H. Westley Clark, MD, JD, MPH, CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration U.S. Department of Health and Human Services Oakland, CA, February 8, 2007 Homelessness and Substance Abuse: SAMHSA–CSAT Response
The Substance Abuse and Mental Health Services Administration (SAMHSA) is one of eleven grant-making agencies of the U.S. Department of Health and Human Services, with a budget of approximately 3 billion dollars. SAMHSA • Vision: A life in the community for everyone • Mission: Building resiliency and facilitating recovery
SAMHSA’s Three Centers • The Center for Mental Health Services (CMHS) • The Center for Substance Abuse Prevention (CSAP) • The Center for Substance Abuse Treatment (CSAT)
Substance Abuse, Co-Occurring Disorders, and Family Homelessness
Boston Charleston Charlotte Chicago Cleveland Denver Des Moines Detroit Kansas City Los Angeles Louisville Metro Miami Nashville Norfolk Philadelphia Phoenix Portland Salt Lake City San Francisco Santa Monica Seattle St. Paul Trenton Cities Participating in the US Conference of Mayors Hunger and Homelessness Survey The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006
A Portrait of Homelessness The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006
A Portrait of Homelessness The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006
A Portrait of Homelessness Percentage The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006
Children & Families: Homelessness • 71% of homeless families were headed by single parents. • Children represented 24 percent of the entire population in emergency shelters in the cities. • 87% of the surveyed 23 cities reported that there was an increase in homeless children in the emergency shelter system. • The average percentage of members of homeless families who are children in the survey cities is 55%. The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006
Mental illness and the lack of needed services Lack of affordable housing Substance abuse and the lack of needed services Jobs Domestic violence Prisoner re-entry Unemployment Poverty Main Causes of Homelessness Factors associated with homelessness are diverse, complex and interrelated. Causes identified by the survey cities include: The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006
Boston Charleston Chicago Cleveland Denver Los Angeles Louisville Metro Miami Nashville Norfolk Phoenix Portland Salt Lake City San Francisco Santa Monica Seattle St. Paul Trenton Receives a SAMHSA Grant in this area √ 18 Survey Cities Identified Mental Illness and the lack of needed services as a Major Cause of Homelessness √ √ √ √ √ √ √ √ The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006
Chicago Cleveland Los Angeles Louisville Metro Miami Nashville Norfolk Philadelphia Phoenix Portland Salt Lake City San Francisco Santa Monica Seattle St. Paul Trenton Receives a SAMHSA Grant in this area √ 16 Survey Cities Identified Substance Abuse and the lack of needed services as a Primary Cause of Homelessness √ √ √ √ √ √ √ √ The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006
Boston Charleston Cleveland Denver Des Moines Los Angeles Louisville Metro Miami Philadelphia Phoenix Portland Salt Lake City San Francisco Santa Monica Seattle St. Paul Trenton 17 Survey Cities Identified Lack of Affordable Housing as a Main Cause of Homelessness The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006
Boston Chicago Cleveland Denver Louisville Metro Norfolk Philadelphia Phoenix Portland Salt Lake City San Francisco St. Paul Trenton 13 Survey Cities Identified Low-paying Jobs as a Main Cause of Homelessness The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006
Domestic Violence Charleston Chicago Kansas City Los Angeles Salt Lake City San Francisco Seattle Prisoner Re-Entry Boston Cleveland Denver Los Angeles Louisville Metro Phoenix San Francisco Receives a SAMHSA Grant in this area √ Seven Survey Cities Identified Domestic Violence or Prisoner Re-Entry as a Cause of homelessness √ √ √ √ √ The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006
Unemployment Charleston Chicago Denver Des Moines Los Angeles Poverty Cleveland Phoenix Seattle St. Paul Trenton Five Survey Cities Identified Unemployment or Poverty as a Main Cause of homelessness The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006
What do we know about homelessness? The December 2006 report from the U.S. Conference of Mayors cites trends in utilization of services (2005–2006, based on reports from 23 cities) and estimates the unmet needs of homeless persons and families. It finds: • Overall, requests for emergency shelter beds increased in 68 percent of the cities surveyed (p. 50). • 23 percent of general emergency shelter requests are unmet and 29 percent of family shelter requests are unmet (p.59). • 86 percent of the cities surveyed report that families have been turned away from shelters due to a lack of resources (p. 59). Hunger and Homelessness: A Status Report on Hunger and Homelessness in America’s Cities (2006). U.S. Conference of Mayors. www.usmayors.org/uscm/hungersurvey/2006/report06.pdf
What do we know about homelessness? Through the Continuum of Care (CoC) planning process, we know that about 744,313 persons were homeless in January 2005. These data are taken from a 2007 report by the National Alliance to End Homelessness, which compiled statistics from 463 CoC point-in-time counts. www.naeh.org
What do we know about homelessness? • 41 percent, or 303,551, of the homeless population counted in January 2005 were persons in families with children. • Nearly half (44%) of the homeless persons identified in January 2005 were unsheltered. • 23 percent (171,192) of those in the January 2005 count were chronically homeless. Homelessness Counts (2007). National Alliance to End Homelessness. www.naeh.org
What do we know about homelessness? • The statistics presented here are based on point-in-time counts. • “The reality is that the homeless population is quite fluid—people move in and out of homelessness and most are homeless for short periods of time. [It is estimated] that between 2.3 and 3.5 million people each year experience homelessness” (p. 9). Homelessness Counts (2007). National Alliance to End Homelessness. www.naeh.org
What do we know about substance abuse? • In 2005, an estimated 22.2 million persons aged 12 or older were classified with substance dependence or abuse in the past year (9.1% of the population aged 12 or older). • Of these, 3.3 million were classified as dependent on or abusing bothalcohol and illicit drugs, 3.6 million were dependent on or abused illicit drugs but not alcohol, and 15.4 million were dependent on or abused alcohol, but not illicit drugs. Results from the 2005 National Survey on Drug Use and Health: National Findings (NSDUH). SAMHSA, Office of Applied Studies (2006). oas.samhsa.gov/NSDUH/2k5NSDUH/2k5results.htm
What do we know about co-occurring disorders? • Co-occurring disorders are common. At least 5.2 million Americans 18 years of age and older have substance use disorders and serious psychological distress. • Co-occurring disorders are complex. Often, people have multiple, interactive conditions that complicate their treatment and recovery. • Co-occurring disorders are often not treated. Nearly half of people with co-occurring disorders receive no treatment for either disorder and only 6 percent receive treatment for both.
What do we know about co-occurring disorders? • People with co-occurring disorders can and do recover. • Prevention of co-occurring disorders is both necessary and effective. This is especially true for children with serious emotional disturbance who are at heightened risk for substance abuse. • Evidence-based practices—including integrated treatment for the most serious disorders—improve outcomes. • System-level changes are often needed to support innovative services.
22.2 Million 24.6 Million 5.2 Million Substance Use Disorder SPD Co-Occurring Disorders Co-Occurrence of Serious Psychological Distress (SPD) and Substance Use Disorders Among Adults, Aged 18 or Older: 2005 * NSDUH 2005
What do we know about substance abuse and homelessness? • Half of all homeless adults have substance use disorders.1 • 13 percent of those in substance abuse treatment were homeless at the time of admission (up from 10% in 2000).2 • More than 120,000 people admitted for substance abuse treatment are homeless at the time of admission.3 1 Blueprint for Change, 2003. CMHS, SAMHSA. 2 The DASIS Report: Characteristics of Homeless Female Admissions to Substance Abuse Treatment, 2002. Drug and Alcohol Services Information System (DASIS), SAMHSA, OAS. 3 The DASIS Report: Characteristics of Homeless Admissions to Substance Abuse Treatment, 2000. Drug and Alcohol Services Information System (DASIS), SAMHSA, OAS.
What do we know about mental illness and homelessness? • Approximately 20–25 percent of single adults who are homeless have a serious mental illness.1 • As many as two-thirds of all people with serious mental illnesses have experienced homelessness or have been at risk of homelessness at some point in their lives.2 • 20 percent of State prison inmates, 19 percent of Federal prison inmates, and 30 percent of local jail inmates with mental illnesses were homeless in the year before their arrest.2 • 1 National Resource Center on Homelessness and Mental Illness • 2 Blueprint for Change. CMHS, SAMHSA, 2003
What do we know about co-occurring disorders and homelessness? • Nearly one-quarter of homeless persons admitted for substance abuse treatment had co-occurring disorders.1 • Among homeless veterans, one-third to one-half have co-occurring mental illnesses and substance use disorders.2 • Among detainees with mental illnesses, 72 percent also have a co-occurring substance use disorder.2 • 1 The DASIS Report: Characteristics of Homeless Admissions to Substance Abuse Treatment, 2000. Drug and Alcohol Services Information System (DASIS), SAMHSA, OAS. • 2 Blueprint for Change. CMHS, SAMHSA, 2003
What do we know about family homelessness? • 50 percent are homeless for first time • 25 percent are homeless more than a year, half in transitional housing • 29 percent were homeless for first time before age 18 • 25 percent experienced out-of-home placement before age 18 • Family homelessness is expensive. The average annual cost of shelter for a homeless family in NYC is $25,000 per year (NYC Master Panel Report, 2003, p. 51) • 29 percent of family requests for shelter went unmet in 2006 (U.S. Conference of Mayors, 2006) *Unless otherwise indicated, data are from Burt et al., 2001. Based on women with children.
What do we know about homeless families? • 84 percent are single mothers • Average age: late 20s • Average 2–3 children, most under age 6 • 66 percent are women of color(African American, 44%; Latina, 16%; Native American, 6%)
Health Care Needs* ofHomeless Families • 27 percent have no insurance; 67 percent have Medicaid • 27 percent needed medical treatment in the past year • 45 percent had one or more chronic health condition • In one study, 48 percent had at least one family member with a disability or chronic illness(Beyond Shelter, 2003) *Burt et al., 2001, unless otherwise noted. Based on women with children.
Behavioral Health Needs* of Homeless Families • 23 percent—Problems with alcohol • 27 percent—Problems with drugs • 44 percent—Mental health problems (primarily depression, anxiety, PTSD) • 58 percent—One or more of the above *Burt et al., 2001. Based on women with children; self-report of problems within past year.
Experience of Violence* • 67 percent—Severe childhood physical abuse • 43 percent—Childhood sexual abuse • 63 percent—Severe violence by adult intimate partner(s) *Bassuk et al., 1996. Based on women with children.
Needs of Children • Homeless children go hungry at twice the rate of other children. • Nearly 25 percent have witnessed acts of violence in their families, usually against their mother. • They experience physical and sexual abuse at 2–3 times the rate of other children. • 22 percent of homeless children spend some time apart from their family in a typical year, with 12 percent placed in foster care.
Needs of Children Emotional and Behavioral Problems • 12 percent of preschoolers and 47 percent of school-age children who are homeless have anxiety, depression, withdrawal, and other clinical problems. • 16 percent of preschoolers have behavior problems, including severe aggression and hostility. • 36 percent of school-age children exhibit aggressive or delinquent behavior.
Challenges Homeless individuals with alcohol/substance use disorders pose substantial challenges to the substance abuse treatment community…
Service System Challenges • Inadequate screening and assessment • Fragmented services • Categorical funding • Lack of discharge planning • Poor integration of care • Other fiscal and coverage limitations
Societal Challenges • Stigma • Oppression and racism • Discrimination • Poverty • Housing costs • Lack of employment
Treatment Challenges • Engagement • Retention • Relapse • Interagency collaboration • Needs versus access to services • Treatment philosophies • Policy and financing
Challenges to Successful Engagement • Social isolation • Distrust of authorities • Mobility • Multiplicity of needs
Meeting the Challenges:Engagement Challenges • Outreach (aggressive/assertive) • Providing housing or other practical assistance • Creating a safe, nonthreatening environment • Strategies to increase motivation • Family-based treatment engagement strategy • Peer leadership
Meeting the Challenges: Retention • The challenge of retaining clients in substance abuse and alcohol abuse treatment is intensified when the target population is homeless. • Dropout rates of two-thirds or more are common.
Meeting the Challenges: Relapse • Relapse must be considered to be an integral component of treatment. • Relapses must be used in the treatment as opportunities for growth and change. • Addiction is a chronic and relapsing condition. • Nonjudgmental intervention is critical for success. • Discharge to the street = relapse.
Successful Approaches: Interagency Collaboration • Essential to meet multiple needs in a context of scarce community resources • Highly complex • Necessary to reduce fragmentation of care • Linkage vs. Integrated Treatment—Which is better? • Research on this question is mostly descriptive • Controlled comparisons are prohibitive
Challenges to Integrating Services • Well-established programs and a specialized work force • Interagency turf battles • Funding limitations • Lack of technology and resources to support information needs • Lack of available services • Size and complexity of the service system • Lack of political will and mechanisms to channel public support • Legislative and political opposition
“No Wrong Door” Policy • Each provider should be aware that he/she has the responsibility to address the range of client needs whenever a client presents for care. • Properly refer clients for appropriate care as needed • Follow up on referrals to ensure clients received proper care
Federal Response to Homelessness • Targeted Homeless Assistance Programs • Resources • Coordination/Linkages • Treatment for Homeless Program • Homeless Family Program • Collaborative Initiative to Help End Chronic Homelessness • Policy Academies • Federal Leadership
Creating a Comprehensive Service System for Homelessness • Support concept of “No Wrong Door” to services • Provide services determined by evidence to be effective • Change ineffective policies or regulations • Leverage existing resources • Use mainstream resources • Pursue new resources