Jennifer-Porter-Psyd

2/11/2020

INTERVENTIONS, STRATEGIES, AND RESOURCES FOR WORKING WITH THE HOMELESS POPULATION

JENNIFER PORTER, M.A., PSY.D KATIE MENDOZA, M.A., PRE‐DOCTORAL INTERN NATALIA OLARTE STAUNTON, M.A., LMFT, PRE‐DOCTORAL INTERN

PREVALENCE OF HOMELESS OLDER ADULTS

• Literature review conducted by Ng, Rizvi, and Kunik (2013), examined the prevalence and contributing factors of homelessness in older adults. • Prevalence studies were grouped • Comprehensive focus on homeless populations (4) • Range from 20% ‐ 38% • Information gathered at outreach events for the homeless (2) • 55% and 39% • Sample shelters (3) • Range from 8% to 24%

• Overall median prevalence is 24%, up from 11% in 1990s.

CAUSES OF HOMELESSNESS IN OLDER ADULTS

• Ng, Rizvi, and Kunik (2013), reviewed 7 U.S. studies that came up in their search for causes of homelessness. • 7 categories for risk factors were created: • Financial/employment problems, • Housing problems, • Lack of social support, • Physical health problems, • Mental illness, • Substance use and gambling disorders, and • Criminal history

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NG, RIZVI, AND KUNIK (2013) FINDINGS

• Financial problems (6) • Employment problems (6) • Lack of social support (6) • Health problems (4) • Mental health • Physical • Addiction problems (3) • Criminal behavior (4) • Housing problems (2)

LITERATURE REVIEW IN CANADA

• Grenier, Barken, Sussman, Rothwell, Bourgeois‐Guérin, and Lavoie (2016) discussed the complex interconnections between • Structural conditions • Cumulative circumstances • Risk factors, and • Trigger events

“PATHWAYS INTO HOMELESSNESS”

• Macro‐level forces • Structural issues associated with homelessness include: • Inadequate affordable housing, • Fewer available jobs, • Poverty, and • Limited access to health, disability, and pension benefits

• Individual‐level forces • Family breakdown, • Eviction, and • Loss of employment

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CAUSES OF HOMELESSNESS IN OLDER ADULTS

• Shinn, Gottlieb, Wett and Bahl (2007) interviewed 61 housed and 79 homeless adults aged 55 and over from New York • Disability, • Physical, mental, substance problem • Economic capital, • Economic stressors, housing title, number of building problems • Human capital, • High school or GED, length of longest job • Social capital, and • Number of disruptive events in youth, child housing resource, relative/friend housing resource, organizational ties • Stressful life events • Number of events, apartment or job loss

FINDINGS OF SHINN, GOTTLIEB, WETT AND BAHL (2007) • Over half of the homeless respondents lived relatively conventional lives before becoming homeless at an average age of 59 • Long periods of employment • Residential stability

• Predictors of homelessness: • Male gender • Younger age • Higher levels of education • Shorter tenure in the longest job held • Loss of an apartment or job while in conventional housing • Lack of children or other ties who would provide housing

PREDICTORS OF HOMELESSNESS (SHINN, GOTTLIEB, WETT, &BAHL, 2007)

• Disability and economic capital • No statistical significance in predicting homelessness

• Human Capital • High levels of educational‐level attainment and tenure in the longest job held

• Social Capital • Social ties, especially to children who would allow individual to stay with them were a protective factor

• Stressful Life Events • Indication of loss of resources, i.e., eviction, being asked to leave, job loss

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TAKE AWAY

• The literature reviews (Ng, Rizvi, & Kunik, 2013 and Grenier, Barken, Sussman, Rothwell, Bourgeois‐Guérin, & Lavoie, 2016), 3‐Nation study (Crane, et al., 2005) and the New York study (Shinn, Gottlieb, Wett, & Bahl, 2007), highlight: • Need for increased attention to the elderly homeless as a significant part of the homeless population • Specific services that might benefit the elderly homeless

STRATEGIES AND INTERVENTIONS

• Research literature notes: • Safety • Access to health and social services • Specialized medical care • Housing

HOUSING

• Kushel (2011) stated, “Supportive housing, or subsidized housing linked with on‐site or closely linked supportive services (medical, psychiatric, vocational, social work, substance abuse treatment), has been shown to maintain housing, improve health outcomes and reduce acute health utilization for chronically homeless individuals” (p. 6). • Grenier, Barken, Sussman, Rothwell, Bourgeois‐Guérin, & Lavoie (2016) highlighted Canada’s housing‐first model that is intended to immediately provide housing followed by other forms of support.

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HOUSING CONT’D

• Housing First in the US (National Alliance to End Homelessness, 2016) • Does not require • Address all of their problems, including behavioral health problems • Graduate through a series of service programs before accessing housing • Mandate participation in services before obtaining or to retain housing

• Services have been found to be more effective when a person chooses to engage

ACCESS TO HEALTH AND SOCIAL SERVICES

• Understand the • Ways our society makes life difficult for the elderly • Social context in which the client lives to be able to understand the client and work effectively with him/her • Social context well enough to be of active assistance to the older client when this is needed.

• Provide accurate information on all available services • Actually providing or setting up services for the client

LINKAGE TO HEALTH AND SOCIAL SERVICES

• Physicians who are knowledgeable about and comfortable with the elderly • Various types of residences available to older adults, including independent living, assisted living, residential care, and skilled nursing facilities • Geriatric case management services • Specialized services for older persons with dementia • Services for caregivers of frail older adults • Congregate meal sites and home delivered meal programs • Senior recreation centers Knight, B. G. (2006)

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LINKAGE TO HEALTH AND SOCIAL SERVICES

SAFETY

• Qualitative study by Daiski (2006) interviewed 24 homeless individuals in Canada with whose age ranged from 18‐81. • Living in fear and feeling unsafe • Fear of violence • Shelters viewed as most dangerous accommodation • Robbery • Assault • Fighting • Streets • Dangerous • Stressful • Distrust of law enforcement

THERAPEUTIC INTERVENTIONS TO ADDRESS SAFETY • Assessment • Hypervigilance • Some level of hypervigilance may be necessary if older adult continues to live in shelters or on street • Empower the client to regain control • Identify cues of who, what, and where are safe • Harmful coping mechanisms • Alcohol, drugs, prescription meds • Closely monitor clients substance use • Teach coping skills, enhance positive coping skills

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CASE EXAMPLE

• 56 y.o. African American female presented with sxs of severe depression, anxiety, trauma history, IPV, heroin and marijuana use, homelessness.

• Phase 1 • Housing • Referral to psychiatry • Alternate coping to drug use

• Phase 2 • Collaboration • Reinforcement of healthy coping

• Phase 3 • Additional linkages • Termination

HOUSING DEFINITIONS

• Living in shelters • In vehicles • Abandoned building • Friends/ Families homes (“doubled up homeless” Cousineau, 2001) • Motels/ Hotels • Rooming house • Institutionalization includes Hospitals, Jail, Transitional housing

RISK FACTORS

• Disability • Physical health problems • Mental illness • Substance Abuse • Economic • Low levels of income • Not owning a home • Doubling up • (Shinn et al., 2007)

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RISK FACTORS

• Human Capital • Educational attainment • Work history • Social Capital • Having children and other relatives • Having friends • Participation in organizations outside of work • Stressful Events • Widowhood • Loss of job/ income • Evictions • Major illness • Increased severity of mental health illness • (Shinn et al., 2007)

MENTAL HEALTH CHALLENGES: ADDICTION

• Problem: Many Homeless Shelters require that individuals be sober • Research: Edens, Tasi and Rosenheck (2013) suggest that sobriety should be a requirement for housing (p.243) • Differences between Drug Use and Alcohol Use: • Those homeless using Alcohol had a higher mean of institutionalization (hospitalized or jail) compared with illicit drug users (Edens, et al., 2013, p. 246) • Individuals who used stimulants versus other illicit drugs tended to have fewer days housed and more days homeless (Edens, et al., 2013, p. 247) • Those that use alcohol or non stimulant illicit drugs had a higher success rate of staying housed at a 2 year follow up compared to those who used stimulants (Edens, et al., 2013, p. 247)

MENTAL HEALTH CHALLENGES‐ ADDICTION RECOVERY

• Clients who are homeless and with “poor mental health status” need longer treatment periods to address their substance abuse to reach abstinence and was more impactful then the severity of drug use (Guerrero, 2013, p. 234) • Rate of completion of treatment was reduced by • 32% for cocaine and marijuana users • 42% for metamphetamine users when compared to alcohol users (Guerrero, 2013, p. 234)

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MENTAL HEALTH CHALLENGES‐ ETHNIC AND GENDER CONSIDERATIONS

• African American and Latinx clients stayed in treatment for shorter periods of time and had higher number of treatment episodes compared to Whites who had lower treatment drop out rates (Guerrero, 2013, p. 234) • These differences disappeared when comparing outpatient treatment to residential treatment (Guerrero, 2013, p. 237) • Women are more likely to drop out of treatment for substance abuse than men (Guerrero, 2013, p. 235) • Guerrero (2013) suggests that Latinx have lower enrollment rates and completion rates because they tend to receive fewer services and report being less satisfied with the services (Guerrero, 2013, p. 237) • This might be related to lack of cultural sensitivity from counselors

MENTAL HEALTH CHALLENGES‐ INCARCERATION

Risk Factors associated with becoming homeless: • Was homeless before going to prison • Lived alone before going to prison or planning on living alone when released • Has mental health issues • Has a chronic medical condition • History of incarceration • Most reentry programs focus on individuals 35 years old or younger or Veterans (Williams et al, 2010).

MENTAL HEALTH CHALLENGES‐ POVERTY

Living on the streets can have a negative impact on the elderly adults physical health • Being exposed to the weather • Street violence • Requires agility and street smarts but the elder adults judgment and cognition can be impaired with age (van Wormer, 2004, p. 42) • Socio‐Economic Risk Factors • Less education, including not graduating from high school • Being unemployed or only working part time • Earned less than 200% of the Federal Level of Poverty • Enrolled in Public Assistance • Self‐report being in poor health (Cousineua, 2001, p. 697)

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MENTAL HEALTH CHALLENGES‐ SEVERE MENTAL HEALTH DISORDERS

Onset of disorders in youth and early adulthood results in individual not having the typical protective factors found in a non‐ clinical samples: • Forming relationships • Maintain steady employment • Attaining and completing higher education • Developing life goals • This can lead to isolation, lack of financial resources, social support which compounds the mental health symptoms increasing likelihood of homelessness (van Wormer, 2004, 44)

MENTAL HEALTH CHALLENGES‐ AGING

• Diminished social support (friends, family, co‐workers) • Impaired judgment • May contribute to financial abuse • Physical deterioration • May make them easy targets in shelters from other homeless individuals ( Proehl, 2007, p. 301) • Hearing and Vision Loss • can contribute to lack of trust in others and increased hypervigilance (Proehl, 2007, p. 301) • Do not want to be institutionalized or lose their independence (Proehl, 2007, p. 301) • If they lose employment‐ they may be considered too old to gain new employment to cover expenses including rent (Shinn et al., 2007, p. 705)

TREATMENT SUCCESS

• Psychosocial Adjustment • Help with housing • Focus on mental health • Work on substance abuse recovery • Self Direction: • Helping client’s has a sense of internal locus of control • Assume self efficacy • Meaning‐Making: • Creating meaning in their life • Affirmation of their lives • (Proehl, 2007, p. 303)

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HISTORICAL CONTEXT

• The current Cohort of Elderly adults are Baby Boomers and were born 1940’s‐ 1960’s • May have experienced forced institutionalization in their youth which may contribute to their reluctance to access services (van Wormer, 2004, p. 45) • Changes in laws related to institutionalization contribute to the cycle in and out of hospitals and the streets • Eg: client does not take medication, is hospitalized as danger to self. Becomes medication compliant at hospital and no longer meets the criteria for hospitalization. Given a referral to homeless shelter and sent back out to street. Without supervision client might stop medications and may be re‐ hospitalized. (van Wormer, 2004, p. 45)

HISTORICAL CONTEXT

• Baby Boomers experienced the recessions in the 1970’s/ 1980’s when many of them were entering work for the first time. • Recession led to lower wages for unskilled workers and increased unemployment among first time workers • Housing costs were rising at the same time • Cocaine epidemic in 1980’s increased risk of homelessness • Changes in criminal sentencing law • Social welfare expenditures dropped in 1980’s and 1990’s (Brown, Thomas, Cutler, Hinderlie, 2013, p. 127) • Results: • Have lower income throughout lifetime • If they become homeless as an older adult it is usually the result of unforeseen event and may not have experienced the risk factors (Shinn et. al 2007, p. 705)

PROTECTIVE FACTORS: ETHNICITY AND IMMIGRATION • Ethnicity: • Latinos and Asians make up the lowest percentage of absolute homeless compared to the percentage found among the general population (DeVerteuil, 2001, p. 929) • Willingness to live in nontraditional (Western) arrangements

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PROTECTIVE FACTORS: ETHNICITY AND IMMIGRATION • Immigration: • Immigrants may congregate within communities made up of other immigrants from their home country (DeVerteuil, 2001, p. 931) • These communities are both voluntary and involuntary • Voluntary‐ self segregated space that helps their survival (language, social, emotional, religious support) • Historical legacy that this is a community for immigrants • Social networking • Financial support and job help (DeVerteuil, 2001, p. 936) • Involuntary‐ community is the only place that society has designated for the immigrants, reinforcing segregation and decreasing opportunity for mobility (DeVerteuil, 2001, p. 931)

HISTORICAL CONTEXT

Spirituality • Hope and Motivation • Client can have hope that God will help them get through this or that they as individuals have the strength to survive being homeless • Social Capital • Having Children, Relatives or Friends who will notice a deterioration in client and will help client if they lose their home (Shinn et al., 2007)

STRATEGIES OF OUTREACH

• Proehl (2007, p. 303) suggests that homeless are more likely to engage in services initially when the services are concrete • Food, Housing, Medication, Medical, Clothing, Finances • Research has demonstrated that clients remain in treatment longer when it is combined with social services (Proehl, 2007, p. 305). • Clients might have difficult being self‐reflective, and this could be a protective factor/ coping mechanism for dealing with the daily adversities they are facing as elderly adults who are homeless. (Snodgrass, 2014, p. 316)

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OUTREACH INTERVENTIONS

Self‐ Direction: • Help Older Adults gain control over their lives and empower them • Foster a sense of internal locus of control for client can increase client’s agency (Snodgrass, 2014, p. 314)

• Meaning Making: • “Focus of Meaning and purpose provides a positive, optimistic perspective that is counter to disempowering views of aging based on losses and deficits” (Penick, & Fallshore, 2005, p. 17). • Elderly lose many sources that had previously created meaning such as career, friends, family, independence, hobbies (Proehl, 2007, p. 304) • Faith in God can help client maintain a sense of identity and creates an external locus of control over their circumstances (Snodgrass, 2014, p. 314)

CLINICIAN/ STAFF TOOLS

• Set aside “prejudgments, biases and preconceived ideas about things” (Moustaskas, 1994) • Move Away from expectation from Self sufficiency to Supervised Care (van Wormer, 2004, p.39) • Be cognizant of The Stigma of Homelessness (Snodgrass, 2014, p. 311) • Clients can feel patronized by staff that they must have committed some mistake in order to end up homeless • Client may prefer to use another term to homelessness to reduce the shame and stigma they feel (Snodgrass, 2014, p. 313) • Social Stigma focuses on individual failure and not societal failure (Snodgrass, 2014,p. 315) • Helping Client feel Human • Many clients report feeling subhuman, looked down upon by others • Given other circumstances, any of us could be homeless (Snodgrass, 2014,p. 315) • Society places a value on what one does (work, paycheck, material possessions) as opposed to the result of being (Snodgrass, 2014,p. 316)

AGENCY TOOLS: HOMELESS BOOT CAMP

• Full day event with all the providers at your agency. • Use a magnetic boardgame to represent the housing process for a client from beginning to end • Use magnets to put in all the steps necessary from first contact to client getting key to home • This helps the agency understand the full process and helps create a larger vision that ever employee vision and Goal (Guerrero, Henwood & Wenzel, 2014,p. 52).

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CHALLENGES RELATED TO RESEARCH OF HOMELESS POPULATIONS

• Lack of address makes it difficult to contact and follow up

• Lack of phones can make telephone surveys difficult

• Poor access to health care make it difficult to use medical records as data (Kleinman, Freeman, Perlman and Gelberg, 1996,p. 535).

NEED FOR AFFORDABLE/SUPPORTIVE HOUSING

• According to studies from the County of Los Angeles Community and Senior Services and the City of Los Angeles Department of Aging the number of L.A. County residents over age 60 is projected to double in the next 20 years, increasing from 1.5 million to nearly 3 million. • A third of homeless adults were 50 and older in 2003 (Hahn et al., 2006), with this number likely growing today. This is believed to be due to a cohort effect: persons born in the second part of the baby boom generation, in the middle of 1954 and 1964, are more likely to experience homelessness compared to other cohorts (Culhane et al., 2013).

SHORT TERM TRANSITIONAL HOUSING

• Bridge Transitional Housing Program • Currently there is only a 2.7% vacancy rate in the apartment inventory and high rental prices make it very challenging to link qualified people into permanent housing. Many who qualify for or obtain a “Section 8” voucher still have to search and wait for months for an apartment to become open. The aim is to provide transitional housing to persons who are employed but homeless that have a permanent housing voucher and need up to 90 days to save funds for move in costs for permanent housing.

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MODELS FOR HOUSING THE HOMELESS

• Housing First does not make those experiencing homelessness address the all of their problems, such as behavioral health problems, etc. before they can obtain housing. This program does not require involvement in services prior to obtaining housing or as a requirement to retain housing. • Two models are similar to the Housing First model but are implemented differently. Permanent supportive housing (PSH) is aimed at persons with chronic illness, disabilities, mental health issues, and/or substance use disorders who have experienced long‐term or chronic homelessness. PSH provides long‐term rental help as well as supportive services.

MODELS FOR HOUSING THE HOMELESS

• Rapid re‐housing, another model, is used to assist many individuals and families, providing short‐term rental assistance and services. The aim is to assist people in getting housed quickly, increasing autonomy, and remaining housed. The Core Components of rapid re‐ housing: housing identification, rent/move‐in assistance, case management and services utilize Housing First ideologies. • Persons in a Housing First model are housed more quickly and typically remain stably housed. This is true for both Permanent Supportive Housing and rapid re‐housing programs. PSH has a long‐term housing retention rate as high as 98 percent. Studies show rapid re‐housing links people to housing rapidly, with an average of two months time, and helps them to remain housed. They have also shown that between 75 percent and 91 percent of households remain housed a year after being rapidly re‐housed.

COORDINATED ENTRY SYSTEM

• The Los Angeles County Coordinated Entry System (LA County CES) aids in the linkage and management of resources that are components of the crisis response system in the county. CES enables users to connect people more quickly and effectively to resources to attempt to resolve their housing crisis. This system works to connect persons with the highest needs, and those with high vulnerability to housing and supportive services in a fair manner.

• CES integrates Housing First, Harm Reduction, and Trauma Informed Care approaches into its housing and supportive services.

• Housing First moves people experiencing homelessness into housing and provides support and services as needed for stabilization.

• Harm Reduction focuses on reducing risky behaviors and consequences connected with drug and alcohol use.

• Trauma Informed Care focuses on recognizing and responding to the effects of various types of trauma.

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In Greater Los Angeles, Homelessness is experienced by :

6% of 61% of 24 % of 18‐24 years old 25 to 54 years of age Adults 55 & older

56, 257 on any 28 %are chronically homeless. given night are experiencing 14 %have a substance use disorder homelessness 25 % have a serious mental health condition 9 % are developmentally disabled 18 % have a physical disability

Current Solutions within Los Angeles County

Rapid Rehousing Housing ends Homelessness Recovery Bridge Housing

Supportive Housing Police Department Homeless Outreach Teams Health Homes Models

Housing First Model Public Library Departments Case Management Non‐profit Organizations

Targeted Homelessness Los Angeles County School Districts Shelters throughout Los Angeles Prevention LAHSA‐Los Angeles Homeless Services Authority

DMH Innovation 2 Purpose: To build the capacity of the community to identify and support community members at risk of trauma or experiencing trauma utilizing the assets of the community, work collaboratively as a community.

Build Community Capacity Identifying and Support Community Collaboration with Members at risk for trauma and/or community assets experiencing trauma

DMH Innovation 2 Goal: To improve mental wellness and prevent and reduce the impacts of any form of trauma.

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Community Capacity Building • Collaborative Community Meetings • Trainings • Community Activities • Workshops

Linkage to Services • Outreach within Pasadena and San Gabriel Valley Cities • Quick screening to identify needs • Linkage and Follow Up with needs by Peers and Case Managers Collaboration in Community

• Creating Community Partners and providing support • Ensuring individuals in the community receive adequate services.

TAY Link & GEM Link Services

• Onsite Case management with screenings and warm • Onsite Case management with screenings and warm handoffs to mental health, medical, dental, and social or handoffs to mental health, medical, dental, and social or supportive services. supportive services. • Onsite Housing Specialist • Onsite Nurse • Laundry & Shower facilities • Onsite Housing Specialist • Recreation • Meals (breakfast, lunch, and snacks) • Clothing • Laundry & Shower facilities • Computers/Internet • Pet kennels • Education and Vocational Linkage • Lockers • Participation in TAY Peer Network to be involved in • Recreation planning activities, outings, and assistance with • Clothing resources. • Computers/Internet

GEM & TAY Link Linkage Program to Social & Support Services for Homeless individuals 18‐24 and 60 and over

Location: Jackie Robinson Center 1020 N. Fair Oaks Avenue, Pasadena, CA 91103 626‐744‐7200 Community Meetings Community Activities to TAY Program Coordinator & GEM Program Coordinator Workshops for Build Capacity Nereida Carrasco Juana Infante Youth and Older Adults within Pasadena 626‐744‐7234 626‐744‐7349 Psychoeducation [email protected] [email protected]

Identification of Quick Linkage to Follow Up Person at risk and/or Screening to Needed Services with participant experiencing Identify until housed and Homelessness Needs no longer at risk.

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REFERENCES

• Brown, R., Thomas, L., Cutler, D., Hinderlie, M., 2013. Meeting the Housing and Care needs of older homeless adults: A Permanent supportive housing program targeting homeless seniors. Seniors Housing & Care Journal,21 (1), 126‐ 135. • Los Angeles Mission. (2019) Bridge Housing. Retrieved from https://losangelesmission.org/bridge‐housing/ • Crane, M., Byrne, K., Fu, R., Lipmann, B., Mirabelli, F., Rota‐Bartelink, A., … Warnes, A. M. (2005). The causes of homelessness in later life: Findings from a 3‐nation study. Journal of Gerontology, 60(3), S152‐S159. • Cousineau, M. (2001) Comparing Adults in Los Angeles County who have and have not been homeless, Journal of Community Psychology, 29 (6), 693‐701. • Culhane DP, Metraux S, Byrne T, Steno M, Bainbridge J. The age structure of contemporary homelessness: Evidence and implications for public policy. Analyses of Social Issues and Public Policy. 2013;13:1–17. • Daiski, I. (2006). Perspectives of homeless people on their health and health needs priorities. Journal of Advanced Nursing, 58(3), 273‐281. doi: 10.111/j.1265‐2648.2007.04234.x

REFERENCES

• DeVerteuil, G. (2011). Survive but not thrive? Geographical strategies for avoiding absolute homelessness among immigrant communities. Social and Cultural Geography, 12(8). 929‐ 945. • Eden, E., Tsai, J., Rosenheck, R. (2013) Does Stimulant use impair housing outcomes in low‐demand supportive housing for chronically homeless adults? The American Journal of Addictions. 23, p. 243‐248. • Goldberg, J., Lang, K., & Barrington, V. (2016). How to prevent and end homelessness among older adults. Justice in Aging: Fighting Senior Poverty Through Law, Special Report [PDF file]. Retrieved from https://www.justiceinaging.org/wp‐ content/uploads/2016/04/Homelessness‐Older‐Adults.pdf • Grenier, A., Barken, R., Sussman, T., Rothwell, D., Bourgeois‐Guérin, V., & Lavoie, J‐P. (2016). A literature review of homelessness and aging: Suggestions for a policy and practice‐relevant research agenda. Canadian Journal on Aging, 35(1), 28‐ 41. doi: 10.1017/S0714980815000616 • Guerrero, E. (2013). Examination of treatment episodes among women and racial and ethnic minorities in addiction treatment. Journal of Social Work Practice in the Addictions. 13, 227‐243.

REFERENCES

• Guerrero, E., Henwood, B, Wenzel, S. (2014). Service Integration to Reduce homelessness in Los Angeles County: Multiple Stakeholder Perspectives. Human Service Organizations: Management, Leadership and Governance, 38, 44‐54.

• Hahn JA, Kushel MB, Bangsberg DR, Riley E, Moss AR. The aging of the homeless population: Fourteen‐year trends in San Francisco. Journal of General Internal Medicine. 2006;21:775–778.

• Knight, B. G. (2006). Unique aspects of psychotherapy with older adults. In S. H. Qualls and B. Knight (Eds.), Psychotherapy for depression in older adults (pp. 1‐28a). Hoboken, NJ: John Wiley & Sons, Inc.

• Kushel, M. (2011). Older homeless adults: Can we do more? Journal of General Internal Medicine, 27(1), 5‐6. doi: 10.1007/s11606‐01101925‐0

• Kleinman, L., Freeman, H., Perlman, J. and Gelberg, L. (1996). Homing in on the homeless: Assessing the physical health of homeless adults in Los Angeles county using an Original Method to obtain physical examination data in survey. Health Service Research, 30(5), 533‐549.

• Najavits, L. (2002). Seeking Safety: A Treatment Manual for PTSD and Substance Use. New York, NY: The Guilford Press.

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REFERENCES

• National Alliance to End Homelessness. (2016). Fact sheet: Housing first [PDF file]. Retrieved from http://endhomelessness.org/wp‐content/uploads/2016/04/housing‐first‐fact‐sheet.pdf • National Coalition for the Homeless. (2009). Homelessness among elderly persons [PDF file]. Retrieved from http://www.nationalhomeless.org/factsheets/Elderly.pdf • Ng, S., Rizvi, S., & Kunik, M. E. (2013). Prevalence of homeless older adults and factors causing their homelessness: A review. The Internet Journal of Geriatrics and Gerontology, 8(1), 1‐8. • Proehl, R. (2007). Social Justice, Respect and Meaning‐Making: Keys to working with the Homeless Elderly population. Health and Social Work, 32(4), 301‐307. • Shinn, M., Gottlieb, J., Wett, J. L., & Bahl, A. (2007). Predictors of Homelessness among older adults in New York City. Journal of Health Psychology, 12(5), 696‐708. doi: 10.1177/1359105307080581

REFERENCES

• Shinn, M., Gottlieb, J., Wett, J., Bahl, A., cohen, A., Baron Ellis,D., 2007. Predictors of Homelessness among Older Adults in New York City. Disability, Economic, Human and Social Capital and Stressful Events. Journal of Health Psychology, 12( 5) 696‐ 708. • Snodgrass, J. (2014). Spirituality and Homelessness: Implications for Pastoral Counseling. Pastoral Psychology, 63, 307‐ 317. • Zarit, S. H. & Knight, B. G. (1996). Introduction‐Psychotherapy and aging: Multiple strategies, positive outcomes. In S. H. Zarit and B. G. Knight (Eds.), Effective clinical interventions in a life‐stage context: A guide to psychotherapy and aging (pp. 1‐16). Washington, DC: American Psychological Association. • van Wormer, R. (2004). Homelessness among older adults with severe mental illness: a biologically based Developmental perspective. Journal of Human Behavior In the Social Environment, 10(4), 39‐49. • Williams, B., McGuire, J., Lindsay, R., Baillargeon, J., Cenzer, I., Lee, S., Kushel, M. (2010). Coming Home: Health Status and homelessness Risk of Older Pre‐Release Prisoners, Journal of General Internal Medicine, 25(10), 1038‐1044.