Jan 15, 2016 - National Call Center for Homeless Veterans hotline: 1-877-4AID VET. This VA service provides information
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Homeless Veterans: United States Description/Etiology An individual is considered homeless when he or she is unable to secure or maintain safe, adequate housing or lacks a constant, suitable nighttime residence. A veteran is a person who has served in the United States military and was not dishonorably discharged. Veterans are disproportionately represented among homeless persons in the United States (Blackstock et al., 2012). Homelessness is linked with “significant unmet health care needs and an increased risk of morbidity and mortality” (Blackstock et al., 2012). Not having the ability to care for themselves and possibly their families can lead to stress, anger, shame, and depression among homeless veterans. They may be dealing with mental and physical health issues, such as traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), substance abuse, and pain from injuries, and have little access to health care or support from family and friends. Family problems, financial stresses, substance abuse, and mental health issues are the main causes of homelessness among veterans. Family problems include a lack of support from family members and strained relationships due to physical or mental health issues. Financial stresses may stem from a lack of affordable housing; job skills developed in the military that do not translate easily into the civilian workforce, resulting in unemployment; low wages; lack of medical insurance; and inadequate welfare benefits. Substance abuse treatment costs are among the highest healthcare costs for military veterans. Intervention and treatment are essential for the homeless veteran’s well-being. Effective interventions that can be provided by social workers include crisis intervention, housing referrals, individual, group, and/or family therapy, formal and informal support programs, and financial assistance.
Facts and Figures
Author Noelle Ainslie, MSW Cinahl Information Systems, Glendale, CA
Reviewers Lynn B. Cooper, D. Criminology Cinahl Information Systems, Glendale, CA Jessica Therivel, LMSW-IPR Cinahl Information Systems, Glendale, CA
The 2014 Annual Homeless Assessment Report (AHAR) presented by the U.S. Department of Housing and Urban Development to Congress reports that on a single night in January 2013 there were 49,993 homeless veterans in the United States. Just under 10% of these veterans were women. Homeless veterans account for 11% of all homeless individuals (HUD, 2014). In 2009, the Obama administration committed to ending veteran homelessness by 2015. Although this goal has not been met, veteran homelessness has decreased 33% (National Alliance to End Homelessness, 2015).From 2013 to 2014, the rate declined by 10% (HUD, 2014). California has the highest number of homeless veterans, representing 24% of the total population of homeless veterans, followed by Florida (9%), Texas (5%), and New York (5%) (HUD, 2014). Many homeless veterans have mental health problems, alcohol and/or substance abuse issues, and other co-occurring disorders (NCHV, n.d.). TBIs were found in 47% of homeless veterans who sought services at a VA hospital (Russell et al., 2013). America’s homeless veterans have served in World War II, the Korean War, the cold war, the Vietnam War, Grenada, Panama, Lebanon, Afghanistan, Iraq, and the military’s anti-drug-cultivation efforts in South America; nearly half of all homeless veterans served during the Vietnam era (NCHV, n.d.).
Risk Factors January 15, 2016
There are several factors to identify when assessing the risk for homelessness among veterans: poverty, mental health issues (e.g., PTSD, depression), substance abuse,
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disabilities or other physical ailments, and lack of support from family and friends. Additional risk factors for veteran homelessness are limited employment opportunities or unemployment; lack of adequate and affordable housing; and insufficient medical care. TBIs can lead to problems with social and occupational functioning that may increase risk for homelessness. Military sexual trauma (i.e., sexual harassment or assault that occurs during military service) is associated with homelessness.
Signs and Symptoms/Clinical Presentation › Psychological: Homeless veterans may experience PTSD or other mental health disorders; experience delusions, hallucinations, flashbacks, and nightmares; have high levels of anxiety and depression; experience suicidal thoughts or ideations; experience feelings of shame, guilt, and hopelessness; have low self-esteem › Behavioral: Homeless veterans may abuse substances; act out violently or show signs of anger; engage in criminal acts › Physical: The general appearance of homeless veterans may be affected as a result of living on the streets; they may have disabilities or injuries as a result of military experience; they may have poor personal hygiene and be malnourished › Social: Homeless veterans may withdraw from social relationships; have a lack of family or friend support; show signs of isolation; experience victimization and assault; have difficulty expressing emotions
Social Work Assessment › Client History • Ask about history of military experience and assess for any physical disabilities or limitations as a result of military service • Complete a biopsychosocialspiritual assessment to examine all areas in the client’s life and determine their role in the client’s homelessness or risk for homelessness • Assess client’s psychiatric and substance abuse history • Assess client’s stress-management skills and coping mechanisms • Obtain permission to ask any known, available family members for any additional relevant information • Assess for any illnesses as a result of minimal medical care/health problems • Assess for any disabilities the client may have suffered during his or her time in the military › Laboratory and Diagnostic Tests of Interest to the Social Worker • Testing for substance abuse may be indicated depending on the client’s assessment • Screen veterans for TBI
Social Work Treatment Summary When a veteran is identified as being homeless or at risk of being homeless, intervention and treatment are essential for his or her well-being. The services a social worker may provide include referrals for temporary housing; evaluations for mental health and substance abuse treatment; food assistance; family counseling, if the client’s family is involved or supportive; and financial assistance. The veteran may also need assistance enrolling in TRICARE, the health insurance program available to active-duty and retired military personnel and their families. In addition, referrals may be made for individual counseling, transportation services, support groups, employment opportunities, and case management services. The client may need to be referred for a psychiatric evaluation to determine underlying problems such as substance abuse or mental health issues. The social worker should contact local Veterans Affairs offices to determine if the client is eligible for medical, social, and psychological services. In addition to providing temporary assistance to clients it is important to encourage long-term self-sufficiency. This may require the social worker to assist the veteran in identifying both formal and informal support systems and helping him or her to identify ways to obtain retraining for employment in the civilian workforce. Social workers should be aware of their own cultural values, beliefs, and biases and develop specialized knowledge about the histories, traditions, and values of their clients. Social workers should adopt treatment methodologies that reflect their knowledge of the cultural diversity of the communities in which they practice. . Problem
Goal
Intervention
Veteran is at risk of becoming homeless
Assist individual with needed services to prevent homelessness
Provide housing referrals, counseling, and financial support; assess for other needs such as mental health or substance abuse services; refer to local VA services
Veteran is homeless
Provide individual with a safe environment and any additional aid needed
Ensure basic needs are met; refer to outreach programs; refer to individual therapy; conduct mental health/ substance abuse evaluation; refer for psychiatric evaluation to determine pharmacological therapy; ensure that medical needs have been met; provide emotional support
.
Applicable Laws and Regulations › Each country has its own standards for cultural competency and diversity in social work practice. Social workers must be aware of the standards of practice set forth by their governing body (National Association of Social Workers, British Association of Social Workers, etc.) and practice accordingly › The United States Homeless Veterans Comprehensive Assistance Act of 2001 provides benefits and services for homeless veterans › The United States Jobs for Veterans Act of 2002 revised and improved employment, training, and placement services furnished to veterans › Title 38, Chapter 41 and Chapter 42 United States Code provide job counseling, training, and placement services for veterans
Available Services and Resources › National Call Center for Homeless Veterans hotline: 1-877-4AID VET. This VA service provides information about local programs and services to prevent homelessness among veterans › National Coalition for Homeless Veterans, www.nchv.org › Veterans advocates at VA medical centers
Food for Thought › In 2009 President Obama and the secretary of veterans affairs set a goal to end veteran homelessness by 2015 through the development of programs that provide housing, job training, and health care to veterans who are homeless or at risk of being homeless (VA, 2014) › In fiscal year 2013 the VA served approximately 349,000 veterans who were homeless or at risk of homelessness, a 43% increase from the previous year; the increase is attributed to improved outreach, referral, and advocacy (VA, 2014) › Once enrolled in a supported housing program, homeless veterans with criminal histories had the same rate of successful outcomes (e.g., finding employment, avoiding substance use) as homeless veterans without criminal histories (Tsai & Rosenheck, 2013a) › The VA’s homeless support programs must be multifaceted and specialized to meet the needs of homeless veterans. Some homeless veterans have relatively few problems whereas others have comorbid conditions (e.g., mental health disorders, substance use disorders), issues related to poverty and incarceration, or significant medical problems and disabilities (Tsai et al., 2013) › Homeless veterans with military sexual trauma had increased prevalence for all mental health conditions that were studied (i.e., PTSD, depression, anxiety, substance use, bipolar disorder) and were more likely to have made visits to the VA for mental health reasons (Pavao et al., 2013)
› Although trauma exposure increases the risk that a veteran will become homeless, researchers found that socioeconomic factors and behavioral health factors (e.g., PTSD, depression, anxiety, personality disorders, substance use) were stronger indicators of an increased risk for homelessness than trauma exposure (Metraux et al., 2013)
Red Flags › The main causes of veteran homelessness are poverty, mental health issues, substance abuse, disabilities or other physical ailments, and a lack of support from family and friends › Veterans are twice as likely as other Americans to become chronically homeless › Homelessness among female veterans is rising. Women veterans are 4 times more likely to be homeless than non-veteran women (Hamilton et al., 2012). Homeless female veterans are more likely than homeless male veterans to be thinking about suicide (48.7% versus 44.4%) and to have attempted suicide in the past 5 years (36.5% versus 26.7%) (Benda, 2005b) › Homelessness is linked with high rates of hospitalization and age-adjustedmortality › Homeless veterans have higher incidences of suicide attempts and self-harming behavior when compared to veterans with housing. In one study 47% of homeless veterans were found to have attempted suicide versus 27% of domiciled veterans; 33% had self-harmed or engaged in reckless behavior in the previous 2 weeks compared to 18% of domiciled veterans (Lee et al., 2013) › Street outreach is still considered to be an important way to reach homeless veterans. Veterans living on the streets who normally avoid shelters and medical assistance are more likely to be chronically homeless than those veterans who are referred by a medical provider or who are self-referred (Tsai et al., 2014)
Discharge Planning › Provide client with necessary resources, including housing and food referrals, to ensure that basic needs are met › Emphasize importance of attending treatment programs, support group meetings, and individual therapy previously agreed upon › Encourage client to maintain strict adherence to prescribed medication schedule (if needed) and to notify psychiatrist of any adverse side effects › Inform involved family members of the need to communicate any pertinent information to identified professional involved with the client › Ensure that any referred housing support program matches client need › Recognize disparities in rates of homelessness and the need to advocate for veterans of particular ethnic and racial minority groups
References 1. Adams, J., Rosenheck, R., Gee, L., Seibyl, C., & Kushel, M. (2007). Hospitalized younger: A comparison of a national sample of homeless and housed inpatient veterans. Journal of Health Care for the Poor and Underserved, 18(1), 173-184. 2. Benda, B. B. (2005). A study of substance abuse, traumata, and social support systems among homeless veterans. Journal of Human Behavior in the Social Environment, 12(1), 59-81. 3. Benda, B. B. (2005). Gender differences in predictors of suicidal thoughts and attempts among homeless veterans that abuse substances. Suicide and Life-Threatening Behavior, 35(1), 106-116. 4. Blackstock, O., Haskell, S., Brandt, C., & Desai, R. (2012). Gender and the use of Veterans Health Administration homeless service programs among Iraq/Afghanistan veterans. Medical Care, 50(4), 347-352. 5. Carlson, E. B., Garvert, D. W., Macia, K. S., Ruzek, J. I., & Burling, T. A. (2013). Traumatic stressor exposure and post-traumatic symptoms in homeless veterans. Military Medicine, 178(9), 970-973. doi:10.7205/MILMED-D-13-00080 6. Copeland, L., Miller, A., Welsh, D., McCarthy, J., Zeber, J., & Kilbourne, A. (2009). Clinical and demographic factors associated with homelessness and incarceration among VA patients with bipolar disorder. American Journal of Public Health, 99(5), 871-877. 7. Hamilton, A., Poza, I., Hines, V., & Washington, D. (2012). Barriers to psychosocial services among homeless women veterans. Journal of Social Work Practice in the Addictions, 12, 52-68. 8. International Federation of Social Workers. (2012, March 3). Statement of ethical principles. Retrieved November 5, 2015, from http://ifsw.org/policies/statement-of-ethical-principles 9. Lee, H., Iglewicz, A., Golshan, S., & Zisook, S. (2013). A tale of two veterans: Homeless vs. domiciled veterans presenting to a psychiatric urgent care clinic. Annals of Clinical Psychiatry, 25(4), 275-282. 10. Metraux, S., Clegg, L. X., Daigh, J. D., Culhane, D. P., & Kane, V. (2013). Risk factors for becoming homeless among a cohort of veterans who served in the era of the Iraq and Afghanistan conflicts. American Journal of Public Health, 103(S2), S255-S261. doi:10.2105/AJPH. 2013.301432 11. National Alliance to End Homelessness. (2015). Veterans. Retrieved November 4, 2015, from http://www.endhomelessness.org/pages/veterans_overview 12. National Coalition for Homeless Veterans (NCHV). (n.d.). Background and statistics. Retrieved November 4, 2015, from http://nchv.org/index.php/news/media/ background_and_statistics/ 13. Pavao, J., Turchik, J. A., Hyun, J. K., Karpenko, J., Saweikis, M., McCutcheon, S., ... Kimerling, R. (2013). Military sexual trauma among homeless veterans. Journal of General Internal Medicine, 28(Suppl 2), 536-541. doi:10.1007/s11606-013-2341-4
14. The Policy, Ethics, and Human Rights Committee, British Association of Social Workers. (2012, January). The Code of Ethics for Social Work: Statement of principles. Retrieved November 20, 2014, from http://cdn.basw.co.uk/upload/basw_112315-7.pdf 15. Russell, L. M., Devore, M. D., Barnes, S. M., Forster, J. E., Hostetter, T. A., Montgomery, A. E., ... Brenner, L. (2013). Challenges associated with screening for traumatic brain injury among US veterans seeking homeless services. American Journal of Public Health, 103(S2), S211-S213. doi:10.2105/AJPH.2013.301485 16. Tsai, J., Kasprow, W. J., Kane, V., & Rosenheck, R. A. (2014). Street outreach and other forms of engagement with literally homeless veterans. Journal of Health Care for the Poor and Underserved, 25(2), 694-704. doi:10.1353/hpu.2014.0087 17. Tsai, J., Kasprow, W. J., & Rosenheck, R. A. (2013). Latent homeless risk profiles of a national sample of homeless veterans and their relation to program referral and admission patterns. American Journal of Public Health, 103(S2), S239-S247. doi:10.2105/AJPH.2013.301322 18. Tsai, J., & Rosenheck, R. A. (2013). Homeless veterans in supported housing: Exploring the impact of criminal history. Psychological Services, 10(4), 452-458. doi:10.1037/ a0032775 19. United States Department of Veterans Affairs (VA). (2014). About the initiative. Retrieved November 4, 2015, from http://www.va.gov/HOMELESS/about_the_initiative.asp 20. U.S. Department of Housing and Urban Development (HUD). (2014). The 2014 Annual Homeless Assessment Report (AHAR) to Congress: Part 1 -- Point-in-Time Estimates of Homelessness. Retrieved November 4, 2015, from https://www.hudexchange.info/resources/documents/2014-AHAR-Part1.pdf 21. Wheeler, D. (2015). NASW standards and indicators for cultural competence in social work practice. Retrieved December 10, 2015, from http://www.socialworkers.org/practice/standards/PRA-BRO-253150-CC-Standards.pdf
