Select Page

Behavioral Health Services for People
Who Are Homeless
Dr. Dawn-Elise Snipes
• Recognize and address homelessness as a special dynamic that affects your clients.
• Help prevent potential crises that result from becoming homeless.
• Provide preventive services for individuals and families who are homeless,
• Be more aware of the effects of psychological trauma and co-occurring disorders (CODs) among people who are homeless.
• Provide integrated, more effective services to people who are homeless.
• Understand and know how to utilize resources for homelessness in your community.
• Influence the understanding of others in your community regarding the interrelationship of homelessness, substance abuse, and mental illness.

– Homelessness means
– An individual who lacks or is at risk of losing a fixed, regular, and adequate nighttime residence —or
– Who has a nighttime residence that is
– A public shelter designed to provide temporary living accom­modations (including transitional housing)
– An institution that provides a temporary residence for individuals intended to be institutionalized
– A public or private place not designed for, nor ordinarily used as, a regular sleeping accommodation for human beings.
– In 2018 552,830 (0.2% of the population) people were homeless in the US.
– 35% were unsheltered.
– Children comprised 111,592—1 in 5—of the nearly 553,000 people experiencing homelessness on a single night

– 26.2% of all sheltered persons who were homeless (includes 1st episode and chronic) had a current, severe mental illness, 34.7% had chronic substance use issues, 45% had any mental illness
– Over 60% of people who are chronically homelessness have experienced lifetime mental health problems and over 80% have experienced lifetime substance use issues

– People with substance use or mental disorders who are homeless are more likely to have immediate life-threatening health conditions and to live in life-threatening situations
– Keeping things together while being homeless takes considerable skill and resourcefulness.
– 20% of men and 33% of women who are chronically homeless and have substance use disorders also have posttraumatic stress disorder
– Prior to COVID, 78% of individuals were only a paycheck away from homelessness.

Who is Homeless
– There is no typical profile for persons experiencing homelessness.
– Someone who has lost his or her job or experienced mortgage foreclosure and has been evicted along with family members.
– A loner who sleeps in the park in a sleeping bag.
– Has experienced domestic violence, sexual assault, and/or other dangerous or life-threatening conditions in a housing situation that he or she is leaving.
– A person in early recovery or recently released from jail without enough money to pay the rent.
– A person with SPMI who needs long-term permanent supportive housing.
– A person kicked out of the family home
Who Is Homeless
– Veterans who are homeless report that three aspects of their service contributed to their homelessness
– Substance abuse beginning in the military (75 percent)
– Inadequate preparation for civilian employment (68 percent)
– Loss of structure (68 percent)
– Criminal Justice
– Substance abuse or mental health issues prior to incarceration
– Inadequate job preparation
– Loss of Structure / Lack of life skills
– Up to 80% of people who are homeless have cognitive impairment (FASD, intellectual disability, TBI, dementia (including Korsakoff’s syndrome due to alcohol or poor nutrition)
– 38% of people who were homeless and received services lacked a high school diploma or equivalent
BioPsychoSocial Needs
– Solving homelessness is more than just having a safe place to live.
– Substance abuse / mental health issues
– Medical problems
– Legal/criminal justice issues
– Lack of social support

Flexible Treatment Principles
– People who experience homelessness can be particularly demoralized, needing active and often persistent engagement; be flexible in engaging them
– Person centered: What do they want or need from you and how do they want or need it.
– Identify strengths
– Help them identify personal goals for a rich and meaningful life
– Recognize what they perceive as the benefits of homelessness (friends, freedom, safety…)

Homelessness and Trauma
– Recognize their trauma triggers
– Social workers
– Hospitals
– Law enforcement
– Rules/Disempowerment
– Communal living (i.e. shelters)
– Ways you might represent someone or something that traumatized them in the past
– Other…

– Respect– Meet clients where they are and understand behavior as communication
– Empathy and curiosity. Change may be very overwhelming and scary. What do they fear they will lose by engaging- (Support, choice, pets-)
– Support
– Treatment (Support groups, IOP, Residential)
– Opportunities (housing, employment)
– Recognition of worth and achievements
– Encouragement

– Substance use and/or mental disorders
– Current and past exposure to trauma and related safety issues.
– Medical & dental including risk of and treatment for HIV/AIDS and other communicable diseases.
– Onset and course of homelessness and how it relates to the course of other symptoms.
– Current skills and ability to maintain stable housing.
– Current and/or pressing criminal justice issues
– Social functioning in terms of social supports, literacy, education, job skills, employment, and income, as well as:
– Immediate stressors (e.g., shelter living, housing instability, lack of money, debt, legal issues).
– Client interest in services
Types of Services
– Secondary Prevention: Keep the problems from getting worse
– Tertiary prevention: Prevent the development of additional problems.
– Service Areas
– Permanent supportive housing programs.
– Flexible consumer-directed and recovery-oriented services (ROSC)
– Access to Social Security and other benefits.
– Medical/Psychiatric/Dental care
– Nutrition
– Childcare
– Animal/Pet care
– Legal assistance (civil and criminal)
– Job placement assistance / Job coaching
Types of Services
– Income stability
– Federal Bonding Program provides no-cost fidelity bonds that protect the employer against losses caused by the fraudulent or dishonest acts of the bonded employee to encourage hiring hard-to-place persons:
• Justice-involved citizens
• Individuals in recovery from substance use disorders
• Welfare recipients
• Individuals with poor credit records
• Economically disadvantaged people who lack work histories
• Individuals dishonorably discharged from the military
• State Bonding Coordinator

Treatment Goal Best Practices
• Specific (e.g., days medication taken, attendance at medical appts, groups attended (life skills, treatment, support), or job applications completed).
• Measurable/verifiable
• Achievable (Tailored to the individual's level of functioning and resources)
• Relevant/restorative
• Time Limited Can be completed successfully in a given timeframe
• Keep it short. No more than a week at a time.
• Provide a written plan with step-wise goals to facilitate change even if the person leaves the area.

Finding Services
– United Way 211
– National Health Care Homeless Council
– State departments for housing and homeless services
– “Indigent” services [your area]
– SAMHSA Treatment Locator
– Medicaid
– Section 8 or search for your local housing authority (public vs Section 8)
– PATH Grants PATH-eligible clients with the following services:
• Outreach, screening and diagnostic treatment
• Habilitation and rehabilitation
• Referrals for primary health care, job training, educational services, and housing
• Housing services as specified in Section 522(b)(10) of the Public Health Service Act


Personal Issues
• Considerable anxiety regarding clients in dangerous situations (e.g., refusing shelter on frigid nights).
• Repeatedly trying to persuade someone to go to treatment because you are concerned about his or her recovery.
• Strong urges to use involuntary measures (e.g., police transport to the hospital) despite no clear risk of imminent danger
• Anger over family members’ reactions to the person, given their experience with an individual’s past behavior.
• Feeling overwhelmed or frightened by the person’s irritability, anger, and frustration.
Personal Issues
• Struggle to understand and appreciate the strengths & survival skills of a person who is homeless, particularly when his or her choices and behaviors (e.g., distrust, agitation) create barriers to receiving services.
• Guilt about going home at night while a client is sleeping on the street.
• Anger or frustration about missed appointments, which indicate resistance to engaging with services.
• Services may be
• Too hard
• Too scary
• Ineffective

Personal Issues
• Feelings of helplessness leading to thinking about violating ethical boundaries or agency policies to meet the immediate needs of a person who is homeless (e.g., give them personal funds).
• Reluctance to continue providing services to someone whose priorities conflict with your ideas about their needs (finding drugs rather than adequate housing, resistance to obtaining medical care for an immediate problem)
• Frustration and feelings of ineffectiveness and being unappreciated.
• A sense of disconnection from clients who seem demanding, needy, miserable, or overwhelmed.

– People who are homeless are often extremely creative and resilient.
– Many homeless people live in their own loose-knit communities and often travel together.
– Engagement may be hindered by fear of loss of that community, fear of the establishment, prior trauma history, addiction or mental health issues Remember to RESTORE hope.
– Respect
– Empathy and curiosity
– Support
– Treatment (Support groups, IOP, Residential)
– Opportunities (housing, employment)
– Recognition of worth and achievements
– Encouragement

– It is likely there will be a surge in people who are homeless after major negative economic or pandemic events
– Most people who are homeless desire stable, safe housing.
– Secondary prevention should focus on helping to person develop a safer living situation and prevent worsening of current medical, dental and psychiatric issues (if any)
– Tertiary prevention should focus on preventing development of additional problems: Addiction, hepatitis, Covid etc.
– In Part 2 we will discuss unique issues for those who are homeless and unsheltered and the prevalence and impact of homelessness on children