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Treatment Improvement Protocol 55: Behavioral Health

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Treatment Improvement Protocol 55: Behavioral Health A TREATMENT IMPROVEMENT PROTOCOL Behavioral Health Services for People Who Are Homeless A Review of the Literature* CONTENTS Section 1—A review of the literature Section 2—links to Select Abstracts Section 3—General Bibliography TIP 55 *This document is available online only (http://kap.samhsa.gov) and supports TIP 55, Behavioral Health Services for People Who Are Homeless. Contents Section 1—A Review of the Literature ..................................................................................... 1-1 Introduction ............................................................................................................................ 1-1 Understanding the Population ................................................................................................ 1-2 Clinical Issues ...................................................................................................................... 1-32 Behavioral Health Interventions .......................................................................................... 1-37 Other Services ...................................................................................................................... 1-47 Treatment Settings ............................................................................................................... 1-54 Housing ................................................................................................................................ 1-60 References ............................................................................................................................ 1-68 Section 2—Links to Select Abstracts ........................................................................................ 2-1 Section 3—General Bibliography ............................................................................................. 3-1 Section 1—A Review of the Literature Introduction This Treatment Improvement Protocol (TIP) is designed to assist behavioral health service providers and administrators of behavioral health programs in adapting their services, counseling techniques, and resources when working with clients who are homeless, formerly homeless, or at risk of being homeless. It presents evidence-based and promising practices and model programs for this population, which has high rates of substance use and mental disorders as well as a broad spectrum of other service needs. This review focuses largely on literature published after 1998 and highlights the treatment and prevention of mental and substance use disorders among adults. The literature on homelessness and substance abuse treatment prior to 2001 is well reviewed in the National Health Care for the Homeless Council’s Substance Abuse Treatment: What Works for Homeless People? A Review of the Literature (Zerger, 2002). Reviews by Martens (2001) on physical and mental disorders among people who are homeless; by Bhui, Shanahan, and Harding (2006) on the services available to treat mental illness among people who are homeless; and by Folsom and Jeste (2002) specifically on schizophrenia and homelessness are also available. The Substance Abuse and Mental Health Services Administration (SAMHSA) Homelessness Resource Center’s regularly updated annotated reference list covers homelessness and behavioral health issues, relevant training materials, Webcasts, and publications (http://homelessness.samhsa.gov/). Definitions of Homelessness There is no single Federal definition of homelessness. However, this TIP follows most Federal programs addressing homelessness in using the definition of an individual who is homeless provided by the McKinney-Vento Act (P.L. 100-77): . an individual who lacks a fixed, regular, and adequate nighttime residence; and a person who has a nighttime residence that is (a) a supervised publicly or privately operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for the mentally ill); (b) an institution that provides a temporary residence for individuals intended to be institutionalized; or (c) a public or private place not designed for, nor ordinarily used as, a regular sleeping accommodation for human beings (42 U.S.C. § 11302). In the category of people who are homeless, three distinct clusters can be defined based on length of time homeless and number of episodes of homelessness: (1) transitionally homeless— generally homeless for a short period or a single stay of somewhat longer duration, (2) episodically homeless—frequently in and out of a state of homelessness or of various institutions that may house them temporarily, and (3) chronically homeless—regularly and for long periods of time either in the shelter system or living on the street. Among shelter users, 80 percent are estimated to be transitionally homeless, 10 percent episodically homeless, and 10 percent chronically homeless (Kuhn & Culhane, 1998). Behavioral Health Services for People Who Are Homeless 1-1 This literature review does not cover literature on mental health and substance abuse treatment in general, but much of that literature can be applied to homeless populations. Where appropriate, this TIP refers readers to relevant TIPs and other publications available from SAMHSA. Understanding the Population Homelessness has been and remains a significant problem in the United States that, according to some estimates, may affect more than 2 million people per year (Burt et al., 1999). According to recent data, approximately 650,000 people were homeless on a given night in 2009 (U.S. Department of Housing and Urban Development [HUD], 2010). Ending chronic homelessness is a Federal Government priority. Treating mental and substance use disorders as well as preventing homelessness among those affected by such disorders are priorities for SAMHSA. The reasons for homelessness among those with mental and substance use disorders are many and varied. Both substance use and mental disorders are highly correlated with homelessness, as are loss of employment, poor health, and an inability to access needed services. In addition, systemic problems such as changes in housing markets, loss of public services or institutional supports, and persisting social ills (e.g., poverty and racism) affect who becomes homeless and why (Burt, Aron, Lee, & Valente, 2001). These systemic issues are important for understanding the causes and cures for homelessness but are beyond the scope of this literature review. Prevalence of Homelessness Accurate data on the number of people and families who are homeless are difficult to obtain. Assessing prevalence requires an operationalized definition of homelessness, as well as a keen understanding of sampling (e.g., geographic areas, periods of time). Prevalence estimates are difficult to interpret and can be misleading without consideration of data sources (e.g., actual counts, agency records), how to avoid counting the same people twice, how to deal with missing data, when to count (e.g., because shelter use varies by season), and so forth. Even when these factors have been clarified, enumerating people who are homeless poses considerable research challenges, and estimates of prevalence are generally imprecise. Thus, one must pay careful attention to the accuracy estimates reported (when available) for the studies reviewed herein. A historically important study of homelessness pointed to possible underestimations of rates of homelessness in the 1990 U.S. Census and in other research studies of the time (Link et al., 1994). Using telephone surveys to gather self-reports of homelessness in a nationally representative sample of currently domiciled individuals ages 18 and older, the study found that lifetime prevalence and 5-year prevalence of “literal” homelessness (e.g., sleeping in shelters, abandoned buildings, bus and train stations) were 7.4 percent and 3.1 percent, respectively. The authors translated these percentages to national estimates of 13.5 million and 5.7 million people, respectively. The error rate for these estimates is roughly plus or minus 20 percent. Concurrent research with different methodology (Culhane, Dejowski, Ibanez, Needham, & Macchia, 1994) generally confirmed Link and colleagues’ (1994) estimates, suggesting that the magnitude of the homelessness problem was being underestimated in the early 1990s. From a national policy perspective, the most important current data on homelessness prevalence are from HUD. HUD (2007) uses the definition of homelessness from the 1987 McKinney-Vento 1-2 Part 3, Section 1—A Review of the Literature Act (using emergency shelters or transitional housing or living on the street) to develop its prevalence estimates. HUD has conducted agency counts of individuals who were sheltered as well as “street counts” of unsheltered individuals every January since 2005 (HUD, 2010). Street counts of individuals who are unsheltered are particularly challenging, and responsibility for data collection rests with HUD’s Continuum of Care (CoC) programs—the Supportive Housing Program, the Shelter Plus Care Program, and the Section 8 Moderate Rehabilitation Single Room Occupancy Program—which were created to address the problems of homelessness in a comprehensive manner with other Federal agencies. CoC programs cover roughly 90 percent of the United States population that is homeless. The 2004 HUD Guide to Counting Unsheltered Homeless People describes several methods for street counts: (a) conduct counts in areas where people who are homeless
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