receive appropriate or comprehensive reunification services incarceration (Barbell & Freundlich, 2001; Cowal et al., 2002). Contact The President’s New Freedom Commission on Mental may be lost between parents and children during foster care Health (2003) identified the eradication of the co- placements. Adolescents who age out of foster care at 18 occurrence of homelessness, mental illness, and involvement years of age, especially those who were removed from their in the criminal justice system as a national priority. The families for long periods of time, may lack a stable home to term describes the movement of people institutional circuit which to return (Barbell & Freundlich, 2001; Choca et al., between shelters, jails, prisons, and other institutions 2004) and may end up without homes (Courtney et al., 1999; in lieu of stable housing (Hopper, Jost, Hay, Welber, & Firdion, 2004; Fowler, Toro, & Miles, 2009; Fowler, Toro, Haugland, 1997), an unfortunate cycle which makes it Tompsett, & Hobden, 2006; Toro et al., 2007). In addition difficult to achieve stable residence, employment, and to lacking family connections, these youths may also lack the family ties. While the associations between homelessness, requisite education and job skills that would enable them to mental illness, and incarceration are widely established, the support themselves adequately or pay for suitable housing. multidirectional relationships are complicated and make it The same structural deficiencies that cause homelessness in difficult to firmly establish policies and interventions that adults may result in the lack of housing for this population of can interrupt the circuit. youths (Choca et al., 2004). Recent studies indicate that out The rate of homelessness among the general U.S. population of 1,087 former foster care clients, 22% experienced at least is estimated to be 1.36–2.03%, whereas the rate of recent one night of homelessness. Helping People Without Homes 19 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Psychosocial Factors Associated With Entering and Exiting Homelessness

25 Street and shelter homelessness and severity of psychiatric homelessness among jail inmates is 15.3%—an odds ratio of symptoms predict increases in nonviolent crime; sheltered 7.5–11.3% compared with the general population (Greenberg status and symptom severity also predict increases in violent & Rosenheck, 2008). Estimates of the percentage of crime (S. N. Fischer, Shinn, Shrout, & Tsemberis, 2008). incarcerated people without homes vary, but recent studies Additionally, a recent study of veterans with bipolar disorder reported 23% (Kushel et al., 2005) and 37% (LePage et showed a clear relationship between mental illness and both al., 2005). As many as 1 out of every 6 incarcerations lifetime and recent homelessness (Copeland et al., 2009). involves a person who was without housing at the time of Compared with other inmates, those with mental illness are arrest (McNiel, Binder, & Robinson, 2005). Inmates who more likely to have been homeless in the year prior to arrest have recently lost housing are more likely to have prior (Ditton, 1999). Inmates without housing are also more likely involvement with the criminal justice system and mental to have mental illness than inmates who were housed before health and substance use problems. They are also more likely arrest (Michaels, Zoloth, Alcabes, Braslow, & Safyer, 1992). to be incarcerated for property crimes, which may be a result of “survival behavior” (Greenberg & Rosenheck, 2008), and/ The majority of studies of homelessness and police contact or to be arrested for “nuisance offenses” such as indecent involve adults without homes (Thrane, Chen, Johnson, & exposure and camping without a permit (DeLisi, 2000). Whitbeck, 2008), although some research focuses on the arrest of unaccompanied adolescents and their involvement A history of incarceration is associated with a significantly with the legal system. Among a sample of adolescents greater likelihood of being homeless (Burt et al., 2001), who ran away, 44% were arrested (Thrane et al., 2008). and former prisoners are at increased risk for recidivism Externalizing disorders, including substance abuse and when homelessness is involved (Metraux & Culhane 2004). conduct disorder, are associated with arrest, and runaway Different homelessness patterns emerge for those released youth with multiple externalizing and internalizing disorders from prison as opposed to jail. Metraux and Culhane (2006) have a greater likelihood of arrest (Chen, Thrane, Whitbeck, found that over 60% of study participants released from & Johnson, 2006). Other risk factors for arrest of homeless prison began shelter stays within 30 days of release but and runaway youths include association with deviant peers, had shorter stays and reduced risk of subsequent shelter prior arrest, and sexual abuse; deviant peer association and stays, compared with those furloughed from jail. People prior arrest are the stronger factors for boys (Chapple, released from jail tended to have more extensive histories of Johnson, & Whitbeck, 2004). prior shelter stays and were at higher risk for future use of shelters. Those who experienced homelessness after release This important issue of incarceration and mental illness from jail had typically been incarcerated for relatively short is a significant societal issue. The Mentally Ill Offender periods of time, mostly less than 30 days. This sequence of Treatment and Crime Reduction Act (MIOTCRA), signed jail and shelter stays seems to indicate a sustained pattern of into law by President George Bush in 2004, authorized a residential instability. $50 million grant program to be administered by the U.S. Department of Justice and is an acknowledgment of the need Mental health and substance use problems are related to for collaborative efforts between criminal justice and mental greater risk of homelessness among inmates. Eighteen health systems. The 2008 reauthorization of MIOTCRA percent of homeless people arrested had a diagnosis of expanded training for law enforcement to respond sensitively mental illness (McNiel et al., 2005). Limited access to to people with mental illness. Athough MIOTCRA is not mental health services, especially inpatient hospitalization, designed specifically to address the needs of people without may account for some of this association (Greenberg & homes, it is reasonable to expect that it will have positive Rosenheck, 2008). In addition, when crimes are committed outcomes for those with mental illness. Given the frequency by people with mental illness who are also without homes, with which such people are arrested, the types of programs police may not identify their mental illness as a primary created through this law are extremely valuable to the welfare factor (Lamb & Weinberger, 1998). of those who are mentally ill and without housing. Co-occurring severe mental disorders and substance use disorders are of particular concern. Of inmates with mental institu tionalization illness who were also without housing, 78% had substance use and homelessness problems; in addition, increased duration of incarceration is The link between institutions and homelessness is associated with homelessness and co-occurring serious mental longstanding. Many argue that deinstitutionalization illness and substance use disorders (McNiel et al., 2005). is directly responsible for the problem of homelessness and for the people who have serious mental illness. Helping People Without Homes 20 Psychosocial Factors Associated With Entering and Exiting Homelessness The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy

26 young adults discharged from state mental hospitals in Ohio Communities lack sufficient funding to adequately address became homeless within 6 months. the needs of their members with serious mental illness. The lack of comprehensive services—especially supportive Methods to combat the problem of homelessness after housing—has an impact on homelessness. Supportive discharge from institutions include initiating discharge community-based housing programs for people with planning upon admission for those without preexisting pervasive mental illness are critical to breaking the cycle of housing (Lauber et al., 2006); establishing emotional support institutionalization and homelessness. during the transition out of the hospital to help facilitate stable housing at discharge (Kuno, Rothbard, Averyt, & There is a strong link between homelessness and Culhane, 2000); making concentrated efforts to find housing; hospitalization. People without homes have higher rates and providing income support and advocacy. Other programs of hospitalizations for physical illnesses, mental illness, include those that provide subacute, step-down, or day and substance abuse than other populations (Kushel et al., treatment support to people in their communities. Home- 2001; Salit, Kuhn, Hartz, Vu, & Mosso, 1998). Inpatient based services also foster maintenance of people in their admissions for mental illness and substance abuse account communities. Psychologists must advocate for the funding of for the majority of hospitalizations among veterans living such programs and provide clinical services to people at risk without homes. A great deal of the literature on the for homelessness in community and home settings. relationship between mental illness and homelessness focuses on people with long histories of illness and hospitalization; Resilience, Social Support, however, those new to psychiatric hospitalization are also at risk. Among adults with psychotic disorders hospitalized for and Resources the first time, 15% had experienced at least one episode of Much research and discussion focus on the negative homelessness before or within 2 years of their first admission mental health outcomes associated with homelessness; (Herman, Susser, Jandorf, Lavelle, & Bromet, 1998). however, many people without housing function quite Interestingly, over two thirds of the participants in that study well (Buckner, 2008; Cowan, 2007; Haber & Toro, 2004; experienced their homelessness episode prior to the first Masten & Sesma, 1999). For example, while homelessness hospital admission, suggesting that the homelessness was not is clearly a complex and stressful experience for children, attributable to poor discharge planning, which is frequently most do not meet criteria for clinical levels of emotional blamed in other circumstances. disturbances or behavioral dysfunction (Cowan, 2007). By understanding protective factors, including social support, The risk of homelessness after being discharged from that foster resilience among adults, adolescents, and families treatment settings is affected by such issues as self-discharge living without homes, psychologists can develop targeted against medical advice, lack of community living skills, prevention and intervention models. and paranoia that can impede attempts to locate affordable housing. Among the identified systemic issues are a Resilience is defined as “manifested competence in diminished low-income housing market; hospitals’ need the context of significant challenges to adaptation or to discharge patients once they are psychiatrically stable; development” (Masten & Coatsworth, 1998; Masten & short hospital stays, which leave less time to find suitable Sesma, 1999; Obradovic et al., 2009). Resilience is achieved housing; long wait times for public income or entitlements; when adaptation is positive in light of exposure to severe and lack of financial resources to pay for security deposits adversity or trauma. One factor consistently linked to and rent (Forchuk et al. 2008). When people do not have resilience in children is the presence of caring and supportive stable housing before admission to hospitals, they are at role models such as parents or other adults. Other factors higher risk of discharge to homeless situations (Lauber, also associated with resilience include solid cognitive skills, Lay, & Rossler, 2006). Other risk factors include showing self-esteem, realistic self-appraisal, problem-solving skills, less clinical improvement during the hospital stay, receiving and emotional regulation. fewer therapeutic measures while hospitalized, and being Masten and her colleagues have investigated factors discharged early and without follow-up care after discharge. associated with resilience in school-aged children without Adolescents are also at high risk for homelessness after homes (e.g., Masten & Sesma, 1999). Evidence of resilience being discharged from psychiatric residential treatment. among this population of children was associated with Associated factors include a history of substance abuse, a high achievement scores and positive school behavior. history of running away, being in state custody, or having In addition to solid cognitive skills and low absenteeism, experienced physical abuse (Embry, Vander Stoep, Evens, resilient children had positive relationships with parents Ryan, & Pollock, 2000). Belcher (1991) found that 35% of Helping People Without Homes 21 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Psychosocial Factors Associated With Entering and Exiting Homelessness

27 homelessness (Eyrich, Pollio, & North, 2003). According and caregivers, including teachers and attachment figures to Eyrich and colleagues (2003), social support can be who were invested and somewhat involved in their school formal or informal. Formal support, for example, is provided experiences. Participation in tutoring and mentoring by professional service providers, while informal support programs is also tied to school success. Students without is provided by family, friends, and acquaintances. Social homes have benefited academically from such programs, support can be instrumental in nature and include shelter, and the consistent and close relationship with a concerned food, or money. Support can also be emotional and include adult has been associated with increased interest in school acceptance, care, interpersonal connectedness, and concern and lower absenteeism. Mentoring programs at various sites (Benda, 2006; Johnson, Whitbeck, & Hoyt, 2005). around the country have replicated these results (Eiseman, Cove, & Popkin, 2005; Masten & Sesma, 1999; Obradovic Social support can have negative aspects, such as when it et al., 2009; Wake County Public School System, 2009). comes from people engaged in risky or unhealthy behaviors like substance use (Nyamathi, Leake, Keenan, & Gelberg, Fostering resilience in people without homes is not solely 2000) or from people who are emotionally draining or hurtful a concern for children. Families and adults benefit from (Eyrich et al., 2003). Negative interactions with network supportive relationships and enhanced competence. Work members can exacerbate stress and have negative effects on with families without homes should address all household psychological well-being (Cramer & McDonald, 1996). members. Many families have histories of trauma that affect adults and children alike (Health Care for the Homeless Despite the perception that people without homes are Clinicians’ Network, 2003). Mothers who have not had the completely isolated from social networks, many studies opportunity to heal from cumulative traumatic exposures indicate the presence of social support and connection for often lack emotional resources needed to be positive role adults, families, and adolescents. Perceived social support models or involved parents. Children living with depressed has an effect on psychological symptoms and can buffer or traumatized parents are at risk for depression and the impact of high stress on poor people who are housed or behavioral dysfunction (Bassuk, as cited in Health Care without homes (Bates & Toro, 1999; Toro et al., 2008). It for the Homeless Clinicians’ Network, 2003). Parenting appears that most homeless adults have regular contact with groups and child–parent therapeutic collaborations are family members (Bates & Toro, 1999; Toro et al., 1999). models for building resilience and adaptive coping (Fraenkel, Adolescence is prime time for development of social support 2006; Gerwitz, 2007). These interventions should continue networks as young people move from dependence and through the transition to housing and be a readily available affiliation with family to the formation of primary friend resource. Mentoring programs for both sheltered adults and and romantic supports. Social support reduces symptoms those living independently also foster resilience. of depression and adverse health outcomes for youths For adolescents, protective factors framed within a without homes (Unger et al., 1998); however, affiliation with developmental context may be linked to resilience and deviant peers is associated with increased depression (Bao, include family, peers, and social institutions such as Whitbeck, & Hoyt, 2000) and antisocial schools. Emerging research has examined behavior (Heinze, Toro, & Urberg, Despite the perception that resilience in homeless adolescents from 2004). Research indicates that 80% of people without homes are this perspective (Milburn, Rosenthal, & unaccompanied adolescents report having completely isolated from social Rotheram-Borus, 2005; Milburn et al., relationships that predate their time on 2009; Tevendale et al., 2009). Groups that networks, many studies indicate the streets and having more friends from provide ongoing support to adolescents the presence of social support and home than from the streets. Runaway once they are re-housed may prove critical connection for adults, families, and other unaccompanied youth who are to their stabilization. Increased community experiencing homelessness tend to retain and adolescents. support and focused services for social ties to family, including parents and adolescents who are gay, lesbian, bisexual, other family members; however, youths who report abuse at and transgendered are urgently needed. home are less likely to report parents as part of their network ( Johnson et al., 2005). Contact with family is linked to Social support for homeless people is conceptualized in a returning home (Milburn et al., 2009). Gay, lesbian, and variety of ways. Basic social support theory posits that people bisexual youth are significantly more likely to report having require mutual support and assistance to meet their needs social network members from the streets. (Benda, 2006). Resources are an important factor; fewer resources among the members of a network affect the ability of the network to support or protect an individual from Helping People Without Homes 22 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Psychosocial Factors Associated With Entering and Exiting Homelessness

28 There are some conflicting findings about social support for extremely poor mothers, with some studies showing less social support available to mothers without homes than to those who are housed (Bassuk & Rosenberg, 1988; Wood, Valdez, & Hayashi, 1990), and others finding few or no differences (Clinton-Sherrod et al., 2007; Goodman, 1991). There may be an intense use of support networks when a family is about to enter homelessness, yet some mothers may find that the members of their support networks are unable or unwilling to house them and thus prevent their homelessness (Shinn, Knickman, & Weitzman, 1991; Toohey, Shinn, & Weitzmann, 2004). Some studies have suggested that children may “protect” mothers from negative outcomes such as mental illness and substance abuse (Banyard, 1995; Shinn & Weitzman, 1990), yet further research is needed. Findings on social support and other resources for children without homes are also mixed. Almost half of the children in a study of psychosocial adaptation for those experiencing a housing crisis reported having no friends in their social network (Torquati & Gamble, 2001). Although the size of social support networks was not related to psychosocial adaptation, children’s satisfaction with the support received was related to less negative affect. Cowan (2007) reported that despite the fact that sheltered homeless children report a network of friends, the presence of that social support was not sufficient to influence mental health morbidity. Helping People Without Homes 23 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Psychosocial Factors Associated With Entering and Exiting Homelessness

29 The Role of Psychologists in Ending Homelessness Theoretical Models The adequacy of some macro-level models was ascertained Applying theoretical perspectives to understanding by examining the change in environment-centered factors homelessness is not a simple process. The majority of over time to account for trends in homelessness numbers. theoretical models pertaining to homelessness explain For example, Burt (1992) posited that if mental illness were how people become homeless. Others examine how responsible for increases in homelessness, there would be homelessness affects people, how people exit homelessness, an increase in rates of mental illness in the general public as or some combination of these (Goodman et al., 1991; well as in homeless populations. The rates of mental illness, Haber & Toro, 2004; Milburn & D’Ercole, 1991; Milburn however, remained relatively stable over time, despite rises et al., 2009; Rew, 2003; Toro et al., 1991; Whitbeck & in the numbers of homeless people, most notably in the Hoyt, 1999; Wright, 1998). 1970s and 1980s. Models that describe how people become homeless include Deinstitutionalization was targeted extensively as a cause micro- and macro-level perspectives. Models with micro- of homelessness, but if it directly caused the problem, it level perspectives focus on individual factors such as a would have had an immediate effect. There was, however, a family history of mental illness, current substance abuse, significant lag in homelessness rates until the late 1970s and or previous physical and/or sexual abuse. Macro-level 1980s, when former patients began to appear in significant models focus on societal, structural, or systemic problems numbers in the homeless population. Furthermore, only a with environment-centered factors such as major societal minority (perhaps about 30%) of people who are homeless economic changes (e.g., an economic depression or recession are seriously mentally ill. This suggests that other factors are that leads to decreased jobs and housing opportunities or at play (Hamberg & Hopper 1992). the deinstitutionalization of mentally ill people with the associated decreased funding of mental health treatment Most of the emphasis within psychology is on micro-level services and community-based support services). models, but there are macro-level models that adopt an ecological approach derived from Bronfenbrenner’s (1979) Macro-level theories about environmental factors associated work. These models take into account environment-centered with homelessness mainly focus on economic and social factors such as poverty, neighborhood and community trends, including the employment market, family structure characteristics, and service system characteristics (Shinn, and systems, distribution of income, limited resources, and 2007; Toro et al., 1991) and are examples of the more failure of governmental policies (Shinn, 1992; Sommer, balanced causal models emerging to account for both 2001). Such structural explanations pinpoint the causes of individual and structural factors interacting to create at-risk homelessness beyond the individual, calling for intervention populations and homelessness (Sommer, 2001). to occur on a broad societal scale (Neale, 1997). Helping People Without Homes 24 The Role of Psychologists in Ending Homelessness The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy

30 et al., 2009) that complement and build upon RAM to The most promising theoretical models that demonstrate determine how adolescents emerge from homelessness. how psychology can better address homelessness are the Assuming that socializing agents influence homeless trauma model (Goodman et al., 1991), the risk amplification adolescents across multiple levels of social organization— model (Whitbeck & Hoyt, 1999), and the ecological model specifically, family, peers, social services, and formal (Toro et al., 1991). institutions—RAAM examines how positive and negative trauma model experiences across these socializing agents can amplify Building on basic research on the harmful effects of trauma, or abate homelessness. RAAM builds upon RAM by Goodman et al. (1991) and van der Kolk (1987) proposed supporting the assertion that negative contact with that homelessness typically involves a series of traumatic socializing agents amplifies risk, but it adds another events that put people at risk for PTSD, depression, assertion that positive contact abates risk. RAAM further substance abuse, and other negative outcomes. A number extends the work of RAM by incorporating an ecological of studies support this view, documenting high levels of perspective, which links person-centered factors (e.g., stressful events and victimization, depression and PTSD, family relationships) to environmental factors (e.g., social and substance abuse among all subgroups of homeless people institutions) (Haber & Toro, 2004). RAAM is supported (as documented in this report). by longitudinal findings. For example, homeless adolescents who had connections to positive socializing agents such as ecological model family (e.g., maternal support), peers (e.g., prosocial peers The ecological model frames homelessness within the who were in school and got along with their families), and context of person-centered factors (e.g., resources of and social institutions (e.g., attending school) were more likely to barriers for homeless people) and environmental factors (e.g., exit homelessness over 2 years (Milburn et al., 2009). external resources) and specifically posits that homelessness Future research must address the limitations of these results from a lack of resources (Toro et al., 1991). This theoretical models. Most were developed for specific model was expanded to include developmental factors such subpopulations of homeless people—for example, the trauma as family bonds and relationships to examine homelessness model was developed for homeless adults, primarily women among children and adolescents (Haber & Toro, 2004) and (Goodman et al., 1991), and the RAM was developed for has served as an explicit or implicit guide for a number of homeless adolescents (Whitbeck & Hoyt, 1999). Yet some policy analyses on homelessness (Shinn, 1992, 2007; Toro & of these models, such as the ecological model, hold promise Warren, 1999). for understanding homelessness among the full range of homeless subgroups (Haber & Toro, 2004; Toro et al., 1991). risk amPlification model The risk amplification model (RAM) explains how Traditionally, theory development pertaining to adolescents become homeless by focusing on negative life homelessness was based on observed associations between events and negative developmental trajectories to argue that homelessness and other factors. This work is generally most homeless adolescents come from disorganized family correlational rather than causal. Since the late 1980s, environments characterized by conflict, neglect, violence, and however, there has been more emphasis on systematic parental substance abuse (Paradise et al., 2001; Whitbeck analyses (Sommer, 2001), and longitudinal work has & Hoyt, 1999; Whitbeck, Hoyt, & Yoder, 1999). These emerged in the research literature (Ahmed & Toro, 2004; adolescents leave home, link with other homeless adolescents, Cauce et al., 1994; Fowler et al., 2006; Milburn et al., 2006, and become embedded in deviant social networks that 2007, 2009; Pollio, Thompson, Tobias, Reid, & Spitznagel, amplify the risk of engaging in high-risk behaviors such as 2006; Rosenthal, Mallett, Gurrin, Milburn, & Rotheram- sex work, substance abuse, and criminal activity (Cauce et al., Borus, 2007; Roy et al., 2003, 2004; Shinn et al., 1991, 1998; 2000; DeRosa et al., 2001; Rice, Milburn, Rotheram-Borus, Toro et al., 1999). Mallett, & Rosenthal, 2005; Tyler, Hoyt, & Whitbeck, There continue to be challenges to assessing the viability 2000). RAM provides a solid explanation for the problems of theories because of differences in methodology between of homeless adolescents and their continued homelessness various studies, modeling errors, and other weaknesses, but (Haber & Toro, 2004; Milburn et al., 2009). enumeration techniques for determining the prevalence of homelessness have improved over time (Sommer, 2001). new models and f uture research Homelessness is not well explained by any one theoretical Researchers are testing new models, such as the risk paradigm, as the circumstances of those who are homeless amplification and abatement models (RAAM; Milburn are so diverse (Peressini, 1995). Helping People Without Homes 25 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy The Role of Psychologists in Ending Homelessness

31 Conceptualization of the Survey introduction In order to document psychologists’ current views and Table 1 activities related to homelessness, we designed and Activities Performed (in Past Year) conducted a Web-based survey through the APA Public = 411) N in Relation to Homelessness ( Interest Directorate in coordination with APA’s Center for N activity % Workforce Studies. Requests to participate in the survey 20.0 82 Assessments were sent to a sample of APA’s membership (including Therapy/counseling 100 24.2 4,000 members and 4,000 student members). Potential Research 49 11.9 participants were contacted via e-mail and were assured that 3.2 Grant writing 13 their responses would be confidential. Four hundred eleven Psychologist training 26 6.3 individuals responded to the survey (the response rate of 8.0 Other staff training 33 5.1% is similar to that obtained in other recent member surveys conducted by APA). 7.3 30 Speaking to community groups Interviews with media 5 1.2 The survey asked participants to identify activities in which 35 Member of organization advisory group 8.5 they participate that benefit homeless people, including 56.4 Donate money, food, clothes, etc. 232 therapy, research, service administration, and fundraising. In addition, participants were asked how much time they 15.3 63 Participate in fundraising events spent on those activities and whether they performed these None of the above 117 28.5 functions as part of their professional work or in a volunteer capacity. Identification of the ways in which psychologists work on Table 2 behalf of homeless people is central to understanding how Capacity in Which Work Was Done well the discipline is addressing this important social issue. a N capacity % It is equally important, however, to understand what would As part of my job 58 19.5 help psychologists become more involved in this work. 147 49.3 As a volunteer Participants were asked if certain things would increase their willingness to work with this population, including options Both as part of my job and as a volunteer 93 31.2 a such as more training, more time, and access to funding. Out of 298 valid. Finally, the general attitudes and compassion of respondents toward people who are homeless were assessed on the basis of six items used in recent national and international surveys (Tompsett, Toro, Guzicki, Manrique, & Zatakia, 2006; Toro et al., 2007). results and discussion Here we present preliminary results from the member survey On the whole, the information in Table 1 suggests that (more complete analyses will be available through various psychologists are already significantly involved in a wide reports produced during 2010). The range of activities range of activities in relation to people who are homeless. relevant to homelessness as reported by the 411 respondents About half of psychologists reporting activity involving is shown in Table 1. By far the most common activity was homeless people did it as part of their job (19.5%) or as the donation of money, food, and other items. This activity part of their job and volunteer work (31.2%; see Table 2). has also been reported as common among the general The remaining half did the reported activities solely as part public (Toro & McDonell, 1992). However, respondents of volunteer work (49%). It was surprising that so many also reported engaging in activities typically associated with psychologists reported being involved (at least in part) with psychologists: 24% reported doing therapy and/or counseling homelessness in connection with work activities, given that with homeless people, and 20% reported doing assessments. funding for such involvement is so scarce (see Table 5 on Only 28.5% of respondents reported doing nothing barriers to becoming involved with homeless people). regarding homeless people in the prior year. Helping People Without Homes 26 The Role of Psychologists in Ending Homelessness The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy

32 While Tables 1 and 2 suggest that psychologists are Table 3 significantly involved with assisting people who are homeless, Time Spent on Activities a Table 3 shows that the total amount of time they devote is N time spent % rather small, with 30% of all 411 respondents reporting only 29.2 120 No response (mainly due to no activity) a few hours per year and another 22% reporting only a few 30.2 124 A few hours per year hours per month. However, while a majority (52%) shows 21.9 90 A few hours per month limited involvement or no involvement (29%), there are a 33 A few hours per week 8.0 significant number of psychologists who work with those 10.7 10 or more hours per week 44 who are homeless for a few hours per week (8%) or 10 or a Out of 411 total. more hours per week (11%). Examination of analyses in which the information on time spent was cross-tablulated with the types of activities listed Table 4 in Table 1 revealed that the large numbers engaging in the Subgroups Worked With ( N = 411) donation of food or clothing tended to spend little time a N subgroup % on this type of activity (78% of those who did this spent a 58 14.1 Families and children few hours per month or less), whereas the small numbers 14.6 60 Adolescents engaging in several other activities spent much more time Individual adults 36.1 138 doing them (e.g., grant writing, research, and psychologist Families 80 19.5 and other staff training). Regardless of the types of activities 10.9 45 Groups of adults that psychologists engage in, most spent at least a few hours People with: per week on the activities. Those who engaged in traditional 123 Mental illness 29.9 clinical activities (i.e., assessments and therapy/counseling) tended to spend moderate amounts of time at these activities 26.3 108 Substance abuse/dependence (e.g., 52% of those doing therapy/counseling did so for a few HIV/AIDS 49 11.9 hours per week or more). 64 15.6 Chronic health problems 10.9 45 Other disabilities Psychologists work with a broad range of subgroups among the overall homeless population (see Table 4). The largest Veterans 13.1 54 a numbers work with individual adults (36%), those who Out of 411 total. abuse substances (26%), and those with mental illness (30%). However, significant numbers also work with families, adolescents, and veterans. The large emphasis on serving Table 5 those who abuse substances and who have mental illness is What Would Help You Get Involved? consistent with the high rates of these disorders among the a N item % population of adults who experience homelessness. 124 More training 30.2 Almost half of the participants (49%) reported that simply Access to the people who are homeless 121 21.4 having “more time” could encourage them to get involved More time 202 49.1 with people who are homeless (see Table 5). Simply Money for my time 20.0 82 being asked to assist those who are homeless would also Funding for research 67 16.3 appear to encourage many more to get involved (37% of Funding for services 97 23.6 respondents), as would more training in homelessness issues 37.0 152 Being asked to do something (30%) and easier access to those who are homeless (21%). I don’t want to be involved 10.0 41 Reimbursement for their time spent (20%) and more funding a Out of 411 total. for research (16%) and services (24%) would also encourage some to become involved. Very few psychologists (only 10%) actively indicated that they wish not to become involved with people who are homeless. In summary, although they are generally willing to become involved, psychologist report many barriers that make it difficult to become involved with people who are homeless. Helping People Without Homes 27 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy The Role of Psychologists in Ending Homelessness

33 Table 6 General Attitude and Comparison Items disagree item strongly a gree agree strongly disagree 3.4% 58.7% 37.6% When you think about homeless people, do you feel sad 0.2% and compassionate? (3.5%) (51.0%) (38.3%) (7.0%) 1.5% It makes you angry to think that so many people are 50.1% 36.3% 12.1% (16.1%) (2.6%) (34.8%) homeless in a country as rich as ours. (46.6%) 36.1% 52.4% 9.8% 1.7% You feel less compassion for homeless people than you used to. (28.8%) (48.7%) (15.1%) (7.4%) illing w very illing somewhat illing not w w 60.0% 29.6% 11.4% Pay $25 a year or more in taxes to reduce homelessness? (32.9%) (36.8%) (30.3%) 50.6% 12.0% 37.3% Have housing for the homeless in your neighborhood? (39.5%) (25.5%) (35.0%) 16.5% 50.4% 33.1% Have a shelter for the homeless located near your home? (39.5%) (36.9%) (23.6%) N = 405–410). Comparative results in parentheses are from a representative U.S. sample from 2001, N Percentages are of valid responses ( Note. = 435 (see Tompsett et al., 2006). Like most Americans (see Tompsett et al., 2006) and most citizens in other developed nations (see Toro et al., 2007), the psychologists and students responding to our survey were generally concerned and “compassionate” toward people who are homeless (see Table 6). For example, the vast majority of respondents (96%) agreed or strongly agreed that they are “sad and compassionate” when thinking about individuals without homes. On many items, it seems that psychologists are even more compassionate toward homeless people than is the general U.S. public. For example, 60% would be very willing to pay $25 more in taxes to reduce homelessness (vs. 33% of the general public), and 88% would be very willing or somewhat willing to have housing for people who are homeless in their neighborhoods (vs. 75% of the U.S. public). Additional analyses will compare the characteristics of this respondent sample of 411 to general characteristics of the APA membership to assure that the sample was not biased. It is important to note that the psychologists who were more likely to work with people who are homeless may have been more likely to respond to this survey. Analyses will also allow a statistical comparison of the above “compassion” items with the most recent national sample of the general public. Results will be submitted to the APA membership through reports (such as in the Monitor on Psychology and/or the ). American Psychologist Helping People Without Homes 28 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy The Role of Psychologists in Ending Homelessness

34 Remediation of Homelessness family therapy are promising tools for providing vital Interventions for Homelessness services to people who are homeless. There are, however, Efforts to remediate homelessness address individual factors, a limited number of studies documenting interventions prevention measures, and public policy. Psychologists may aimed at families and adolescents. While the remediation play an important role in the remediation of homelessness at of homelessness ultimately may depend mostly on the individual level through the treatment of substance abuse improving the ratio between low-income and other mental health disorders and— households and increasing the number Providing housing without addressing at a more structural level—by using of affordable housing units (Shinn & housing as an environmental strategy to the psychosocial factors that influence Gillespie, 1994), psychologists can play a meet basic needs. homelessness is insufficient to role in helping people with mental health remediate the problem. and substance abuse problems get and individual factors keep such housing. Efforts by psychologists to remediate homelessness at the individual level include involvement orted housing and residential suPP in providing housing and a range of supportive services, continuum models including addiction treatment, mental health services, medical The question of whether safe and affordable housing is treatment, and case management. These interventions address sufficient to remediate homelessness has special significance the factors that lead an individual or a family to homelessness for people with comorbid substance abuse and other mental or those factors that make it difficult to become and remain and physical disorders. This question forms the basis for the housed. The provision of housing is a leading intervention evolution of two philosophically unique housing paradigms: in the effort to end homelessness among members of low- , also called supported housing or rapid re- • Housing first income households (Shinn & Gillespie, 1994); however, housing (for immediate housing of families from shelters. providing housing without addressing the psychosocial factors that influence homelessness is insufficient to remediate the Treatment first , also referred to as linear, contingent, • problem. A variety of housing models for people experiencing continuum-based, or residential continuum approaches. homelessness are described in the literature, all of which aim Rog (2004) described treatment first as a range of housing to facilitate stable housing among people with mental illness options coupled with required service participation through or substance abuse problems. which an individual’s transition to independence is achieved Other interventions relevant to psychologists, including over time. This is in contrast to housing first, which simply the critical time intervention, intensive case management, offers voluntary services to those receiving housing first. assertive community treatment, and ecologically based Such programs couple housing in the community with Helping People Without Homes 29 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy The Role of Psychologists in Ending Homelessness

35 participants retained housing after 5 years, whereas only 47% supportive services, usually for addiction and/or other of the comparison group did so (Tsemberis & Eisenberg, mental disorders, but they differ in their requirements to 2000). In another study of the housing-first approach, 84% obtain and keep housing benefits. Whether housing is of program participants with serious mental illness and often contingent on compliance with such services forms the basis co-occurring substance use disorders remained enrolled of the difference. in the program for at least one year, indicating housing In housing first, there are no contingencies or barriers success for people with chronic homelessness with histories to receiving housing. In treatment first, housing is either of significant housing instability (Pearson, Montgomery, contingent on treatment compliance or completion of a & Locke, 2009). In a 2-year experimental investigation of part of the treatment program itself. Housing first is a way supported housing among homeless people in San Diego to implement a housing-first strategy for people who need with chronic and severe mental illness, those who received intensive services or are nonresponsive to contingency- Section 8 housing vouchers were much more likely to achieve based housing entry paradigms. Services in housing first independent housing (Hurlburt, Hough, & Wood, 1996). are voluntary, but residents have the opportunity to see a Housing is also associated with HIV risk reduction. Aidala, case manager regularly depending on their health status and Cross, Stall, Harre, and Sumartojo (2005) found in a stability. The services that a case manager makes available to sample of more than 2,000 people living with HIV/AIDS them are voluntary. Within a housing-first philosophy, there presenting for services that the odds of recent use of drugs, are models that have intensive case-management services use of needles, and sex trading were as much as four times available. One of the new areas of research to look at is higher for the not-housed than for the housed clients. housing-first models and their effectiveness in improving Follow-up data collected up to 9 months later showed that health and recovery. Typically, housing-first models measure improvements in housing status resulted in significant housing stability and only recently have started to evaluate reductions in needle use, drug use, and unprotected sex health status and so forth. among the clients, whereas the odds of sex trading increased Conversely, criticism of the contingency-based, or significantly for clients whose housing status worsened or treatment-first, housing model is that people who are who became homeless. chronically homeless may find it difficult to engage in The first randomized experiment designed to compare treatment without being housed first. They may be unable the effectiveness of housing first and treatment first was to meet or commit to the demands related to housing conducted by Padgett, Gulcur, and Tsemberis (2006). The readiness (e.g., sobriety, basic living skills, personal hygiene, New York Housing Study was a and commitment to engage in longitudinal experiment contrasting treatment) and ineligible for these The majority of people with serious a housing-first program (offering types of housing resources. In contrast, mental illness who are engaged in housing immediate permanent housing without the housing-first approach offers with supports available are less likely to requiring treatment compliance direct access to housing without drug experience hospitalization and more likely or abstinence) and treatment-first abstinence or treatment participation (standard care) programs to 225 adults requirements and voluntary to have improved quality of life. with mental illness who were homeless participation in supportive services in New York City. After 48 months, results showed no based on consumer choice. Homelessness or housing needs significant differences between housing-first and treatment- are considered first and foremost in housing-first programs, first programs in alcohol and drug use, but treatment-first and many such programs actively target those unable to participants were significantly more likely to use treatment succeed in other structured settings. services. This study and previous reports concluded that Safe and affordable housing is associated with residential adults with homelessness “dual diagnoses” can remain stably stability for formerly homeless adults with serious mental housed (Tsemberis & Eisenberg, 2000) without increasing illness (Lipton, Siegel, Hannigan, Samuels, & Baker, their substance use in a housing-first model. Thus, regarding 2000). In addition, the majority of people with serious housing-first and treatment-first programs, one is not mental illness who are engaged in housing with supports necessarily better than the other. It may be that the two available are less likely to experience hospitalization (Rog, programs are not comparable, as they are designed to target 2004) and more likely to have improved quality of life different outcomes, and that matching the program to the (Sullivan, Burnam, Koegel, & Hollenberg, 2000). Compared needs of the person may be the best approach. with a matched group of individuals participating in the linear residential treatment model, 88% of housing-first Helping People Without Homes 30 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Remediation of Homelessness

36 housing was offered as part of the behavioral treatment In contrast to models that offer housing with no (or limited) (Kertesz et al., 2006). Finally, consecutive weeks of strings attached, treatment-first (contingency-managed) abstinence during treatment predicted long-term housing housing is designed to engage and sustain homeless people and employment stability in Milby et al.’s (2010) most in effective substance abuse programs that provide housing. recent trial. Psychologists can play many roles in this type It is an example of an effective intervention that offers safe of treatment-first intervention in terms of assessment, housing to homeless people with substance use disorders, diagnosis, goal setting, relapse prevention, and voucher but on the condition that the person successfully engage in reinforcement activities. and respond to treatment services. Contingency-managed housing is more of a behavioral intervention (in which In sum, more than 350 communities in the United States housing is used as a reward) than a housing program (in are committed to ending chronic homelessness. Kertesz which program-provided housing is made contingent on and colleagues (2009) reviewed studies of housing-first and abstinence from additive drugs). more traditional rehabilitative (or treatment-first) recovery interventions, focusing on the outcomes obtained by both In Birmingham, AL, Milby et al. (1996) first used program- approaches for homeless people with addictive disorders. provided housing and work therapy as reinforcement for According to reviews of comparative trials and case series crack cocaine abstinence while encouraging participation reports, housing-first reports document excellent housing in comprehensive day treatment as an intervention for drug retention, despite the limited amount of data pertaining to addiction and homelessness. Milby and colleagues, under the homeless clients with active and severe addiction. Several sponsorship of the National Institute on Drug Abuse and linear programs cite reductions in addiction severity but have the National Institute on Alcohol Abuse and Alcoholism, shortcomings in long-term housing success and retention. developed this treatment-first intervention and have studied They suggest that the current research data are not sufficient it over the past 2 decades. Homeless participants are initially to identify an optimal housing and rehabilitation approach exposed to furnished, rent-free housing to experience its for all important homeless subgroups. reinforcing effect. While attending behavioral day treatment, participants continue to earn access to housing contingent It is likely that the answer lies in the use of different on weekly drug-free toxicology tests. A positive drug test modalities to meet the needs of different populations. (indicating drug use) results in loss of housing, transportation For example, how will the housing approach cope with to a local shelter, transportation to behavioral day treatment, people with criminal records who may be restricted from and continued drug testing. Two consecutive drug-free tests government-subsidized housing, and to what extent could earn access back into the program-provided housing. this undermine housing interventions for people with criminal records? Some treatment arms that were studied used contingency- managed work therapy in the same manner. This was the The research regarding housing-first and linear approaches first of six programmatic contingency-managed housing and can be strengthened in several ways, and policymakers work therapy clinical trials and one cost-effectiveness study should be cautious about generalizing the results of available by these authors in Birmingham, Houston, and Ukraine housing-first studies to people with active addiction when (Kertesz et al., 2006, 2009; Milby et they enter housing programs. The al., 2000, 2004, 2007, 2008, 2010; Housing-first and treatment- work of the authors cited above not Milby, Schumacher, Wallace, Freedman, first programs may actually be only represents rigorous approaches to & Vuchinich, 2005; Schumacher, measuring the outcomes of effective conceptualized as two different Mennemeyer, Milby, Wallace, & Nolan, housing interventions but also highly entities that are not easily compared. 2002; Schumacher et al., 2003, 2007; practical clinical models for working Vuchinich et al., 2009). with people in homeless conditions. Details of their research offer strategies for outreach, screening, assessment, diagnosis, A meta-analysis of contingency-managed housing/work goal management, relapse prevention, HIV risk reduction, therapy and behavioral day treatment interventions from and other psychosocial roles for psychologists in this context. the Birmingham Cocaine Treatment Studies (1990–2006) conducted by Schumacher and colleagues (2007) found that Housing-first and treatment-first programs may actually be contingency management and behavioral day treatment conceptualized as two different entities that are not easily consistently produced higher abstinence rates from drugs compared. One is a housing program and the other is a than no contingency management. People with cocaine treatment program. This may be the reason housing first dependence and co-occurring nonpsychotic mental illness has better housing outcomes and treatment first has better had better housing and employment outcomes when Helping People Without Homes 31 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Remediation of Homelessness

37 outcomes. Participants in intensive mental health case treatment outcomes. In this schema, housing first represents management were also more likely to report satisfaction a housing option for people with long-term homelessness with life and lower levels of aggression (Cauce et al., who refuse to go to treatment or who have repeatedly failed 1994). Case management is a useful intervention for adults in treatment. It may be that housing first and treatment who are homeless as well. For those with mental illness, first are not on the same continuum—rather, they are case management linked to other services is effective in two different options for two different groups of people. improving psychiatric symptoms and results in greater Psychologists can contribute to matching people to programs decreases in substance use (Hwang, Tolomiczenko, in the most efficient way. Kouyoumdjian, & Garner, 2005). other suPPort-based interventions Assertive community treatment (ACT) provides In addition to housing assistance, there are a number of community-based mental health treatment and support other interventions documented in the research literature to people with serious mental illness. This team-based designed to address homelessness. These include intensive approach is used extensively with people without homes case management, assertive community treatment, critical and improves housing stability for people with mental time intervention, and ecologically based family therapy. illness (Nelson, Aubry, & Lafrance, 2007). It is effective These are effective for different groups of people without in decreasing psychiatric hospitalizations and increasing homes who have co-occurring addiction and mental and outpatient contacts (Hwang et al., 2005). Drug abstinence physical disorders, including adolescents, despite the dearth is difficult to achieve and maintain, especially when people of data on interventions for homeless youth designed return to their pretreatment environment. Forging ties with specifically to end homelessness. formal social support networks in the community, such as Homeless youths are at high risk for substance abuse, religious organizations, may reinforce abstinent behaviors mental illness, and blood-borne infections, such as hepatitis established during treatment among people without homes C (Nyamathi et al., 2005). Robertson and Toro (1999) (Stahler et al., 2005). ACT offers advantages over standard found that 48% of these youths have alcohol disorders and case-management models in reducing homelessness and 39% have other drug disorders. Adolescents experiencing symptom severity in homeless persons with severe mental homelessness face unique challenges and may benefit from illness (Coldwell & Bender, 2007). interventions based on harm reduction (Nyamathi et al., Critical time intervention (CTI) is a more recently 2005). Innovative youth-centered interventions may include published empirically supported model for preventing service-based care, street outreach, case management, and homelessness in high-risk groups. CTI is designed to motivational interviewing as well as integrated health prevent homelessness for people with severe mental services, such as hepatitis A/B vaccination, and mental disorders by intensifying the continuity of care during the health and substance abuse programs. transition from controlled to community environments One empirically supported approach to the problem of through building problem-solving skills, motivational substance abuse among runaway youths without homes coaching, and advocacy with community agencies. is ecologically based family therapy (EBFT; Slesnick & Herman and colleagues (2000) provided the background Prestopnik, 2005). Compared with service as usual, EBFT and rationale for this model, described the intervention, reduced overall substance abuse in this population. It and illustrated how it was adapted for women’s transition involves individual and family sessions and includes not only from shelters to living in independent housing. Draine the adolescent and parents but also siblings and extended and Herman (2007) described CTI as a promising model family members. Slesnick and colleagues (2005) proposed to provide support for reentry from prison for people with that future research may demonstrate that intervention with mental illness. K. Jones and colleagues (2003) investigated families whose relationships have not fully deteriorated the cost-effectiveness of the CTI program and found might prevent future homelessness. A brief motivational that it is not only an effective method to reduce recurrent intervention also demonstrated success in reducing substance homelessness among people with severe mental illness but use for adolescents without homes (Baer, Garret, Beadnell, also represents a cost-effective alternative to the status quo. Wells, & Peterson, 2007). Kasprow and Rosenheck (2007) suggested that CTI can Case management is also successful in supporting the be successfully implemented in systems that have little past mental health needs of youths who are homeless. Cauce experience with the approach and yields improved housing and colleagues (1994) demonstrated that adolescents and mental health outcomes (Herman, Conover, Felix, engaged in case-management services had improved Nakagawa, & Mills, 2007; Susser et al., 1997). Susser and Helping People Without Homes 32 Remediation of Homelessness The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy

38 address this multiplicity of needs, nor is one need necessarily colleagues (1997) suggested that strategies that focus on a more dominant than another. critical time of transition may contribute to the prevention of recurrent homelessness among people with mental illness. Psychologists do not necessarily need to serve as team leaders and must recognize the particular expertise of all team Clinical Applications With members. Among the necessary team members are people Homeless People who operate and staff shelters, outreach workers on the street Clinical work with people living without homes requires and in various community sites, housing program advocates, the same strong commitment to assessment and case facilitators of drop-in centers, workers in food pantries, conceptualization used by psychologists in working with any health care providers, and income benefit staff. Professional individual or population. All clinical work with marginalized collaborations between mental health professionals and populations requires psychologists to exhibit multicultural primary care or other medical providers is especially competence as well as appropriate empathy and respect for important (Health Care for the Homeless Clinicians’ the experiences of all people. Building strong therapeutic Network, 2000) alliances with individuals is a critical component of success. assisting with welfare benefits Recognition of personal strengths as well as challenges underlies an authentic therapeutic relationship. The reality Many people without homes are unemployed and dependent of living without homes is a critical component of a person’s on government welfare benefits, sometimes called general experience. Adjustment must be made by therapists to assistance, for minimal sustenance and accommodations. accommodate the needs of the people with whom they To be eligible for the minimal welfare benefit, a person work. Treatment modalities as well as must have documentation of a Although traditional clinical skills are service settings must be responsive to recognized disability that interferes with essential in treating any individual, the demands posed by experiences of sustained gainful employment. Such treating people with mental illness homelessness. The following sections documentation must be completed by highlight practical applications of clinical a health or mental health professional. who also lack housing requires a work with people living without homes. The provider must include diagnosis specialized set of clinical skills as well of a physical disorder or mental health as specific knowledge. Regardless building trusting disorder listed in the fourth edition (text of a provider’s best intentions, skills relationshiPs Diagnostic and Statistical revision) of the Many poor individuals do not trust acquired in the treatment of housed (American Manual of Mental Disorders psychologists. Based on prior experience Psychiatric Association, 2000) and an people may not be sufficient. or beliefs shared within marginalized estimate of benefit duration. communities of poor people, mistrust for all mental health A considerable number of physicians and psychologists are providers is high. Although traditional clinical skills are hesitant to provide authorization for this welfare benefit essential in treating any individual, treating people with for various reasons. Some providers employ a “bootstrap” mental illness who also lack housing requires a specialized set approach, believing all but the severely impaired should of clinical skills as well as specific knowledge. Regardless of work. Others believe they are being manipulated or a provider’s best intentions, skills acquired in the treatment enabling a person’s substance abuse. Others state that they of housed people may not be sufficient (Hoffman & Coffey, are a “therapist” and not a social services provider. These 2008). Clinicians must bring knowledge of the needs of providers demonstrate a sociopolitical philosophy that homeless populations to their work. denies people with mental illness the most basic necessities: a minimal cash benefit, shelter, access to regular food, and art of a team w orking as P access to health care. Many psychologists work as part of a clinical team in a variety of professional settings. Interdisciplinary teamwork Although there may be people who manipulate the system and collaboration are particularly salient to interventions and falsify a renewal authorization or allow others to use directed to those without homes. The need for shelter, their documentation to falsify authorization, life for a food, clean clothes, laundry, showers, social security and person without housing is a matter of survival, and at times other benefits, legal services, and referrals for mental health psychologists will indeed be taken advantage of. A therapist’s care require access to a wide range of psychosocial services authorization of welfare benefits may be the access point and providers with diverse formal training, expertise, life to engage people in treatment, despite the risk of being experience, and knowledge. No single provider can expect to manipulated. Psychologists who are not willing to authorize Helping People Without Homes 33 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Remediation of Homelessness

39 detecting other conditions these minimal benefits for people who are without homes and also experiencing mental illness should question their Clinical services that involve more extensive evaluation of desire and ability to effectively work with this population. clients have important implications for obtaining additional services or benefits that will enhance a person’s life, meeting self-care both immediate and long-term needs, such as substance abuse Psychologists who work with populations of people living treatment. This requires patience and seeking differential without homes may adopt different attitudes and values diagnoses, an approach that has often never been taken with regarding clinical treatment than many of their colleagues. the homeless person (Buckner, Bassuk, Zima, 1993). Work with this population may also involve clinical practice In addition to severe and persistent mental illness, there are with people suffering from extensive trauma. Clinicians some frequently occurring disorders, disabilities, and issues may encounter criticism or denigration of that work by among the homeless population that can benefit from being colleagues. Clinicians may feel isolated and stressed and recognized and addressed. These include developmental may suffer from burnout. It is important to seek appropriate disabilities, reading and other learning disorders, fetal supervision as well as to have a support system of coworkers alcohol syndrome/effect, attention-deficit hyperactivity and others who appreciate and value working with this disorder, traumatic brain injury, subtle expression of population (Chafetz, 1992). mental illness, past physical/sexual abuse and other child maltreatment, separation from children and family, loss of hands-on treatment employment, and history of criminal acts. There is often When working with people without homes, psychologists considerable shame surrounding these conditions, and bring unique and useful skills and competency in evaluation individual and group therapy, with or without medication, (with or without psychological testing) and diagnosis of a can be effective treatment. wide range of mental health disorders. Being a consultant from a distance is usually a disservice to all involved. To be Prevention of Homelessness of maximum value to frontline workers, direct contact with The existing literature devotes considerable attention to clients is necessary. treatment-oriented approaches for dealing with the social Location is an important consideration when treating clients problem of homelessness. Psychologists, other researchers, in this population. Many people with mental health or and policymakers have only recently begun to consider ways substance abuse disorders are reluctant to meet in a provider’s to prevent homelessness from occurring in the first place office, and providing services on a homeless person’s “turf ” (Burt et al., 2007; Haber & Toro, 2004; Lindblom, 1996; may provide the greatest chance for initial success (Morse et Shinn & Baumohl, 1999; Toro et al., 2003, 2007). Although al., 1996). This hands-on approach enables a provider both there are virtually no examples, to date, of empirically to consult with frontline caregivers and to establish rapport supported preventive interventions, recent publications have with the homeless person. suggested a number of possible directions. One model for treating homeless clients is similar in many targeting those at risk ways to disaster services known as “psychological first aid” for homelessness (Schultz, Espinel, Galea, Shaw, & Miller, 2006) in which There are many ways to identify people at risk of the provider obtains a brief snapshot of the person and experiencing homelessness. The poor and people with provides reassurance and a treatment plan. The psychologist histories of residential instability, prison/jail time, and sees up to four people in 2 hours, establishing initial contact. foster care placements are some identifiable groups that With a structured model in mind, the psychologist is able could be targeted for preventive interventions and policies. to obtain a great deal of information in 30 minutes. Some Adolescents who are aging out of the foster care system at homeless clients will require shorter initial contacts, but age 18 are particularly vulnerable to homelessness in the for others a longer session is necessary. When a homeless United States as well as in other developed nations. Studies client has acute problems, a flexible psychologist can show that 20–50% of adolescents/adults experiencing depart from the brief-contact model and provide necessary homelessness have a history of foster care placement clinical services. Psychologists must realize, above all, that (Firdion, 2004; Toro et al., 2007, 2008). Extending their credibility is constantly being judged by the homeless comprehensive interventions and/or support services to age community. Establishing trust and credibility takes time and 21 or older could assist youths in making the transition from can be quickly lost. foster care to independent adult life (Toro et al., 2007). Helping People Without Homes 34 Remediation of Homelessness The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy

40 financial viability, and housing, other services such as case Teenage mothers with children are another at-risk group. management, educational and employment assistance, and R. L. Fischer (1997) targeted pregnant teens and provided parent training could be even more important in preventing pre- and postnatal care, educational assistance, job training, future homeless episodes. parent training, intervention aimed at preventing subsequent pregnancies, and services to strengthen support from the School-based programs may also have potential for family of origin. Compared with a control preventing homelessness among older group, girls who received intensive Given the close connection between children and adolescents. For example, services showed more educational Hendrickson and Omer (1995) discussed homelessness and poverty, it is attainment, better health outcomes, the “comprehensive service school” that reasonable to consider that school- fewer subsequent pregnancies, and more provides adult education and career based and other programs that employment at an 18-month follow- development, child care, economic and up. Similarly, O’Sullivan and Jacobsen reduce poverty and its harmful social services (e.g., helping families find (1992) found that, compared with a consequences have the potential to housing, jobs, food assistance), family control group, teenage mothers receiving support services (e.g., parenting classes, prevent homelessness in the long run. intensive services showed a much support groups), transportation, legal reduced rate of repeat pregnancy. Such services, health services, and mental health counseling. interventions, in addition to those noted previously, could Given the close connection between homelessness and also help prevent future homelessness. poverty, it is reasonable to consider that school-based In addition to identifying particular groups of people at and other programs that reduce poverty and its harmful risk for homelessness, identifying at-risk communities consequences have the potential to prevent homelessness in or neighborhoods may also be possible. On the basis of the long run. their analysis of prior addresses of families admitted to shelters in New York City and Philadelphia, Culhane, Lee, and Wachter (1996) found that people vulnerable to homelessness are heavily concentrated in certain neighborhoods. One recent intervention called HomeBase (http://www.nyc.gov/html/dhs/html/atrisk/homebase. shtml) provided case management, cash rental assistance, and other coordinated services to at-risk people in certain areas of high poverty in New York City (with other areas serving as comparison communities) and found that, with an average of $2,900 in cash assistance provided to each family served, homelessness was prevented (families in comparison communities had a 10% higher usage of shelter services). school-based Programs Early childhood intervention programs such as Head Start were effective in reducing the harmful developmental outcomes often associated with poverty (Committee on Child Psychiatry, 1999). Such programs, when applied to homeless children, could promote the secondary prevention of homelessness. However, to successfully accomplish secondary prevention for currently homeless children or primary prevention for housed children at risk for homelessness, such programs will need to do more than simply provide day care, educational stimulation, and nutritious meals; they will need to provide additional services targeted to parents (as some of the early Head Start programs did; see Schweinhart & Weikart, 1988). While the day care provider could serve a preventive function by helping the parent(s) maintain employment, Helping People Without Homes 35 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Remediation of Homelessness

41 Policy The task force recognizes safe and stable housing as a right to which every person is entitled. Disability of any kind or socioeconomic status does not negate the right to be housed in one’s community. Homelessness arises out of a lack of housing. We support policies that seek a rapid return of all people to permanent community housing. Similarly, we recognize that many people, with and without homes, are in need of an array of services, including mental health treatment. Supportive housing and a continuum of mental health and other social services must be offered to all people in need. Whenever possible, such services should be community based. We furthermore recognize the ability to earn financial resources and to provide for oneself and one’s family not as a privilege but as a right. Income and other resource disparity rests with a discrimination based on race, gender, age, cultural background, or sexual orientation and other factors. We support policies that enhance opportunities for education, job training, child care, and health care for all people. We recognize the need for psychologists to work across disciplines with others to eradicate social injustices that place certain people at greater risk for loss of housing than others. Recommendations to Advance Research, Training, Practice, and Policy Psychologists, in their roles as clinicians, researchers, Investigate methods to promote resilience in at-risk • and educators, have unique contributions to make to the populations, including children and youth. remediation of homelessness. The task force endorses Training the following research, training, practice, and advocacy recommendations as vehicles by which the discipline of To enhance the ability of psychologists to work effectively psychology can contribute to ending homelessness under the with populations at risk of homelessness or currently living leadership of the American Psychological Association. without homes, the following education and training are recommended: Research • Incorporate into graduate school curricula theoretical To further address the causes, course, prevention and and applied perspectives of working with diverse and remediation of homelessness, social science researchers are underserved populations at risk for homelessness. encouraged to: Develop practicum and internship placements that allow • Direct research efforts toward prevention of homelessness • trainees opportunities to work with at-risk populations in marginalized and vulnerable populations. including sheltered families and adults, children in foster • Design and disseminate evidenced-based interventions for care placements, unaccompanied youth, individuals with work with those currently experiencing homelessness. chronic mental illness, and persons with substance and alcohol dependence. Engage in program evaluation with a focus on mechanisms • that support rapid return to permanent housing and Create continuing education programs that encourage • methods for sustaining housing in vulnerable populations. psychologists to engage in work with populations experiencing homelessness. Conduct research on service utilization among • chronically and pervasively mentally ill populations at Enlist psychologists to offer appropriate mental health • risk for homelessness. education programs to service providers, charitable groups, community volunteers, and the public at large. The focus of such training should include better understanding of Helping People Without Homes 36 Recommendations to Advance Research, Training, Practice, and Policy The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy

42 psychosocial factors associated with both the entrance • Advocate for health care coverage for those without into and exit from homelessness. Educational program homes and those at risk of losing stable or permanent content should strive to dispel stigma associated with housing. homelessness as well as pervasive mental illness and Advocate for education and job training and after-school • promote strength-based approaches to working with and day care programs to support poor families. marginalized populations. • Advocate for debt forgiveness programs for psychologists and others engaged in research on the prevention or Practice amelioration of homelessness. In accordance with APA guidelines that encourage psychologists to provide clinical and other services to Advocate on an individual basis for persons in need of • marginalized and underserved people, the task force services, including low-income housing, supplemental recommends that psychologists: income, food, and benefits. Provide strength-based clinical and assessment services to • populations that are homeless or at risk of homelessness, including families involved with child welfare agencies, children in foster care placements, unaccompanied youth, persons experiencing alcohol or illegal substance dependence, and persons of all ages identified with pervasive and/or chronic mental illness. Maximize the utilization of clinical and assessment • services by providing them in accessible settings and at times that reflect the needs of the populations served. Create meaningful collaborations between psychologists, • social workers, case managers, nurses, physicians, teachers, and schools to best serve the multifaceted needs of individuals at risk of homelessness or those who currently are without stable housing. Advocacy To prevent an increase in homelessness, to better address the needs of those currently without housing, and to promote the rapid exit from homelessness where it currently exists, we encourage psychologists to advocate at the state, local, and federal levels as follows: Advocate for legislation that would fund supportive • housing as well as safe low-income housing in urban, suburban, and rural areas. Advocate for legislation that would provide a range of • needed services, including mental health services to at-risk families, unaccompanied youth, and children and adults with disabilities. Advocate for funding for targeted counseling services, • education and job training opportunities for youth in foster care, and for transitional services for those returning to home placement and/or communities. • Advocate for an increase in substance abuse and alcohol treatment programs, including services that promote the strengthening of families. Helping People Without Homes 37 The Role of Psychologists and Recommendations to Advance Research, Training, Practice, and Policy Recommendations to Advance Research, Training, Practice, and Policy

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