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 1 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. 2 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 3 1 2/11/2020 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) 4 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 5 “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 6 2 2/11/2020 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 7 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 8 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 9 3 2/11/2020 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 10 STRATEGIES AND INTERVENTIONS • Research literature notes: • Safety • Access to health and social services • Specialized medical care • Housing 11 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. 12 4 2/11/2020 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 13 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 14 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) 15 5 2/11/2020 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) 16 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 17 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 18 6 2/11/2020 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 19 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 20 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) 21 7 2/11/2020 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) 22 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) 23 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) 24 8 2/11/2020 MENTAL HEALTH CHALLENGES‐ ETHNIC AND