Evaluating an Individual’s Treatment Needs
Addiction Among The Homeless Population
For most Americans, a home is a vital source of financial and emotional security. Yet as of 2014, over 578,000 people in the United States were sleeping on the streets or in emergency shelters, according to the National Alliance to End Homelessness. Many of the individuals who lack permanent housing suffer from substance abuse or mental health disorders that prevent them from finding safe living conditions. The U.S. Department of Housing and Urban Development (HUD) estimates that over 50 percent of the individuals living in supportive housing programs had either a substance use disorder, a psychiatric disorder, or both. Mental illness and addiction interfere with an individual’s ability to build a satisfying, stable life. Without access to affordable treatment for substance abuse or psychiatric issues, many homeless men and women continue to descend deeper into a cycle of poverty, drug and alcohol use, and mental illness.
There are many resources available for people who are experiencing homelessness or at risk of homelessness. However, connecting these individuals with the right housing programs or support groups can be challenging, especially if the individual is affected by substance abuse and mental illness. Paranoia, disorientation, and depression can cause these individuals to withdraw from mainstream society and make them less likely to reach out for help.
What Causes Homelessness?
Rates of homelessness reflect trends in the country’s economy as well as factors in the individual’s health or lifestyle. In most cases, homelessness is the result of multiple factors leading to poverty and loss of material security. The National Coalition for the Homeless (NCH) lists some of the key economic factors that contribute to homelessness in the US:
- Home foreclosures:
In the past 10 years, home foreclosures have increased by over 30 percent, according to the NCH, resulting in a loss of housing among homeowners and an increase in evictions among renters.
- Lack of affordable healthcare:
Overwhelming medical costs are one of the most common reasons for bankruptcy and poverty, and serious health problems or disabilities can also lead to homelessness.
- Loss of job opportunities:
Changes in the American workforce and a general economic recession have resulted in the loss of employment opportunities, especially among low-wage workers. As a result, more individuals and families are living in poverty and at risk of losing their housing.
- Lack of public assistance programs:
A decline in funding for cash assistance programs has resulted in an increase in homelessness and poverty, especially among individuals with disabilities and families headed by females.
- Lack of affordable housing:
Federal support for low-income housing has decreased in recent years, a trend that is particularly hard on renters. Meanwhile, rental costs continue to rise, placing low-income individuals and families in the difficult position of trying to pay higher housing costs on lower wages.
But changes in the economy are not the only reasons that people lose their homes. NCH also lists addiction and mental illness as two of the primary personal factors that lead to financial instability and the loss of permanent housing. The Substance Abuse and Mental Health Services Administration (SAMSHA) reports that approximately 26 percent of homeless Americans had some form of mental illness, and nearly 35 percent were affected by substance abuse. Mental illness and substance abuse lead to a destructive cycle in which the effects of both conditions lead to increased poverty, which in turn can reinforce the depression, anxiety, and delusional thinking that reinforce drug and alcohol use.
In the 2014 U.S. Conference of Mayors Survey, mental illness and substance abuse were two of the main reasons for homelessness cited by American cities. Mental illness, substance abuse, and adequate treatment programs for both conditions were cited by 43 percent of participating cities as primary causes of homelessness among individuals.
NCH also lists addiction and mental illness as two of the primary personal factors that lead to financial instability and the loss of permanent housing.
Does Substance Abuse Cause Homelessness?
Negative cultural stereotypes portray the homeless as “losers,” “drunks,” or “bums” who can’t hold down a job or maintain a stable home because of their lack of willpower or self-control. In fact, there are many people who keep their jobs and avoid eviction or foreclosure in spite of serious drug or alcohol problems. By the same token, there are many homeless individuals who do not have a problem with drugs or alcohol.
However, statistics show that in general, substance abuse is more common among homeless Americans than in the general population, and many homeless people with substance use disorders also have one or more co-occurring mental health disorders. A study published in JAMA Internal Medicine indicates that drug overdose is becoming the most common cause of death among homeless people, surpassing HIV/AIDS. Over 80 percent of the overdose deaths in this study cohort involved opioids, such as heroin and prescription painkillers. In fact, these incidents have become so common in urban areas that the authors go so far as to propose that opioid overdose is becoming an “epidemic” among homeless individuals.
Substance abuse can play a significant role in homelessness by causing occupational impairment, or the inability to perform well at a job. Job loss and chronic unemployment make it difficult to pay for housing, which can lead to eviction or foreclosure and eventually to homelessness. On the other hand, the despair, fear, and deprivation caused by homelessness can encourage substance abuse, leading the individual to use drugs or alcohol as a way to cope with the stress of living on the streets or moving from one shelter to another. The National Coalition for the Homelessemphasizes that substance abuse can be both the cause and the result of homelessness, and that many people begin abusing alcohol or drugs after losing their homes. Unless substance abuse is treated, homeless persons are unlikely to regain the security or financial stability that can lead them out of poverty.
Substance abuse can play a significant role in homelessness by causing occupational impairment, or the inability to perform well at a job. Job loss and chronic unemployment make it difficult to pay for housing, which can lead to eviction or foreclosure and eventually to homelessness.
When considering the problem of homelessness and substance abuse, it is important to remember that addiction is a chronic disease of the brain, not a sign of personal failure or a weak character. Overcoming substance abuse requires a great deal of support, as well as intensive treatment and follow-up care. Many homeless people lack a strong family support system, have no health insurance coverage to pay for treatment, and do not have reliable transportation. All of these problems must be addressed in order to ensure adequate treatment for people living in poverty or homelessness.
What Are the Common Drugs of Abuse?
Widely available and relatively inexpensive, alcohol is one of the most common substances of abuse in homeless populations, especially in older adults, notes the National Coalition for the Homeless. It is estimated that up to half of single homeless adults have abused alcohol, while up to a third abuse other drugs, according to the National Healthcare for the Homeless Council.
Heroin is one of the most commonly abused opioid drugs among homeless individuals
Alcohol abuse exposes these individuals to other serious health problems, including the following:
- Liver disease
- Seizure disorders
- Gastrointestinal problems
- Certain types of cancer
Alcohol abuse can also worsen the symptoms of mental illness, causing increased confusion, aggression, psychosis, or depression. Having an alcohol problem can make it harder to a homeless person to find safe housing, and it can increase the risk that the person will be the victim or perpetrator of a crime.
Opioid abuse is becoming increasingly common and has been identified as one of the leading causes of death among homeless people in urban areas, reports JAMA Internal Medicine. Heroin is one of the most commonly abused opioid drugs among homeless individuals, many of whom take the drug intravenously. Intravenous drug abuse, especially with shared needles, exposes the user to the risk of communicable diseases like HIV/AIDS and hepatitis.
Among homeless teens and young adults, prescription drug abuse has become increasingly common. Prescription opioids like oxycodone, hydrocodone, and hydromorphone, which are used for pain control in clinical settings, can exert the same euphoric effects as heroin, especially when the pills are crushed and snorted or dissolved and injected intravenously. A study published in Drug and Alcohol Dependence found that among 457 homeless youth living in Los Angeles, 22 percent were currently abusing prescription drugs. Those who abused prescription drugs were more likely to inject drugs intravenously, especially if they were also abusing cocaine, meth, or amphetamines.
What Forms of Mental Illness Affect the Homeless?
The pressures of trying to find food and shelter, avoiding legal problems, and steering clear of violence or crime cause tremendous stress for the homeless. This continuous stress and sense of insecurity contribute to high rates of mental illness and substance abuse in this population. Some of the most common forms of mental illness that affect the homeless are as follows:
This neurological disorder causes a break with reality, leading to episodes of paranoia, disorganized thinking, delusional beliefs, and hallucinations.
- Mood disorders:
Conditions that affect the individual’s state of mind, energy levels, and emotions fall into the category of mood disorders. Many homeless adults have symptoms of depression and bipolar disorder, two of the most common mood disorders.
- Personality disorders:
These disorders interfere with normal social functioning, causing increased hostility, suspicion of others, avoidance of relationships, paranoia, hording behaviors, and other serious problems.
- Anxiety disorders:
Persistent fears and worries characterize this family of disorders, which include generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, panic disorder, and other manifestations of the condition.
The symptoms of severe mental illness, such as paranoia, lack of focus, low levels of energy, delusional thinking, and hallucinations, can make it difficult or impossible to perform the activities that most of us take for granted, such as working, developing relationships, or maintaining a home. Substance abuse among the homeless can worsen the symptoms of mental illness, driving the individual even deeper into a cycle of poverty, homelessness, and despair.
Substance abuse and mental illness often co-exist, a condition known as a dual diagnosis or co-occurring disorders. The Substance Abuse and Mental Health Services Administration estimates that at least 50 percent of homeless individuals have co-occurring substance abuse and mental health disorders. A dual diagnosis can make treatment more complicated, because the symptoms of drug addiction or alcoholism can mask the symptoms of mental illness or make those symptoms much worse. Clinicians working with the homeless must screen for both mental illness and substance abuse in their clients, and services for both conditions should be offered at the same time within the same treatment program in order to encourage retention and prevent a relapse.
What Are the Barriers to Treatment?
Mental illness and substance abuse are themselves barriers to treatment. Many shelters, transitional housing communities, and low-income housing units require that residents pass sobriety tests or drug tests before they can qualify for housing. This requirement can contribute to the problem of substance abuse by excluding homeless individuals from housing opportunities. Instead of finding supportive treatment for a substance use disorder, many of them remain on the streets, sleeping in public places, jails, detox centers, or temporary homeless shelters.
Other barriers to treatment among the homeless with mental illness include:
- Lack of health insurance or financial resources to pay for rehab
- Low motivation to seek help due to depression and hopelessness
- Fears about treatment caused by paranoid beliefs or anxiety
- Inadequate transportation to get to a treatment center
- Lack of awareness of resources for homeless people
- Lack of support from friends or family to recover and lead a sober life
When homeless people do receive mental health or substance abuse treatment, they may have difficulty following through with a therapeutic program or complying with a medication regimen. For people with severe mental illness who need psychiatric medication, noncompliance can quickly lead to relapse. In a population whose members are in constant transition from one shelter, hospital, or jail to another, consistent treatment may be difficult or impossible to find.
Cultural stereotypes and myths about homelessness also stand in the way of affordable health services for this population. Because homeless people are often viewed in a negative light — as “lazy,” “dangerous,” “criminal,” “insane,” or “unwilling to work” — political support for programs that support the homeless is often low. However, the truth is that homelessness, substance abuse, and mental illness can affect anyone from any socioeconomic group.
Because homeless people are often viewed in a negative light — as “lazy,” “dangerous,” “criminal,” “insane,” or “unwilling to work”
What Are the Solutions?
There are many volunteer groups, charitable organizations, churches, and government agencies working to improve the quality of life of homeless people with mental illness and/or substance use disorders. Effective outreach programs help to connect homeless individuals with services that can help them lead more secure, satisfying lives:
- Affordable therapy and counseling:
Affordable, confidential mental health services for the homeless are often lacking. Publicly sponsored programs, like Care for the Homeless in New York City, offer emergency intervention, counseling, case management, and other services to help this population recover from mental illness.
- Medication management:
Psychiatric medication can be highly effective at treating the symptoms of schizophrenia, depression, bipolar disorder, and other serious forms of mental illness. Case managers, therapists, nurses, and physicians are needed to help the homeless find the structure and motivation they need to comply with a medical treatment program.
- Substance abuse treatment:
Treatment for substance use disorders has traditionally been viewed as a prerequisite for mental health treatment or housing services for the homeless. However, the National Health Care for the Homeless Council emphasizes the importance of integrating substance abuse treatment with mental healthcare and housing in order to provide comprehensive, effective treatment. Detox, rehab, 12-Step meetings, counseling, and medication management are among the services that homeless people need to recover from addiction.
- Case management:
Case managers work with public health agencies and other organizations to help homeless individuals find consistent treatment and safe, affordable housing. Case managers follow up with homeless clients to assess their mental status, ask about their needs, and help them find resources in the community to meet those needs.
- Safe housing options:
People who suffer from severe forms of mental illness, such as schizophrenia, are in particular danger of being the victims of violence, robbery, or assault. The Safe Haven programs established by HUD provide temporary accommodations to homeless individuals with severe mental illness, so they can have a secure living environment until their mental health condition stabilizes.
According to the Mental Health America, supported housing services may include:
- Visits from a counselor
- Individual therapy
- Group therapy sessions
- Assistance with transportation
- Occupational counseling
Supported housing programs work simultaneously to treat substance abuse and help individuals create more stable lives. These programs provide access to psychosocial services within the structure of a temporary or permanent living environment.
Supported housing options range from highly structured communities to independent housing options with regular home visits by a case manager. A stable living environment is one of the most important factors in promoting sobriety and preventing relapse. NCH points out that relapse is less common among individuals who have found secure, reliable housing.
In a compassionate society, all members are treated with dignity and respect, no matter what their economic condition or health status may be. Meeting the basic needs of the homeless — for shelter, food, and healthcare — provides the security they need to stay consistent with treatment for mental illness and substance abuse.
Meeting the basic needs of the homeless — for shelter, food, and healthcare — provides the security they need to stay consistent with treatment for mental illness and substance abuse.
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- Federal Housing Resources Guide:
The U.S. Department of Housing and Urban Development publishes this guide to publicly supported housing opportunities and federal funding programs for Americans who are homeless or at risk of homelessness.
- Housing First: Pathways to Housing:
The “Housing First” model was developed to address the need for safe, supportive shelter among homeless people with chronic mental illness and substance use disorders. Unlike other housing models, Housing First takes the approach that homeless people who are actively abusing substances or who have serious mental illness should be provided with a place to live in order to benefit from treatment.
- Mental Health America (MHA):
This community-based nonprofit organization has branches across the country that provide support, advocacy, and assistance for people with mental illness. Resources on affordable housing, homelessness, and affordable mental health treatment are available on their website or through local MHA groups.
- National Alliance on Mental Illness (NAMI), “Securing Housing”:
NAMI offers a number of informational resources for people seeking help with homelessness, substance abuse, and psychiatric disorders. This guide provides advice on the types of housing available, how to find financial support for housing, and what to look for in a transitional or permanent dwelling.
- National Coalition for the Homeless (NCH):
This national network of organizations, volunteers, and policymakers provides advocacy, outreach, and support for homeless Americans. Homeless individuals are actively engaged in NCH efforts to improve their lives and ensure affordable, secure housing.
- S. Department of Veterans Affairs: Mental Health Services for Veterans:
The U.S. Department of Veterans Affairs offers mental health services for homeless veterans, including a 24-hour telephone helpline, the National Call Center for Homeless Veterans: 1-877-424-3838.