BARRIERS TO MENTAL HEALTH AND SUBSTANCE ABUSE SERVICE UTILIZATION AMONG HOMELESS ADULTS By MICHAEL D. BRUBAKER A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2009 1 © 2009 Michael D. Brubaker 2 To all of the women, men, and children who have lived without a home 3 ACKNOWLEDGMENTS I am truly grateful to Dr. Michael Garrett, my chair and advisor, for offering me a creative space to develop and grow as a researcher and human being. I am also thankful to each of my committee members: Dr. Ellen Amatea, who encouraged me to critically engage the existing body of research; Dr. Edil Torres Rivera, who introduced me to the ways of liberation psychology; and Dr. David Miller, who showed me the power of statistics and program evaluations as a way to serve those without permanent housing. I am thankful for the support of my family and friends, especially my parents, Dale and Barbara Brubaker. With good humor and constant encouragement, they have seen me through many challenges in both academics and life. As a supervisor and friend, Dr. James Bass inspired me to consider a career serving those without housing. I am truly thankful for Dr. Brian Dew and Dr. West-Olatunji for showing me how to make research meaningful for me and my community. I am incredible thankful for my two co-investigators on this research, Niyama Ramlall and TaJuana Chisholm. These two women showed endless courage as they walked into the unknown and patience as they put up with me. Finally, I am most grateful for the support of the participants in this study, the women and men who are striving for a better life as they persevere without a home. Each having a different story, they welcomed us into their lives and trusted us to make a difference. 4 TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................................... 4 LIST OF TABLES................................................................................................................................ 8 LIST OF FIGURES ............................................................................................................................ 10 LIST OF TERMS ............................................................................................................................... 11 ABSTRACT ........................................................................................................................................ 13 CHAPTER 1 INTRODUCTION....................................................................................................................... 15 Theoretical Framework ............................................................................................................... 20 An Emancipatory Communitarian Perspective .................................................................. 20 The Behavioral Model for Vulnerable Populations ........................................................... 24 Need for the Study ...................................................................................................................... 26 Purpose of the Study ................................................................................................................... 28 Research Questions ..................................................................................................................... 28 2 LITERATURE REVIEW ........................................................................................................... 30 Who are Those Who Become Homeless? ................................................................................. 32 Defining Homeless .............................................................................................................. 32 Demographics ...................................................................................................................... 33 The Chronic Homeless ........................................................................................................ 35 The Road to Homelessness ......................................................................................................... 38 Mental Health and Addictions ............................................................................................ 39 Interpersonal Violence and Trauma ................................................................................... 40 Natural and Human Inflicted Disasters .............................................................................. 41 Factors Impacting America’s Youth and the Elderly ........................................................ 42 Specific Societal Factors ..................................................................................................... 42 Exiting Homelessness ................................................................................................................. 44 Barriers and Enablers to Substance Abuse and Mental Health Service Utilization................ 46 Predisposing Factors ............................................................................................................ 48 Enabling Factors .................................................................................................................. 49 Need Factors ........................................................................................................................ 52 Applying the Behavioral Model for Vulnerable Populations to Homeless Individuals Seeking Mental Health and Substance Abuse Care .............................................................. 53 An Emancipatory Communitarianism Perspective on Mental Health and Substance Abuse Utilization ..................................................................................................................... 61 Summary ...................................................................................................................................... 63 5 3 METHODOLOGY ...................................................................................................................... 67 Research Hypotheses .................................................................................................................. 68 Research Design and Relevant Variables .................................................................................. 68 Population and Sample ............................................................................................................... 70 Procedure ..................................................................................................................................... 71 Instrumentation ............................................................................................................................ 73 Barriers to Treatment Instrument........................................................................................ 73 Stages of Change Readiness and Treatment Eagerness Scale .......................................... 74 Data Analyses .............................................................................................................................. 76 4 RESULTS .................................................................................................................................... 78 Sample Description ..................................................................................................................... 78 Outcomes of Instrumentation ..................................................................................................... 81 Other Barriers Encountered ........................................................................................................ 83 Societal Barriers ................................................................................................................... 84 Programmatic Barriers......................................................................................................... 84 Individual Barriers ............................................................................................................... 85 Summary of Other Identified Barriers ................................................................................ 86 Hypotheses Tests Results ........................................................................................................... 86 Hypothesis 1 Test Results ................................................................................................... 86 Hypothesis 2 Test Results ................................................................................................... 88 Hypothesis 3 Test Results ................................................................................................... 89 Hypothesis 4 Test Results ................................................................................................... 90 Hypothesis 5 Test Results ................................................................................................... 91 Post-Hoc Analyses ...................................................................................................................... 93 Hypothesis 6 Test Results ................................................................................................... 94 Hypothesis 7 Test Results ................................................................................................... 95 5 DISCUSSION...........................................................................................................................