comments pls? essay on homelessness and mental illness
Formulating a housing-first approach to tackle homelessness among the mentally ill
Homelessness among people with severe and persistent mental illness (SPMI, which also stands for ‘severely and persistently mentally ill’) is both a challenge for the planning departments of mental health agencies, and also for the individuals themselves and their loved ones. This paper will first identify risk factors for homelessness among the SPMI as this helps to inform intervention strategies and policies. The paper will then highlight barriers to service use and critically review two broad approaches in the fight against homelessness among the SPMI. Evidence seems to show that the housing-first approach is able to overcome many of the said barriers, unlike the more traditional treatment-first approach. Accordingly, the closing section will be a brief outline of an implementation and evaluation strategy based on the housing-first approach.
Before beginning, let me define two key terms used in this paper – SPMI and homelessness. The definition of SPMI chosen for this paper is from a study by Ruggeri, Leese, Thornicroft, Bisoffi and Tansella (2000), who based it on the 1987 National Institute of Mental Health definition. A person has SPMI if he or she is diagnosed with psychotic disorders (such as schizophrenia and bipolar), has been treated for at least two years and has a Global Assessment of Functioning (GAF) score of 50 or below. As for homelessness, I use the definition from The Road Home (2008), the White Paper by the Australian government’s Homelessness Taskforce, which includes people sleeping in public places (rough sleepers), as well as in transient, insecure or substandard accommodation such as poorly managed boarding houses.
Risk factors for homelessness among the SPMI
Over the years, there have been numerous studies looking at what puts people with SPMI at risk of becoming homeless (Susser, Lin, & Conover, 1991; Caton, Shrout, Eagle, Opler, Felix & Dominguez, 1994; Caton, Shrout, Dominguez, Eagle, Opler & Cournos, 1995; Odell & Commander, 2000; Sullivan, Burnam & Koegel, 2000; Folsom et al., 2005; Johnson & Chamberlain, 2009). The list of risk factors from these studies, conducted mostly in the US, but also in the UK and Australia, is long. It includes age, geographic location, gender, ethnicity, substance abuse, lack of medical insurance, type and severity of illness, lower functional ability, family background and support, absence of long-term therapist and economic status.
The studies do not always agree, perhaps due to the complexity of the issue. For example, Susser et al.’s 1991 study also found that being an African-American male with alcohol abuse disorder and a schizophrenia-related diagnosis had little or no bearing on homelessness. This contrasts with Folsom et al.’s 2005 study in San Diego County, which found homelessness associated with factors such as being a male and of African-American descent, having a substance misuse and getting diagnosed with schizophrenia or bipolar disorder. This could be due to the difference in locations and the fact that things have changed between the early 1990s and mid-21st century.
Regardless of why risk factors may differ between communities, there is a need to clarify how risk factors create pathways from SPMI to homelessness. The rest of this section will discuss the pathway for one key risk factor that various studies seem to agree on, namely the breakdown of family support (Odell & Commander, 2000; Johnson & Chamberlain, 2009). Johnson and Chamberlain’s study of 4,291 homeless persons in Melbourne found that 31 per cent had mental health issues and half of these became homeless after family relationships broke down (2009).
They explained how this predisposes the mentally ill to homelessness, especially if they are aged below 25. This group is particularly vulnerable because their mental health problems begin when they are relatively young and still living with their families, therefore most of them are inexperienced at maintaining housing on their own. The disease often causes their peer relationships to become strained, leaving them with diminished social networks. Naturally, they will then rely more on their families for survival as the latter provides basic necessities like accommodation and food. However, when relationships sour due to the strain caused by mental illness, family members may withdraw their assistance (Hawkins & Abrams, cited by Johnson and Chamberlain, 2009), leaving the individual with no one else to turn to.
Whether individuals are evicted due to their families’ inability to cope, or intense conflicts causes them to leave home, homelessness follows soon when there is no family support. For those aged 25 or older, the disintegration of family support usually happens after an elderly parent dies or becomes unable to provide care, with a similar outcome of homelessness (Johnson & Chamberlain, 2009). The importance of family support has been borne out by research like the two large, controlled studies of men and women with schizophrenia who were using public mental health services in New York City (Caton et al., 1994; Caton et al., 1995). The researchers found that sufficient family support was the single most crucial factor that made a difference whether people were homeless or not.
With greater understanding of the pathway between SPMI and homelessness for any risk factor, programmes and services can then be tailored to address the issue more effectively. In the example above, Johnson and Chamberlain (2009) recommended early intervention measures that involve increased resources for families and caregivers of mentally ill young people so that the latter avoids homelessness. The authors cited a 2009 report by the Mental Health Council of Australia that proposes an immediate investment in home-based care programmes and support for families. The range of family support includes provision of information and financial assistance, counselling and access to planned short breaks so they can maintain relationships with loved ones who have SPMI.
Besides early intervention, there is also need to break the cycle of homelessness for the SPMI who are already on the streets or in unsuitable housing. Whatever these interventions are, they can only be effective if barriers to their provision and use are overcome. I will now clarify barriers faced by the homeless mentally ill in accessing healthcare services.
Barriers to service use
In 1997, Gillis and Singer described four categories of barriers to healthcare among the homeless, namely financial, bureaucratic, programmatic, and personal. Although the research did not focus on the homeless mentally ill per se, the categories are still applicable to this population. Examples of financial barriers include the lack of health insurance and limited healthcare benefits due to restrictions in eligibility. Particularly for the homeless with SPMI, they need access to subspecialty care but they often cannot afford it. Bureaucratic barriers refer to complicated registration procedures, long waits, inflexible scheduling, restricted clinic hours, and the like.
Programmatic barriers have to do with the healthcare service itself – perhaps it requires multiple providers, resulting in interrupted and fragmented care. This was corroborated by another US study (Calloway & Morrissey, 1998), which found that links were not extensive between community agencies helping homeless people with comorbid sustance abuse and mental illness. Other programmatic barriers are insufficient social services so providers take very long to mobilise these, or the negative attitudes of some of the healthcare providers themselves when dealing with disenfranchised people.
This leads to the homeless mentally ill having personal barriers towards healthcare as they have had previous bad experiences. They could also be reluctant to seek healthcare because food and shelter are their top priorities. Mental health support organisations like Stepping Stone Clubhouse in Brisbane have seen how homelessness profoundly impacts the ability of their members to be able to care for themselves, as related by housing coordinator L. Oldert (personal communication, September 22, 2010).
More recently, a study by Mimi, Swanson, Swartz, Bradford, Mustillo and Elbogen (2007) gave further insight into healthcare barriers faced by SPMI and homeless adults in five US locations. Mimi et al. distinguished between barriers to general medical care (mainly practical concerns such as lack of transportation and high out-of-pocket costs) and barriers to mental health care, which has to do with the fear of social stigmatisation. These barriers have significant impact and need to be taken into consideration when planning programmes and services. The next section will review two approaches to reduce homelessness and examine evidence for whether they work.
Treatment-first or housing-first?
In Australia, the flagship government programme providing services to the homeless is the Supported Accommodation Assistance programme (SAAP), which has been providing crisis (short-term) or transitional (medium-term) accommodation since 1985. Clients must accept support in the form of a case management programme before they can access the accommodation. This treatment-first approach is based on the assumption that mental health issues must be addressed before an individual can be considered for permanent housing (Padgett, cited by Johnson & Chamberlain, 2009). However, it has become increasingly evident that it is difficult to address mental health issues when people feel insecure in crisis or transitional accommodation. The 2004 inquiry report by the NSW Ombudsman found that some homeless mentally ill individuals do not engage with case managers and they are commonly excluded from services. Others want to resist the strong social stigma of being labelled mentally ill and so they deny needing any treatment or support, but this renders them ineligible for SAAP housing.
A different approach is to prioritise the housing needs of individuals before tackling their mental health issues. This housing-first or supportive-housing strategy has been shown to be effective in the US through studies like the one by Tsemberis, Gulcur and Nakae (2004). After two years, Tsemberis et al. found that 80 per cent of those in the housing-first programme had retained their accommodation, compared to only about a third who went into the traditional treatment-first services. In addition, the former group reported higher perceived choice, which could arguably be a key empowering factor that can help overcome the personal barrier to service use. Also helpful in overcoming the personal barrier is the increased effectiveness in building long-term relationships when individuals can engage support workers voluntarily and at their own pace instead of being forced to (Gronda 2009).
It could well be that the personal barrier is the most important barrier because all the other barriers can be resolved through continual improvement, but if people do not want to seek help, the best programme in the world will probably not make a lasting difference. The final section of this paper will elaborate on an implementation strategy to reduce homelessness among the mentally ill that is based on the housing-first approach.
Housing-first strategy to fight homelessness
My proposed strategy is modeled on the successful Pathways Supported Housing (PSH) programme in New York City, which has been replicated in over 27 sites since it was started in 1992. Close to 7,000 individuals in the US, Canada, UK, and Holland have participated in the programme, which has been studied in eight evaluation projects (National Registry of Evidence-based Programs and Practices, 2007).
Key elements of my strategy are as follows (NREPP, 2007; Tsemberis, 1999):
(i) immediate housing (apartments located in scattered sites as the programme rents up to only 10 per cent of units in any building) with no requirements for psychiatric treatment or sobriety.
The 10 per cent cap is to encourage interaction and integration between programme clients and other tenants.
(ii) treatment and support services provided through interdisciplinary Assertive Community Treatment (ACT) teams in the community.
Services are available all the time and may include treatment or management of psychiatric and substance disorders, and employment support. ACT is the preferred support for persons with SPMI, as it has been shown to be better than standard case-management models in reducing homelessness and severity of symptoms for homeless persons with SPMI (Coldwell & Bender, 2007). However, less intensive programmes can be used by consumers who obtain services either directly from their own programme or through referrals to other agencies.
(iii) separate agencies provide housing and treatment services.
Apartments are rented from community landlords who have no direct relationship with the treatment team, who is made up of social workers, nurses, psychiatrists, vocational and substance abuse counselors, peer counselors, and other professionals. This separation is important for participants to feel that their housing is not influenced in any way by their response towards treatment services, and they need only meet the obligations of a standard rental lease.
(iv) customised service plans for each tenant
Consumers are full partners in the development of service plans as they can determine frequency and order of services. The ACT team continues to work with them through hospitalisation or incarceration episodes. Formal clinical services can be refused, but consumers do have to meet with an ACT team member at least twice a month to ensure their safety and well-being.
(v) emphasis on physical health along with mental health
While most mental health residential programmes focus more on psychiatric and substance abuse problems, Tsemberis (1999) noted that poor physical health is related to a host of important variables, e.g. depression and psychiatric symptoms, self-esteem and mastery, and frequency of drug use. Therefore the ACT teams will use the services of a generalist nurse practitioner to provide health- related services directly.
Four key outcomes (residential stability; perceived consumer choice in housing and other services; cost of supportive housing and services; and use of support services) will be evaluated through external research efforts (see Appendix for details on how to measure these outcomes and findings from previous studies). There will also be feedback sessions every six months that are carried out one-on-one and in group settings by an independent and trained evaluators. The group settings are to elicit responses that may not arise in one-on-one interviews.
Summary
The homeless and mentally ill population is one of the most vulnerable sections of society but efforts to “fix” the problem could very well be failing because attention is being put on resolving the wrong “problem”. This paper argues that the problem is not the homeless and mentally ill people themselves; the problem lies in their homeless situation, however that may have arisen. The solution is to provide housing first as this puts them in the right place to tackle other issues. As a caseworker Carla was quoted a study by Dickson-Gomez, Convey, Hilario, Corbett and Weeks (2007, n.p.): “[T]he Housing First model…you don't fix people first. They don't need to be fixed. They don't need to be ready. They just need to be housed and then you work from there.”
Word count: 2391
APPENDIX
REFERENCES not complete
Caton, C.L., Shrout, P.E., Eagle, P. F., Opler, L. A, Felix, A., & Dominguez, B. (1994). Risk factors for homelessness among schizophrenic men: A case-control study. American Journal of Public Health, 84(2), 265-270.
Caton, C.L., Shrout, P.E., Dominguez, B., Eagle, P. F., Opler, L. A., & Cournos, F. (1995).
Risk factors for homelessness among women with schizophrenia. American Journal of Public
Health, 85(8), 1153-1156.
Dickson-Gomez, J., Convey, M., Hilario, H., Corbett, A. M. & Weeks, M. (2007) Unofficial policy: access to housing, housing information and social services among homeless drug users in Hartford, Connecticut. Substance Abuse Treatment, Prevention, and Policy, 2 (8). ??-??. doi:10.1186/1747-597X-2-8
Homelessness Taskforce. (2008) The Road Home: A National Approach to Reducing Homelessness, (Canberra, Commonwealth of Australia). Retrieved from www.fahcsia.gov.au/sa/housing/progserv/homelessness/whitepaper/Documents/
default.htm
http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=155
Odell, S. M., & Commander, M. J. (2000). Risk factors for homelessness among people with psychotic disorders. Social Psychiatry and Psychiatric Epidemiology, 35 (9), 396-401.doi: 10.1007/s001270050256
Ruggeri, M., Leese, M., Thornicroft, G., Bisoffi, G., & Tansella, M. (2000). Definition and prevalence of severe and persistent mental illness. The British Journal of Psychiatry, 177, 149-155. Retrieved from http://bjp.rcpsych.org/cgi/reprint/177/2/149
Sullivan, G., Burnam, A., & Koegel, P. (2000). Pathways to homelessness among the mentally ill. Social Psychiatry and Psychiatric Epidemiology, 35(10), 444-450.
doi: 10.1007/s001270050262
Susser, E. S., Lin, S. P., & Conover, S. A. (1991). Risk factors for homelessness among patients admitted to a state mental hospital. American Journal of Psychiatry, 148 (12). 1659-1664. Retrieved from http://proquest.umi.com/pqdweb?
did=1777328&sid=1&Fmt=6&clientId=20806&RQT=309&VName=PQD
Tsemberis, S., Gulcur, L. & Nakae, M. (2004). Housing First, Consumer Choice, and Harm Reduction for Homeless Individuals With a Dual Diagnosis. American Journal of Public Health, 94 (4), 651-656. Retrieved from www.pathwaystohousing.org/Articles/PTHPublications/
Pathways_American_Journal_of_public_health.pdf
Homelessness among people with severe and persistent mental illness (SPMI, which also stands for ‘severely and persistently mentally ill’) is both a challenge for the planning departments of mental health agencies, and also for the individuals themselves and their loved ones. This paper will first identify risk factors for homelessness among the SPMI as this helps to inform intervention strategies and policies. The paper will then highlight barriers to service use and critically review two broad approaches in the fight against homelessness among the SPMI. Evidence seems to show that the housing-first approach is able to overcome many of the said barriers, unlike the more traditional treatment-first approach. Accordingly, the closing section will be a brief outline of an implementation and evaluation strategy based on the housing-first approach.
Before beginning, let me define two key terms used in this paper – SPMI and homelessness. The definition of SPMI chosen for this paper is from a study by Ruggeri, Leese, Thornicroft, Bisoffi and Tansella (2000), who based it on the 1987 National Institute of Mental Health definition. A person has SPMI if he or she is diagnosed with psychotic disorders (such as schizophrenia and bipolar), has been treated for at least two years and has a Global Assessment of Functioning (GAF) score of 50 or below. As for homelessness, I use the definition from The Road Home (2008), the White Paper by the Australian government’s Homelessness Taskforce, which includes people sleeping in public places (rough sleepers), as well as in transient, insecure or substandard accommodation such as poorly managed boarding houses.
Risk factors for homelessness among the SPMI
Over the years, there have been numerous studies looking at what puts people with SPMI at risk of becoming homeless (Susser, Lin, & Conover, 1991; Caton, Shrout, Eagle, Opler, Felix & Dominguez, 1994; Caton, Shrout, Dominguez, Eagle, Opler & Cournos, 1995; Odell & Commander, 2000; Sullivan, Burnam & Koegel, 2000; Folsom et al., 2005; Johnson & Chamberlain, 2009). The list of risk factors from these studies, conducted mostly in the US, but also in the UK and Australia, is long. It includes age, geographic location, gender, ethnicity, substance abuse, lack of medical insurance, type and severity of illness, lower functional ability, family background and support, absence of long-term therapist and economic status.
The studies do not always agree, perhaps due to the complexity of the issue. For example, Susser et al.’s 1991 study also found that being an African-American male with alcohol abuse disorder and a schizophrenia-related diagnosis had little or no bearing on homelessness. This contrasts with Folsom et al.’s 2005 study in San Diego County, which found homelessness associated with factors such as being a male and of African-American descent, having a substance misuse and getting diagnosed with schizophrenia or bipolar disorder. This could be due to the difference in locations and the fact that things have changed between the early 1990s and mid-21st century.
Regardless of why risk factors may differ between communities, there is a need to clarify how risk factors create pathways from SPMI to homelessness. The rest of this section will discuss the pathway for one key risk factor that various studies seem to agree on, namely the breakdown of family support (Odell & Commander, 2000; Johnson & Chamberlain, 2009). Johnson and Chamberlain’s study of 4,291 homeless persons in Melbourne found that 31 per cent had mental health issues and half of these became homeless after family relationships broke down (2009).
They explained how this predisposes the mentally ill to homelessness, especially if they are aged below 25. This group is particularly vulnerable because their mental health problems begin when they are relatively young and still living with their families, therefore most of them are inexperienced at maintaining housing on their own. The disease often causes their peer relationships to become strained, leaving them with diminished social networks. Naturally, they will then rely more on their families for survival as the latter provides basic necessities like accommodation and food. However, when relationships sour due to the strain caused by mental illness, family members may withdraw their assistance (Hawkins & Abrams, cited by Johnson and Chamberlain, 2009), leaving the individual with no one else to turn to.
Whether individuals are evicted due to their families’ inability to cope, or intense conflicts causes them to leave home, homelessness follows soon when there is no family support. For those aged 25 or older, the disintegration of family support usually happens after an elderly parent dies or becomes unable to provide care, with a similar outcome of homelessness (Johnson & Chamberlain, 2009). The importance of family support has been borne out by research like the two large, controlled studies of men and women with schizophrenia who were using public mental health services in New York City (Caton et al., 1994; Caton et al., 1995). The researchers found that sufficient family support was the single most crucial factor that made a difference whether people were homeless or not.
With greater understanding of the pathway between SPMI and homelessness for any risk factor, programmes and services can then be tailored to address the issue more effectively. In the example above, Johnson and Chamberlain (2009) recommended early intervention measures that involve increased resources for families and caregivers of mentally ill young people so that the latter avoids homelessness. The authors cited a 2009 report by the Mental Health Council of Australia that proposes an immediate investment in home-based care programmes and support for families. The range of family support includes provision of information and financial assistance, counselling and access to planned short breaks so they can maintain relationships with loved ones who have SPMI.
Besides early intervention, there is also need to break the cycle of homelessness for the SPMI who are already on the streets or in unsuitable housing. Whatever these interventions are, they can only be effective if barriers to their provision and use are overcome. I will now clarify barriers faced by the homeless mentally ill in accessing healthcare services.
Barriers to service use
In 1997, Gillis and Singer described four categories of barriers to healthcare among the homeless, namely financial, bureaucratic, programmatic, and personal. Although the research did not focus on the homeless mentally ill per se, the categories are still applicable to this population. Examples of financial barriers include the lack of health insurance and limited healthcare benefits due to restrictions in eligibility. Particularly for the homeless with SPMI, they need access to subspecialty care but they often cannot afford it. Bureaucratic barriers refer to complicated registration procedures, long waits, inflexible scheduling, restricted clinic hours, and the like.
Programmatic barriers have to do with the healthcare service itself – perhaps it requires multiple providers, resulting in interrupted and fragmented care. This was corroborated by another US study (Calloway & Morrissey, 1998), which found that links were not extensive between community agencies helping homeless people with comorbid sustance abuse and mental illness. Other programmatic barriers are insufficient social services so providers take very long to mobilise these, or the negative attitudes of some of the healthcare providers themselves when dealing with disenfranchised people.
This leads to the homeless mentally ill having personal barriers towards healthcare as they have had previous bad experiences. They could also be reluctant to seek healthcare because food and shelter are their top priorities. Mental health support organisations like Stepping Stone Clubhouse in Brisbane have seen how homelessness profoundly impacts the ability of their members to be able to care for themselves, as related by housing coordinator L. Oldert (personal communication, September 22, 2010).
More recently, a study by Mimi, Swanson, Swartz, Bradford, Mustillo and Elbogen (2007) gave further insight into healthcare barriers faced by SPMI and homeless adults in five US locations. Mimi et al. distinguished between barriers to general medical care (mainly practical concerns such as lack of transportation and high out-of-pocket costs) and barriers to mental health care, which has to do with the fear of social stigmatisation. These barriers have significant impact and need to be taken into consideration when planning programmes and services. The next section will review two approaches to reduce homelessness and examine evidence for whether they work.
Treatment-first or housing-first?
In Australia, the flagship government programme providing services to the homeless is the Supported Accommodation Assistance programme (SAAP), which has been providing crisis (short-term) or transitional (medium-term) accommodation since 1985. Clients must accept support in the form of a case management programme before they can access the accommodation. This treatment-first approach is based on the assumption that mental health issues must be addressed before an individual can be considered for permanent housing (Padgett, cited by Johnson & Chamberlain, 2009). However, it has become increasingly evident that it is difficult to address mental health issues when people feel insecure in crisis or transitional accommodation. The 2004 inquiry report by the NSW Ombudsman found that some homeless mentally ill individuals do not engage with case managers and they are commonly excluded from services. Others want to resist the strong social stigma of being labelled mentally ill and so they deny needing any treatment or support, but this renders them ineligible for SAAP housing.
A different approach is to prioritise the housing needs of individuals before tackling their mental health issues. This housing-first or supportive-housing strategy has been shown to be effective in the US through studies like the one by Tsemberis, Gulcur and Nakae (2004). After two years, Tsemberis et al. found that 80 per cent of those in the housing-first programme had retained their accommodation, compared to only about a third who went into the traditional treatment-first services. In addition, the former group reported higher perceived choice, which could arguably be a key empowering factor that can help overcome the personal barrier to service use. Also helpful in overcoming the personal barrier is the increased effectiveness in building long-term relationships when individuals can engage support workers voluntarily and at their own pace instead of being forced to (Gronda 2009).
It could well be that the personal barrier is the most important barrier because all the other barriers can be resolved through continual improvement, but if people do not want to seek help, the best programme in the world will probably not make a lasting difference. The final section of this paper will elaborate on an implementation strategy to reduce homelessness among the mentally ill that is based on the housing-first approach.
Housing-first strategy to fight homelessness
My proposed strategy is modeled on the successful Pathways Supported Housing (PSH) programme in New York City, which has been replicated in over 27 sites since it was started in 1992. Close to 7,000 individuals in the US, Canada, UK, and Holland have participated in the programme, which has been studied in eight evaluation projects (National Registry of Evidence-based Programs and Practices, 2007).
Key elements of my strategy are as follows (NREPP, 2007; Tsemberis, 1999):
(i) immediate housing (apartments located in scattered sites as the programme rents up to only 10 per cent of units in any building) with no requirements for psychiatric treatment or sobriety.
The 10 per cent cap is to encourage interaction and integration between programme clients and other tenants.
(ii) treatment and support services provided through interdisciplinary Assertive Community Treatment (ACT) teams in the community.
Services are available all the time and may include treatment or management of psychiatric and substance disorders, and employment support. ACT is the preferred support for persons with SPMI, as it has been shown to be better than standard case-management models in reducing homelessness and severity of symptoms for homeless persons with SPMI (Coldwell & Bender, 2007). However, less intensive programmes can be used by consumers who obtain services either directly from their own programme or through referrals to other agencies.
(iii) separate agencies provide housing and treatment services.
Apartments are rented from community landlords who have no direct relationship with the treatment team, who is made up of social workers, nurses, psychiatrists, vocational and substance abuse counselors, peer counselors, and other professionals. This separation is important for participants to feel that their housing is not influenced in any way by their response towards treatment services, and they need only meet the obligations of a standard rental lease.
(iv) customised service plans for each tenant
Consumers are full partners in the development of service plans as they can determine frequency and order of services. The ACT team continues to work with them through hospitalisation or incarceration episodes. Formal clinical services can be refused, but consumers do have to meet with an ACT team member at least twice a month to ensure their safety and well-being.
(v) emphasis on physical health along with mental health
While most mental health residential programmes focus more on psychiatric and substance abuse problems, Tsemberis (1999) noted that poor physical health is related to a host of important variables, e.g. depression and psychiatric symptoms, self-esteem and mastery, and frequency of drug use. Therefore the ACT teams will use the services of a generalist nurse practitioner to provide health- related services directly.
Four key outcomes (residential stability; perceived consumer choice in housing and other services; cost of supportive housing and services; and use of support services) will be evaluated through external research efforts (see Appendix for details on how to measure these outcomes and findings from previous studies). There will also be feedback sessions every six months that are carried out one-on-one and in group settings by an independent and trained evaluators. The group settings are to elicit responses that may not arise in one-on-one interviews.
Summary
The homeless and mentally ill population is one of the most vulnerable sections of society but efforts to “fix” the problem could very well be failing because attention is being put on resolving the wrong “problem”. This paper argues that the problem is not the homeless and mentally ill people themselves; the problem lies in their homeless situation, however that may have arisen. The solution is to provide housing first as this puts them in the right place to tackle other issues. As a caseworker Carla was quoted a study by Dickson-Gomez, Convey, Hilario, Corbett and Weeks (2007, n.p.): “[T]he Housing First model…you don't fix people first. They don't need to be fixed. They don't need to be ready. They just need to be housed and then you work from there.”
Word count: 2391
APPENDIX
REFERENCES not complete
Caton, C.L., Shrout, P.E., Eagle, P. F., Opler, L. A, Felix, A., & Dominguez, B. (1994). Risk factors for homelessness among schizophrenic men: A case-control study. American Journal of Public Health, 84(2), 265-270.
Caton, C.L., Shrout, P.E., Dominguez, B., Eagle, P. F., Opler, L. A., & Cournos, F. (1995).
Risk factors for homelessness among women with schizophrenia. American Journal of Public
Health, 85(8), 1153-1156.
Dickson-Gomez, J., Convey, M., Hilario, H., Corbett, A. M. & Weeks, M. (2007) Unofficial policy: access to housing, housing information and social services among homeless drug users in Hartford, Connecticut. Substance Abuse Treatment, Prevention, and Policy, 2 (8). ??-??. doi:10.1186/1747-597X-2-8
Homelessness Taskforce. (2008) The Road Home: A National Approach to Reducing Homelessness, (Canberra, Commonwealth of Australia). Retrieved from www.fahcsia.gov.au/sa/housing/progserv/homelessness/whitepaper/Documents/
default.htm
http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=155
Odell, S. M., & Commander, M. J. (2000). Risk factors for homelessness among people with psychotic disorders. Social Psychiatry and Psychiatric Epidemiology, 35 (9), 396-401.doi: 10.1007/s001270050256
Ruggeri, M., Leese, M., Thornicroft, G., Bisoffi, G., & Tansella, M. (2000). Definition and prevalence of severe and persistent mental illness. The British Journal of Psychiatry, 177, 149-155. Retrieved from http://bjp.rcpsych.org/cgi/reprint/177/2/149
Sullivan, G., Burnam, A., & Koegel, P. (2000). Pathways to homelessness among the mentally ill. Social Psychiatry and Psychiatric Epidemiology, 35(10), 444-450.
doi: 10.1007/s001270050262
Susser, E. S., Lin, S. P., & Conover, S. A. (1991). Risk factors for homelessness among patients admitted to a state mental hospital. American Journal of Psychiatry, 148 (12). 1659-1664. Retrieved from http://proquest.umi.com/pqdweb?
did=1777328&sid=1&Fmt=6&clientId=20806&RQT=309&VName=PQD
Tsemberis, S., Gulcur, L. & Nakae, M. (2004). Housing First, Consumer Choice, and Harm Reduction for Homeless Individuals With a Dual Diagnosis. American Journal of Public Health, 94 (4), 651-656. Retrieved from www.pathwaystohousing.org/Articles/PTHPublications/
Pathways_American_Journal_of_public_health.pdf
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