CAUSES OF HOMELESSNESS AMONG THE VETERAN POPULATION
Patricia Ann Quiroz
B.A., California State University, Sacramento, 2011
PROJECT
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
SPRING
2011
© 2011
Patricia Ann Quiroz
ALL RIGHTS RESERVED
ii
CAUSES OF HOMELESSNESS AMONG THE VETERAN POPULATION
A Project
by
Patricia Ann Quiroz
Approved by:
__________________________________, Committee Chair
Susan Talamantes Eggman, Ph.D., M.S.W.
____________________________
Date
iii
Student: Patricia Ann Quiroz
I certify that this student has met the requirements for format contained in the University
format manual, and that this project is suitable for shelving in the Library and credit is to
be awarded for the project.
________________________________, Graduate Coordinator
Teiahsha Bankhead, Ph.D., L.C.S.W
Division of Social Work
iv
________________
Date
Abstract
of
CAUSES OF HOMELESSNESS AMONG THE VETERAN POPULATION
by
Patricia Ann Quiroz
Statement of Problem
One out of every three homeless men who are sleeping in a doorway, alley or box
in our cities and rural communities has put on a uniform and served this country. The
inability to address the needs of the veteran population concerning mental health issues,
addiction, medical problems, and affordable housing options has lead to a large amount
of the veteran population becoming homeless or at risk for homelessness. Although there
are hundreds of studies documenting the need for additional resources for this population,
there remain significant numbers of veterans who are homeless. This project will allow
social workers to better understand overlapping patterns causes of homelessness and
issues surrounding housing homeless veterans.
Sources of Data
This study was a secondary analysis of data which was originally collected to
assess the outcomes of the Integrated Health Care and Housing Supports from Federal
Agencies in the Evaluation of the HUD-VA Supported Housing Program (HUD-VASH).
v
The data was made available by the Department of Veteran Affairs Northeast Program
Evaluation Center (NEPEC).
Conclusions Reached
This study demonstrated that the HUD-VASH program is effective in reducing the
amount of days a veteran is homeless, helps increase community adjustment and
decreases levels of criminal activity. This study also gave insight into issues with
substance abuse and relapse that need to be addressed to increase the amount of days they
are housed. By acknowledging that 50% of veterans dropped out of this program due to
substance abuse, case managers and program administrators can better target this specific
problem.
, Committee Chair
Susan Talamantes Eggman, Ph.D., M.S.W
______________________
Date
vi
ACKNOWLEDGMENTS
I would like to acknowledge my friends and family for supporting me through this
process. To my Grandma who would read the poem “Don’t Quit” to me when I wanted to
give up. I would also like to thank my mom who has always supported me no matter what
my decisions were with school, work, and life. And of course Eric, who stuck with me
through all my years of school. Thank you for brining humor and love into my life.
vii
TABLE OF CONTENTS
Page
Acknowledgments...................................................................................................... vii
List of Tables ................................................................................................................ x
List of Figures ............................................................................................................. xi
Chapter
1. INTRODUCTION………………………………………………………………....1
Background of the Problem ...............................................................................2
Statement of the Research Problem ...................................................................4
Theoretical Framework………………………………………………………...4
Definition of Terms............................................................................................6
Assumptions.......................................................................................................8
Justification ........................................................................................................9
Limitations .........................................................................................................9
2. LITERATURE REVIEW ......................................................................................10
History of Homelessness..................................................................................10
History of Homelessness among Veterans ......................................................14
Operation Iraqi Freedom and Enduring Freedom ............................................20
Addressing the Issue ........................................................................................25
3. METHODOLOGY ................................................................................................33
Introduction ......................................................................................................33
Study Design ....................................................................................................33
Sample..............................................................................................................34
Data Collection/Gathering Procedures ............................................................34
Instruments Used .............................................................................................35
Data Analysis ...................................................................................................35
Protection of Human Subjects .........................................................................36
4. FINDINGS .............................................................................................................37
Sociodemographic Characteristics ...................................................................38
viii
Summary ..........................................................................................................49
5.
CONCLUSIONS AND IMPLICATIONS ...........................................................50
Findings............................................................................................................50
Implications for Social Work Practice .............................................................53
Implications for Social Work Education..........................................................55
Limitations and Future Research .....................................................................55
Summary ..........................................................................................................56
References ....................................................................................................................58
ix
LIST OF TABLES
Page
1.
Table 1 Race/Ethnicity………..…………………..……………….…..39
2.
Table 2 Marital Status……………………………………….....….…..39
3.
Table 3 Mode of First Contact………………………………………...40
4.
Table 4 Duration of Homeless Episode .……………………………...41
x
LIST OF FIGURES
Page
1.
Figure 1 Gender…………………………………………….….…………..38
2.
Figure 2 Clinical Diagnosis…………………………...……………………42
3.
Figure 3 Number of Days Homeless: baseline vs. HUD-VASH
experimental group……………….………………………………………..43
4.
Figure 4 Substance Abuse Variables baseline HUD-VASH vs.
HUD-VASH experimental group…....………….…………………………44
5.
Figure 5 Clinical Status Medical Problems Index (ASI) &
Psychiatric Index (ASI)……………………………………………………45
6.
Figure 6 Community Adjustment (baseline outcome vs. HUD-VASH
experimental outcome……………………………………………………...46
7.
Figure 7 Community Adjustment: Legal Index and Arrest
(baseline outcome versus HUD-VASH experimental outcome)….….……47
8.
Figure 8 Reasons for Termination.………………………………………...48
xi
1
Chapter 1
INTRODUCTION
There is a misconception that because the United States is a developed country,
we have mastered major issues such as poverty and homelessness. However, we have
seen the homeless population grow over decades and the problem never seems to be fully
addressed. The homeless populations tend to have a negative stigma and conversation
surrounding explanations for why they find themselves in this situation tends to blame
the individual. Often, one may hear that homeless are lazy; or that people who find
themselves on the streets are there due to their own poor choices in life. For most
Americans, these views are often the product of a very narrow paradigm, many who may
have never had to battle homelessness and third-world poverty. As a result, Americans
develop a certain level of insensitivity and ambivalence toward the plight of the homeless
in this country.
But does that mean these issues do not deserve to be addressed? In what ways,
can we, as a country, raise the level of awareness regarding homelessness and poverty?
More importantly, what is being done to address homelessness and poverty, particularly
among certain sub-sections of our community? Ultimately, it may require each individual
citizen to undergo an ‘awakening’ to understand the gravity and depth of these issues. In
this respect, certain local events, such as Stand Downs, can prove to be instrumental.
Recently, there was a gathering of hundreds of men and women dressed in
military gear, carrying packs, and sleeping in military tents. For many, this spectacle
would normally be associated with gatherings on a military base; unfortunately, this
2
Stand Down took place at a local camping ground. Those who were participating were
not current military service members, they were veterans. While these veterans shared a
bond established through their military experience, they were all homeless too.
In recent years, there has been a rise in homelessness among veterans. In fact,
studies show that there are nearly 250,000 veterans facing homelessness on any given
night (Tessler, 2003). There is an over-representation of veterans among the homeless
population and although there are some services for homeless veterans, there is simply
not enough (National Coalition for the Homeless, 2009). It is my belief that if we are
unable to care for the veterans who are currently returning from Operation Iraqi Freedom
and Operation Enduring Freedom we will see a new wave of homeless veterans with
serious mental health, addiction, and medical issues. We must understand the past causes
of homelessness in the general population as well as the unique issues of our military
veteran population. A recent study from the National Coalition for the Homeless states
that “one out of every three homeless men who are sleeping in a doorway, alley or box in
our cities and rural communities has put on a uniform and served this country”. We need
to examine which programs will be effective in helping those who have protected and
helped our county.
Background of the Problem
Veterans have historically represented a large portion of the homeless population
in the United States (Tessler, 2003). The number of urban homeless in the United States
has increased and studies are showing that a large number of the homeless populations
are veterans; the Department of Veteran Affairs estimates about 250,000 veterans are
3
homeless any given night (Tessler, 2002 & Tessler 2003). Another statistic from the
National Coalition for the Homeless (2008) indicates that approximately 400,000
veterans nationwide experience homelessness at some point throughout their lives. Other
studies have shown that in 2003, there were nearly 313,000 homeless veterans and in
2009, this number dramatically dropped to 107,000 (Department of Veterans Affairs,
2010). Part of the difficulty with studying the veteran homeless population is that the
numbers are often inconsistent. The numbers may be inconsistent because some
individuals may fall in and out of homelessness; such inconsistencies may affect funding
because there is never a precise count for how many individuals need services. We need
to continue to research this issue as more veterans return from the Iraq and Afghanistan
conflicts. There are fewer resources available to returning veterans because of the United
States economic situation.
There are currently over 1.6 million American men and women who have served
or are currently serving in Iraq and Afghanistan (Fairweather, 2006). These veterans are
at significant risk for homelessness and chronic homelessness. And many may become
homeless sooner than those of past military wars, with veterans now seeking housing
months after they return from duty (Fairweather, 2006). Department of Veterans Affairs
studies have also shown that by 2006, over 600 veterans had already accessed homeless
healthcare services (Fairweather, 2006). One reason why new veterans are more at risk
and are becoming homeless faster is the lack of adequate transitional services
(Fairweather, 2006). There is an unprecedented amount of veterans returning home from
war with posttraumatic stress disorder and there are not enough resources to treat
4
veterans in need of readjustment and posttraumatic stress disorder services. Many
veterans who are seeking individual treatment are being sent to group therapy while
many others are being put on waiting lists (Fairweather, 2006 & National Coalition for
Homeless, 2009).
Statement of the Research Problem
The inability to address the needs of the veteran population concerning mental
health issues, addictions, medical problems, and affordable housing options has lead to a
large amount of the veteran population becoming homelessness or at risk for
homelessness. Although there are hundreds of studies documenting the need for
additional resources to be given to this population there still remain a significant number
of veterans who are homeless. The problem is that there has not been a best
practice/evidence based solution to apply to housing programs to end homelessness.
Purpose of the Study
This study will examine overlapping patterns that may cause homelessness among
the veteran population. A further examination will be undertaken of current government
programs with a specific emphasis placed on reviewing the HUD-VASH program, in
order to determine what practices are working and what areas need improvement.
Theoretical Framework
In a published study titled “Homelessness and Theory Reconsidered”, two
theoretical ideas were presented as the backdrop of the continued debate regarding the
root causes of homelessness. One emphasizes structural/systemic problems, while the
other emphasizes individual explanations (Neale, 1997). The most common theoretical
5
framework is the Structural Systems Theory Approach, which focuses on the individual
being a part of a larger system that is interconnected with subsections (Neale, 1997).
Systems Theory proves to be helpful when examining causes of homelessness because
unlike the medical model, in which x causes y, Systems Theory provides us the ability to
examine the problem in a multicausal context (Green, 2008). This multi-system approach
may allow us to view systemic/structural problems such as lack of affordable housing,
lack of access to jobs with decent wages, as well as individual factors of the person who
may be homeless. In other words we are able to see the individual not only as the
individual who is homeless but the individual who lives in a community, state, and
country that also plays a role in the issue/concern.
While Systems Theory may provide a framework to analyze and understand the
issues of homelessness at a macro level; Solution Focused Theory may prove to be
equally valuable for understanding homelessness, at a micro level. The HUD-VASH
program that will be reviewed in this study uses a harm-reduction approach and
gravitates more towards Solution Focused Theory. This theory focuses on working with
the clients existing strengths and abilities in order to find a solution to the current
problem (Green, 2008). The goal of this theory is to help clients do something differently.
In this respect, the role of the social worker should be to assist the veteran to make
changes by implementing small steps/goals to achieve solutions on their own.
Another school of thought that could prove to be useful in examining
homelessness among veterans is the Rogerian Person-Centered Approach. This approach
may be useful when working with homeless veterans because each client is treated as a
6
unique individual with the capacity for self-actualization. The Person-Centered Approach
focuses on providing an atmosphere of safety and freedom so that the client can then
explore their true selves (Greene, 2008). Another aspect of this approach is the
individual’s freedom of action and search for meaning and ability of the individual to
make changes on their own (Greene, 2008). The HUD-VASH program employs these
techniques by ensuring that the changes that are made, if any, are client driven. The social
worker does not impose goals that the client has not already come up with on their own
and if the client is not willing to state goals or changes that they want to happen then they
are not required to. By using theories and approaches such as the Systems Theory,
Solution Focused Theory and Person-Centered Approach, we can not only examine
causes of homelessness but also implement these theories and approaches to the way that
we work with homeless veterans.
Definition of Terms
OIF
Operation Iraqi Freedom is the US led military coalition in Iraq that was launched
March 2003, with the immediate stated goal of removing Saddam Hussein’s
regime and destroying its ability to use weapons of mass destruction or to make
them available to terrorists. Over time the mission changed from the regime
removal to the more open-ended mission of helping the government of Iraq
improve security, establish a system of governance, and foster economic
development. (Congressional Research Service, 2009)
7
OEF
Operation Enduring Freedom refers to the war in Afghanistan that was launched
in October 2001 and was targeted at destroying terrorist training camps and
infrastructure within Afghanistan as well as the capture of Al-Qaeda leaders.
Stand Down
Stand Downs are typically one to three day events providing services to homeless
Veterans such as food, shelter, clothing, health screenings, VA and Social
Security benefits counseling, and referrals to a variety of other necessary services,
such as housing, employment and substance abuse treatment (Department of
Veterans Affairs 2011).
Chronic homelessness
An individual who is an unaccompanied disabled individual who has been
continuously homeless for over one year. (Housing and Urban Development,
2009)
Dual Diagnosis
Refers to the concurrent presence of a major psychiatric disorder and substance
abuse disorder in the same individual. (Kasprow 1999).
Veterans Affairs Compensation
Benefits that are monthly payments made to honorably or medically discharged
applications who were disabled by injury or disease that developed or worsened in
the line of duty (Chen et al 2007).
8
Disability compensation
Program/payment that provides funds for veterans who incurred health problems
during their military service (Chen et al 2007).
VA pension
A monthly program that is awarded to applications who were honorably or
medically discharged, who served during wartime, have limited income, and are
permanently and totally disabled or are at least 65 years old (Chen et al 2007).
Delayed- onset PTSD
Defined as occurring when onset is more than 6 months after a traumatic event
that fulfills the stressor criterion (Andrews 2009).
PTSD
Posttraumatic stress disorder is an anxiety disorder that follows exposure to lifethreatening experiences such as war, sexual assault, homicide, vehicular crashes,
and natural disaster (Sayer et al 2009).
HUD-VASH
Housing and Urban Development Veterans Affairs Support Housing program
provides permanent housing and ongoing case management treatment services for
homeless Veterans who require these supports to live independently (Department
of Veteran Affairs, 2011).
Assumptions
This thesis will demonstrate that the current HUD/VASH program appears to treat
homeless veterans as a homogenous group; particularly, accumulated data fails to
9
differentiate between divergent outcomes among ethnicities, and to a lesser extent,
veteran women and men. While it is important to investigate these additional problematic
outcomes, that analysis may be better examined separately.
Justification
The National Association of Social Worker’s Code of Ethics states that “the
primary mission of the social work profession is to enhance human well-being and help
meet the basic needs of all people”; yet, how can that mission be accomplished without
ensuring that basic living needs are met, including shelter and housing? This study will
document the causes of homelessness, evaluate a supportive housing program, and make
recommendations so that social workers can enhance the well-being and welfare of
individuals. By understanding what the causes of homelessness are and how we address
these issues through current homeless/housing programs, we can make changes so that
we can better serve our homeless veterans population.
Limitations
The purpose of this study is to explore the causes of homelessness and conduct a
secondary data analysis to determine if the HUD-VA Supported Housing program is
effective in reducing homelessness among the veteran population. The limitations of this
study are associated with the analysis of secondary data. The information that is going to
be reviewed may have been gathered for other purposes which may limit how much we
may be able to effectively evaluate this specific research question.
10
Chapter 2
LITERATURE REVIEW
There are between 130,000 and 200,000 veterans in the United States who are
homeless on any given night (National Coalition for Homeless, 2009). The veteran
population represents one-fourth and one-fifth of all homeless people; three times that
many veterans are struggling with excessive rental costs and are therefore at higher risk
of becoming homeless (National Coalition for Homeless, 2009). Veterans who are
returning from the Iraq and Afghanistan conflicts are more likely to have posttraumatic
stress disorder or traumatic brain injury and are more likely to become homeless
(National Coalition for Homeless, 2009).
The first part of this chapter will discuss the general information and history of
homelessness. The second part will review general information and history on the
specific population of veteran homelessness; and the third will review the Iraq and
Afghanistan conflicts and issues surrounding homelessness among the most recent
veterans. Each of these sections will be broken down further into subtopics: mental health
issues, addiction issues, and lack of resources, in order to examine patterns of causes for
homelessness among the veterans. In closing there will be an exploration of promising
practices and models of service delivery.
History of Homelessness
Substantial numbers of Americans are homeless or have experienced
homelessness in the past (Greenberg & Rosenheck, 2009). Research has continued to
11
indicate that individuals among the homeless population are strongly associated with
being male and less educated as well as with psychiatric and substance abuse disorders
(Greenberg & Rosenheck 2009, National Coalition for the Homeless, 2009; Tessler,
2002; Calsyn & Roades, 1994). Other factors including socio-demographic, and
economic and health characteristics are key contributors to placing individuals at greater
risk for homelessness (Greenberg & Rosenheck, 2009). Although there are many risk
factors associated with becoming homelessness, extreme poverty is cited as an underlying
cause (National Coalition for the Homeless, 2009; Tessler, 2003). The National Coalition
for the Homeless states that poverty and homelessness are inextricably linked and those
affected by poverty are frequently unable to pay for housing (2009).
There are other structural factors that appear to contribute to homelessness and
poverty. For example, shortages of affordable rental housing, extended periods of
unemployment, deinstitutionalization, and a decline in local and state income assistance
play a significant role in the ability of a person to meet basic living needs (Applewhite
1997; National Coalition for the Homeless, 2009; Belcher, 2005). Public attitudes and
reactions to homelessness may contribute to the continued problem of homelessness
(Applewhite 1997). Examples of public attitude and reactions include laws aimed at
curbing panhandling, public nuisance, loitering, and sleeping in public places
(Applewhite 1997).
Mental Health Issues
Persons with mental illness are over-represented among the homeless relative to the
general population (Sullivan et al, 2000). In the 1980’s a main concerns was that about
12
half of the homeless population suffered from mental health issues including psychiatric
and substance abuse disorders (Chen et al 2007; Jeste, 2002). Current studies estimate
that about 20-50% of homeless adults suffer from a serious mental illness (Greenberg &
Rosenheck 2007; Sullivan et al, 2000; National Coalition for the Homeless, 2009).
Among mental illnesses, depression has been the most frequently identified diagnosis
estimated at 20-25% of the homeless population (Greenberg & Rosenheck 2009).
Another surprising revelation is that homeless tend to be afflicted by more serious
mental disorders. For example, studies have also shown that diagnoses of antisocial
personality disorder, dependent personality disorder, and the indicator for schizophrenia
have a high association with past homelessness (Greenberg & Rosenheck, 2009; Chen et
al 2007; Sullivan, 2000). One sample which compared mentally ill homeless persons,
non-mentally ill homeless persons, and housed mentally ill indicated that the majority of
mentally ill homeless persons had become homeless after the onset of their mental illness
and were more likely to suffer from schizophrenia or bipolar disorder (Sullivan et al,
2000). This study attributed homelessness among the mentally ill to impoverished and
disadvantaged backgrounds (Sullivan et al, 2000). They also described the mentally ill
homeless population as distinct in terms of childhood risk factors (Sullivan et al, 2000).
Childhood family instability and violence or abuse, and residential instability with their
family as a child were characteristics shared by many mentally ill homeless individuals
(Sullivan et al, 2000).
13
Addictions and Medical Problems
A study published in International Journal of Mental Health explored issues
surrounding homelessness among many different countries including the United States,
Canada, Germany, Australia, and France (2001). The study determined that drug
problems were reported to affect 72% of the homeless in the United States (Martens,
2001). Another study that compared mentally ill homeless persons, non-mentally ill
homeless persons, and housed mentally ill persons found that those who became
homeless after becoming ill have especially high rate of alcohol dependence (Sullivan et
al, 2000).
Additionally, there appears to be some strong correlation between physical health
and homelessness. Some studies have revealed that individuals who are homeless have
high rates of a wide range of serious medical problems with over 46% having a chronic
physical illness (Mares & Rosenheck, 2009; Martens, 2001). Homeless people are at
higher risk than non-homeless populations for medical problems such as hypertension,
diabetes mellitus, upper respiratory infections, gastrointestinal problems, and podiatry
problems however, homeless people have low use of medical services relative to their
needs (McGuire 2009; Blue-Howells, 2008). Many homeless individuals do not get
adequate healthcare services even when their health places them at high risk for death
(McGuire 2009; Belcher, 2005).
Access/Lack of Resources
Often times, access to and/or lack of resources appear to have a significant
influence on homelessness. For example, some findings indicate that there are a variety
14
of reasons why people with mental health issues may not seek treatment examples
include distrust of large, impersonal agencies (Rosenheck et al 1999). Several reasons
for not seeking treatment include thinking they do not need treatment, believing treatment
will not help, fearing stigmatization, wanting to solve the problem on their own, and
thinking their problems will go away without treatment (Blue-Howells, 2008;Sayer et al
2009). Many homeless people often experience logistical barriers such as the services
being too far away or too costly (Belcher, 2005).
Access to services such as mental health treatment, financial support, and
affordable housing have proven to be essential for exiting homelessness. However, there
has been a shortage of affordable housing in urban, rural, and suburban settings which
continues to affect individual’s ability to be housed (Belcher, 2005; National Coalition
for the Homeless, 2009). Another factor associated with exiting homelessness is
receiving public support payments. In a study conducted with individuals with mental
health issues, those who received public support had a strong association with exiting
homelessness and no increase in alcohol or drug use (Tessler, 2003, Chen et al 2007).
History of Homelessness among Veterans
The number of urban homeless in the United States has increased and studies show a
large number of the homeless populations are veterans (Tessler et al 2003; National
Coalition for the Homeless, 2009). The actual count of homeless veterans are often varied
however the Department of Veteran Affairs estimate that approximately 130,000veterans
are homeless on any given night (National Coalition for the Homeless, 2009). The
National Coalition for the Homeless state that approximately 40% of homeless men are
15
veterans, but they comprise only 34% of the adult male population (2009). The
Department of Veteran Affairs states that the majority of homeless veterans come from
poor and disadvantaged communities (National Coalition for the Homeless, 2009). 45%
suffer from mental illness and half suffer from substance abuse problems (National
Coalition for the Homeless, 2009). This study also indicates that 67% of homeless
veterans served three or more years, 89% received an honorable discharge, and 33% were
stationed in a war zone (National Coalition for the Homeless, 2009).Other studies have
indicated that the veteran population, statistically, are more educated and older than
homeless nonveterans (Tessler, 2002).
Another recent trend is the rise in homeless female veterans. Some data finds that
women are becoming a growing population among veterans and comprise about 5% of
the total veteran population in 2000 (Gamache, 2003). In comparison with the male
veteran population, women were more likely to be younger, less likely to be employed,
and more likely to have a major mental illness (Gamache, 2003; Fontana, 2010). Veteran
women are 2 to 4% higher risk for becoming homeless (Gamache, 2003).There is
currently no understanding of why veteran women are at such a higher risk how everyone
study hypothesized that although men and women veterans are supposed to have equal
access to healthcare the VA has historically focused on services for male veterans
(Gamache, 2003). This study also stated a potential reason for the high risk of
homelessness among women may be attributed to the loss of social support when leaving
family for periods of time (Gamache, 2003).
16
Mental Health Issues
When examining the causes for homelessness among veterans, mental health
issues are a common risk factor (Martens, 2002). When comparing women versus men,
the women were less likely to have co-morbid diagnosis of mental health and substance
abuse disorders (Gamache, 2003). Studies have shown that at least some of the risk
factors associated with becoming a homeless veteran were not present when they were
originally screened for military service, and may that they developed later (Tessler,
2002). Although there may have been an initial trauma that caused PTSD in the veteran,
it may not have surfaced until after their discharge from the military (Andrew, 2009). The
veteran may also find that civilian stress may have caused the posttraumatic stress
disorder rather than military service (Andrew, 2009).This study stated that hypervigilance
and exaggerated startle were part of the beginning symptoms of PTSD and that
hyperarousal is involved in determining later symptom expression(Andrews, 2009).
Another strong predictor of PTSD is peritraumatic dissociation which may identified by
peritraumatic emotions such as shame and anger (Andrews, 2009)
Compounding the affects of PTSD is the failure to address it in a timely manner.
For example, a qualitative study of 44 U.S. military veterans from Vietnam and
Afghanistan/Iraq wars showed that many veterans with PTSD wait years to decades
before seeking professional help (Sayer et al., 2009).This study also indicated that in
some cases system and social network facilitation lead to treatment initiation despite
individual barriers. Individual barriers are beliefs and values that conflict with helpseeking; these include thinking they “do not need treatment, believing treatment will not
17
help, fearing stigmatization, wanting to solve the problems on their own, and thinking
their problems will go away without treatment” (Sayer et al 2009). Participants described
fears and beliefs about mental health treatment in general and PTSD treatment as a cause
of why they believed treatment wouldn’t work. (Sayer et al 2009). Common fears that
participants expressed included fearing that providers would not understand their
problems. Second, that their social networks would think they were crazy or weak.
Lastly, participants fear that they would be “locked up” if they talked about their thoughts
(Sayer et al, 2009).
Addiction and Medical Problems
Rates of comorbid alcohol abuse/dependence among veterans with PTSD have ranged
from 64-84% and rates of comorbid drug abuse/dependence have ranged from 40-44%
(Stewart et al. 1999). Studies have shown that the correlation between alcohol abuse and
PTSD might originally start from self-medicating with alcohol due to the PTSD
symptoms but what is also noted is that consuming alcohol may also worsen PTSD
symptoms including anxiety and hyperarousal (Stewart et al. 1999). Substance abuse can
heighten the likelihood of trauma as well as heighten the susceptibility of the
development of PTSD (Stewart et al. 1999). It is also suggested that although alcohol is
effective in producing short term symptom relief it may in fact maintain PTSD (Stewart
et al. 1999). This study suggests that chronic abuse of alcohol may interfere with one’s
ability to work through traumatic experiences (Stewart et al. 1999). A study of 13 male
combat veterans with comorbid PTSD and alcohol dependence describes the process of
memory networks that would normally be activated by exposure to trauma reminders or
18
by the experience of PTSD symptoms. The study showed that exposure to combat
imagery elicited a significantly increased desire to drink in these comorbid patients
compared to general stress and neutral imagery (Steward et al, 1999).
Patient perception of drug and alcohol use impact level of use and abuse. A study
showed that veterans often perceived alcohol and some drug use including marijuana,
heroin, benzodiazepines, as making their symptoms better; when in fact it is stated that
alcohol and prescription drug use were found to be common factors associated with
reactivation of the PTSD symptoms in older age (Stewart et al. 1999).Participants
perceived most drug use as effective in reducing symptoms however there were other
drugs, such as cocaine, that they perceived as worsening PTSD symptoms (Stewart et al,
1999). This study concluded that individuals with PTSD and substance abuse disorder
were associated with greater traumatic event exposure compared to PTSD only groups
(Stewart et al, 1999).
Further, homeless veterans who have drug and/or alcohol addiction issues are less
likely to have received regular medical visits (McGuire, 2009).Homeless veterans are at
higher risk for medical problems then the non-veteran populations and although they are
at higher risk they often underutilize healthcare (McGuire, 2009). Two types of barriers
(that are indicated in a social work in health care article) are patient-related and
institutional barriers. Examples of patient-related barriers are lack of personal health
insurance and competing survival needs (Blue-Howells, 2008). Institutional barriers
include negative provider attitudes toward homeless, limited services, cost of health care
coverage and system fragmentation. Examples of system fragmentation are services
19
having separate admission procedures and being located in different facilities (BlueHowells, 2008). Although specific location studies are not predictors of all VA facilities,
in one specific location, a review of medical care utilization indicated that homeless
veterans had only one-third of the medical visits non-homeless veterans had received and
that 22% of homeless veterans had never received a full physical or mental health exam
(McGuire 2009, Blue-Howells 2008).
Access & Lack of Resources
Many issues surrounding access and lack of resources for the veteran population
revolve around two entities, which include the Department of Veterans Affairs and Social
Security Administration. A qualitative study of 44 U.S. military veterans described that
the VA enrollment process is time-consuming and complex, and some participants were
not even aware that they were eligible for VA services (Sayer et al, 2009). This study also
indicated that an individual’s lack of knowledge about treatment options and how to
access them interfered with help-seeking (Sayer et al, 2009). “Homeless people with
mental illness are often distrustful of large, impersonal agencies, have significant
cognitive impairments, and lack family members to help them negotiate complex
bureaucratic procedures” (Rosenheck, 1999). When Social Security Administration and
the Department of Veterans Affairs implemented a Joint Outreach Intervention, those at
the intervention sites were almost twice as likely to apply and receive benefits
(Rosenheck et al 1999). There was a strong correlation between increased public support
payments and successful housing outcomes (Rosenheck et al 1999; Chen et al 2007).
20
One of the major concerns that homeless veterans have surrounds gaining
employment and the barriers associated with gaining employment (Applewhite 1997).
Many have identified lack of available jobs with adequate wages as the most important
resource needed to maintain self-sufficiency (Applewhite, 1997). Veterans have also
indicated that not having a permanent address or having the address of a shelter causes
employers to be distrusting which impedes their ability to gain employment (Applewhite,
1997). Other issues surrounding gaining employment is the lack of job training
opportunities for veterans who have been out of the labor force. It has been shown that
veterans who have combat-related PTSD were much less likely to be employed than
those without PTSD and were likely to have lower hourly wages (Applewhite 1997;
Resnick & Rosenheck, 2008).
When examining issues surrounding housing there were several issues that were
distinct barriers to homeless veterans getting housed (Applewhite,1997). For example
security deposits, evidence of permanent employment, and a credit history (Applewhite,
1997). Another finding indicated that employment and housing work together therefore if
a veteran is unable to find work due to their lack of permanent address they are also
unable to be housed due to the lack of employment and regular income (Applewhite,
1997).
Operation Iraqi Freedom and Enduring Freedom & Issues with Homelessness
Over 1.6 million American men and women have served or are currently serving
in Iraq and Afghanistan (Franklin, 2009; Seal et al, 2010). Operation Iraqi Freedom and
Operation Enduring Freedom have bred an entirely new generation of Veterans who are
21
at significant risk for homelessness and chronic homelessness and are becoming
homeless sooner than those of past military wars(Fairweather, 2006). It would often take
years for veterans’ military symptoms to cause such instability to the veterans’ life that
they would lose housing (Fairweather, 2006). However, in the current OIF/OEF war
veterans are seeking housing assistance months after returning from Iraq (Fairweather,
2006). By the year 2006 there were already approximately 600 Iraq veterans who had
sought homeless health care services from the Department of Veteran Affairs
(Fairweather, 2006; Seal et al. 2010).
Mental Health Issues
Emerging mental health disorders for OIF/OEF have been shown to affect 18.5 to
42.7% of the 1.6 million who have served in the OIF/OEF (Seal et al, 2010). Veterans of
the OIF/OEF war are experiencing physical and mental trauma that in past conflicts, such
as World War II, soldiers did not survive from (Schnurr et al, 2009). More service
members are surviving and dealing with the repercussions of the event (Schnurr et al,
2009). Soldiers who return from a deployment may return with mental health issues and
then may be redeployed to combat zones; according to the Army’s Mental Health
Advisory soldiers deployed to Iraq more than once are much more likely to be diagnosed
with psychological injuries (Schnurr et al, 2009).
Veterans of the OIF/OEF conflicts are often exposed to hostile fire and are in
urban war zones and are exposed to improvised explosive devices (Fairweather, 2006). A
study conducted with four U.S. combat infantry units and a sample of 2,530 veterans
indicated that 90% reported of combat experiences (Hoge et al, 2004). These experiences
22
included being shot at and a high percentage reporting handling dead bodies, knowing
someone who was injured or killed, or killing an enemy combatant (Hoge et al, 2004).
These conditions are further traumatizing because the current veterans are not only going
to Iraq once and experiencing, they may serve multiple tours of duty (Fairweather, 2006).
This has left an unforeseen amount of soldiers returning home from war who have issues
surrounding readjusting back into civilian society while dealing with often times full
blown post-traumatic stress disorder (Fairweather, 2006).
Civilian stress may worsen PTSD and after returning from many tours of duty
there are often marital and family issues to be dealt with (Allen, 2010). In a study
conducted with 434 Army husbands and civilian wives, variables such as marital
satisfaction, negative communication, positive bonding, parenting alliance, confidence,
dedication, and satisfaction with sacrifice were measured with couples who had recent
deployments versus those who did not (Allen, 2010). This study showed that when
soldiers are gone for long periods of time with multiple deployments this causes
significant stress for the active duty personnel as well as their families (Allen et al. 2010).
To compound the problem more active duty soldiers are returning home with
posttraumatic stress disorder which also affects the family they are coming home to
(Allen et al. 2010). These readjustment problems are important to address because it is
shown in previous studies that the homecoming experience often correlate with PTSD
help seeking behaviors (Andrews, 2009). Signs of PTSD and poor readjustment may
include avoidance/numbing, and hyperarousal and isolation. Isolation can lead to
23
rejection of fun activities with the spouse or families which cause greater problems
(Allen et al. 2010, Seal et al. 2010).
Another concern surrounding the OIF/OEF veteran population and the prevalence
of PTSD is suicide rates. A study conducted from 2004 to 2007 of OIF/OEF veterans
found the that veterans with PTSD were over four times more likely to report suicidal
ideation than veterans who did not screen positive for PTSD (Jakupcak et al, 2009).
Another study indicated the rate of suicide is much higher than persons in the general
population and veteran’s are twice as likely to commit suicide than nonveterans, with
over 120 veterans (from all wars) killing themselves every week (Franklin, 2009;
Jakupcak et al, 2009). These findings are consistent with a study done of Vietnam
veterans that showed psychiatric symptoms increasing risk of attempted suicide and that
posttraumatic stress disorder predicting completed suicide (Jakupcak et al, 2009).
Another topic of concern that is being reported is that soldiers who are engaging
in behaviors that are consistent with posttraumatic stress and traumatic brain injury are
being less-than-honorably discharged (Fairweather, 2006).The less-than-honorable
discharge coding is normally attributed to those who have pre-existing personality
disorders, substance abuse and bad conduct (Fairweather, 2006). The less-than-honorable
discharge status for veterans who are experiencing posttraumatic stress and traumatic
brain injury is an issue that may need to be addressed quickly because these
soldiers/veterans will be barred from receiving Veterans Affairs medical and mental
health care (Fairweather, 2006).
24
Addictions and Medical Problems
Although regular consumption of alcohol may be seen as a part of military
culture, OIF/OEF veterans have high rates of misuse (Jakupcak et al 2010). Alcohol
misuse is associated with many things including spousal abuse, occupational impairment,
and legal problems (Jakupcak et al 2010). Studies also indicate that alcohol misuse
among the current OIF/OEF veterans may be a form of self-medicating combat-related
PTSD or depression (Hoge et al, 2004). Alcohol misuse tends to be more common among
younger male veterans, veterans who served in the Army Marine Corps and Veterans
reporting symptoms of PTSD and depression (Jakupcak et al 2010). This study also
indicated that alcohol consumption may be used to improve mood and pleasure as well as
may serve as a facilitator of detachment or blunting of negative emotions (Jakupcak et al
2010).
Access & Lack of Resources
Mental health disorders effect between 18.5% and 42.7% of the 1.6 million
OIF/OEF veterans (Seal et al, 2010). PTSD is one of the most common mental health
issues for this population and a recent report found that veterans were only receiving two
years medical benefits after discharge which limited access to resources for delayed onset
PTSD (Fairweather, 2006). One of the issues surrounding posttraumatic stress disorder is
that there may be delayed on-set and many veterans are only receiving two years medical
benefits after discharge from the military unless they are discharged with the
posttraumatic stress disorder (Fairweather, 2006). There have been an unprecedented
number of veterans from the OEF/OIF who are turning to Vet Centers for counseling. In
25
a study conducted in 2006, the number of OIF/OEF veterans seen for PTSD had doubled
and the number of OIF/OEF veterans seen for readjustment problems tripled from
October 2005 to 2006 (Fairweather, 2006). Veterans who are seeking individual
treatment are being sent to group therapy and many are being put on waiting list
(Fairweather, 2006). The VA expected to treat 2,900 war veterans for PTSD and as of
June 2006 had seen 34,000 (Fairweather, 2006). If there are not enough resources to treat
veterans in need of readjustment and PTSD issues, the United States will see a new wave
of homeless veterans who are unable to stabilize their living and family situations enough
to maintain housing.
Addressing the Issue
Integration of Mental Health and Primary Care
Integrated care continues to surface in a large amount of the research as the
suggested way to address the issue (McGuire, 2009; Blue-Howells, 2008). Combining
and simultaneously delivering subsistence services such as shelter, meals, and income
support as well as mental health and substance abuse services (McGuire, 2009). One of
the major barriers for use of health services by homeless individuals was system
fragmentation and when these systems were integrated homeless veterans were receiving
more prevention services, primary care visits, and had fewer emergency room visits
(McGuire, 2009;Blue-Howells, 2008). It has also been shown that when integrating care
in residential placements for mental health issues and substance abuse disorders there are
slightly better results as compared to a program only aimed at dealing with substance
abuse issues (Kaspow et al, 1999).
26
An additional link that was shown to be apart of many of the integrated care
systems was veterans receiving comprehensive case management either through the
Veteran Affairs Health Care for homeless veterans (HCHV) staff or through another case
management program (Mares & Rosenheck, 2009). There are many ways to address the
issue of system fragmentation and in the Greater Los Angeles Area the VA implemented
a program which put mental health, medical, and homeless services in one building(BlueHowells, 2008). There was an access center which coordinated entry to all needed
services (Blue-Howells, 2008). The facility addressed many issues by placing many
services in one building and implementing a program in which the veteran would be able
to do multiple appointments in one day as they dropped in (Blue-Howells, 2008). When a
veteran needed specialized care, which may include visits to optometrist, there were
connections implemented with those departments in order for the veteran to be able to
gain access to appointments in a much timelier manner (Blue-Howells, 2008). This
particular program was recognized as a best practice model and has improved homeless
veterans access to medical care, mental health treatment, and social services (Greenberg
2010, McGuire 2009, Kasprow et al 1999, Blue-Howells 2008).
Another example of successful integration of services includes a collaborative
between the VA and Social Security Administration (Chen et al 2007). A study was done
of a collaboration between Social Security Administration and Department of Veterans
Affairs in a co-located facility. This study indicated that there was a 8% increase in
veterans who applied for SSI or SSDI and 4% increase of veterans who were awarded
benefits (Chen et al 2007). When the Veterans Health Administration and the Veterans
27
Benefits Administration created an integrated system 22% of the veterans sampled
received newly awarded benefits of those 28% were compensation benefits and 72%
were pension benefits (Chen et al 2007).
Service providers from the benefits side of the VA as well as primary care
providers can also help integrate care. A qualitative study of 44 U.S. military veterans
from Vietnam and Afghanistan/Iraq showed that OIF/OEF veterans saw strategies the
military had implemented to foster help-seeking, such as screening, a web-based referral
system, and on-site services (Sayer et al, 2009). Participants in this study also discussed
how primary care providers encouraged and referred them to mental health treatment and
because they had an established relationship with the primary care provider they often
followed the recommendation (Sayer et al, 2009). Veterans in this study also stated that
Veteran’s Service Officers played a key role in encouraging veterans to seek treatment
and helped them navigate the enrollment process (Sayer et al, 2009)
Mental Health Care Transformation
The Department of Veterans Affairs called for a transformation of Mental Health
Care and the action plan included implementing the recovery model, expanding treatment
for mental health and substance abuse treatment, increasing availability of services to
OIF/OEF veterans, and integrating mental health services with general health care
services (Greenberg & Rosenheck 2009). Between 2004 and 2007 there are have
improvements in population coverage/access, outpatient care, economic performance,
and global functioning (Greenberg & Rosenheck 2009).The increases of new hires and
expanding community-based outreach clinics, as well as increasing mental health care
28
and primary care services at over 100 sites, has helped with integrated care (Greenberg &
Rosenheck 2009)
Disability Benefits
Other studies have focused on receipt of public support payments, VA pension
and compensation benefits, are associated with beneficial outcomes for veterans who are
homeless with mental health issues (Chen, 2007). It has been cited that when comparing
veterans who received payment versus those who have not, there was a higher quality of
life only three months after being awarded benefits (Chen, 2007). Although receiving VA
benefits is shown to provide beneficial outcomes it has also been proven that securing
other assistance such as Supplemental Security Income (SSI), has been an important
factor in those who were domiciled versus those were homeless (Rosenheck et al 1999).
Because research has found that receiving disability benefits has improved homeless
veterans quality of life it is then crucial to be aware of ways to improve access to
disability benefits among homeless persons. In a study conducted in 1999 the idea was to
work from a top-down agency specific approach, forming a collaborative between social
security administration and the VA (Rosenheck, 1999). Figures suggest that substantial
numbers of homeless people with mental illness are entitled to income supports but do
not obtain them; increased public support payments were associated with reduced
homelessness (Rosenheck et al 1999).
Supported Housing
“Supported housing models are effective in helping homeless persons with
psychiatric and/or addictive disorders exit from homelessness and maintain community
29
housing” (O’Connell 2010). One program that is an example of this supported housing
model that has been put into place is the HUD-VASH program. The Department of
Veterans Affairs (VA) partnered with Housing and Urban Development (HUD) to create
a supported housing program for veterans called HUD-VASH. When this program
originally started veterans were allowed a 5 year section 8 voucher from HUD and with
this voucher came intensive case management, which was delivered by the VA. Although
the time it took for a veteran to be entered into the program and receive housing
placement (108 days), when the veteran was housed there was a positive difference in
substance abuse, treatment engagement, and social support. It has been further noted that
supported housing has enhanced quality of life for veterans participating in general as
(O’Connell 2010).
Additional finding suggest that adults who have experienced chronic
homelessness may be successfully housed as well as can maintain their housing when
they are provided with comprehensive services (Mares & Rosenheck, 2009). The
Collaborative Initiative to Help End Chronic Homelessness combined permanent
housing, intensive case management, and access to primary healthcare and mental
health/substance abuse services (Mares & Rosenheck, 2009. When implementing it is
shown that veterans were housed a greater amount of days then those veterans only
receiving permanent housing with case management; 89% of those who were a part of the
CICH appeared to have been placed in housing during the twelve month follow-up period
and were continuously housed thereafter (Mares & Rosenheck, 2009). Other areas
indicate improvement as well including community integration, income increase, and
30
mental health functioning. There was also a decline in psychological distress and
substantial decrease in cost of treatment once these veterans were housed (Mares &
Rosenheck, 2009. Most notably the largest source of decline was reduced inpatient cost
which decreased by $3,000 (Mares & Rosenheck 2010).
Transition/Reintegration Programs
The Department of Veterans Affairs has many programs to help ensure a
successful transition from military to civilian life (2011). However, there are specific
protective factors that can be examined and implemented for OIF/OEF veterans that may
decrease the risk of becoming homeless as they reintegrate into society (Fairweather,
2006). These include training success, choosing to be in the military, continuity of tours
of duty, and Department of Defense housing and rehabilitation (Fairweather, 2006).
There are also protective factors associated with adjustment back into civilian life which
include employment assistance, transition assistance, rehabilitation, medical care,
commensurate employment, compensation and work therapy (Fairweather, 2006). The
VA has put programs into place to ensure the transition to civilian life for example the
Seamless Transition Program which works with OIF/OEF veterans. Issues around this
program include needing more resources and it has been suggested that enrollment into
VA healthcare should be automatic for returning troops (Fairweather, 2006).
Employment Services
The Veteran Health Administration has a vocational rehabilitation program which
help people with serious mental illness (Resnick & Rosenheck, 2008). This program has
proven effective for individual with schizophrenia and bipolar disorder however there
31
have not been many studies that have documented its success in working with veterans
with posttraumatic stress disorder (Resnick 2008). A study done in 2008 showed that
veterans with PTSD demonstrated vocational deficits, they were 19% less likely to be
competitively employed at discharge from the program, and of those were employed in
the program the veterans with PTSD worked fewer days compared with individuals
without PTSD (Resnick & Rosenheck, 2008). This study showed that veterans with
PTSD were less likely to be employed when being compared to individuals with affect
disorders and substance use disorders (Resnick & Rosenheck, 2008). This study
continued by hypothesizing that negative symptoms of PTSD, such as a sense of
foreshortened future, flashbacks, anger, and irritability may make it hard to work in
places where external stimuli are unpredictable (Resnick & Rosenheck, 2008). This study
suggests a specific expansion of evidence-based services for veterans with PTSD may be
best to optimize employment outcomes for veterans with PTSD. (Resnick & Rosenheck,
2008).
Social Network
It has been shown that encouragement, helping veteran recognize symptoms,
motivating veterans to seek assistance from the veterans social support has improved
participation in treatment (Sayer et al 2009). In a recent qualitative study of the
determinants of PTSD treatment initiation, it was noted that socio-cultural environment
influences help-seeking for trauma-related psychiatric problem (Sayer et al 2009). The
environment and reception/homecoming experience is a pivotal time for development of
PTSD, symptoms levels, and now we also know that it affects help-seeking initiation.
32
With this knowledge in mind it is imperative to understand the role of the family and
support not only the active duty/recently discharged veteran but also the family of the
veteran (Sayer et al 2009). One study indicated that PTSD is linked to more relationship
conflict and can challenge the confidence a couple has in their relationship lasting (Allen,
2010).
33
Chapter 3
METHODOLOGY
Introduction
The purpose of this study is to analyze the causes of homelessness among the
veteran population. This study is meant to document the history as well as evaluate
current programs that have been implemented which focus on ending homelessness
among veterans. There were no human subjects for this research project, this study will
conduct a secondary data analysis to review the documented causes of homelessness and
evaluate outcomes of the Department of Veteran Affairs Supported Housing program to
determine if participation in this program enables veterans to gain and maintain
permanent housing. This section will include information on the study design, sample,
data collection and gathering materials, instruments, data analysis and protection of
human subjects.
Study Design
This study was a secondary analysis of data which was originally collected to
assess the outcomes of the Integrated Health Care and Housing Supports from Federal
Agencies in the Evaluation of the HUD-VA Supported Housing Program (HUD-VASH).
The data was made available by the Northeast Program Evaluation Center (NEPEC). The
data is available at http://vaww.nepec.mentalhealth.med.va.gov/PHV/HCHV/hch02SR.pdf;
therefore, permission was not needed to use the data.
34
Sample
The original sample included veterans eligible for VA services who were
contacted through VA community outreach efforts, based at VA medical centers located
in San Francisco; CA, San Diego; CA, New Orleans; LA, and Cleveland OH. Veterans
were eligible for HUD-VASH if they were literally homeless at the time of assessment
(i.e. living in a homeless shelter or on the streets); had been homeless for 1 month or
more; and had received a clinical diagnosis of a major psychiatric disorder and/or an
alcohol or drug abuse disorder (Rosenheck, 2002). Recruitment for the study took place
from 1992 and 1995; 3,489 veterans were contacted through outreach at four sites, who
met minimal eligibility. 460 of the 3,489 eligible gave written consent to participate in
the study. Screening for admission was done by Health Care for Homeless Veterans
program (Rosenheck, 2002).
The veterans signed a written consent, completed a baseline assessment and then
they were randomly assigned through a centralized procedure to either: 1) HUD-VASH
(case management plus voucher), 2) case management-only, or 3) standard care, which
consisted of short-term broker case management provided by HCHV staff (Rosenheck,
2002).
Data Collection/Gathering Procedures
Data was downloaded from NEPEC website. The report was titled “Integrated
Health Care and Housing from Federal Agencies: An evaluation of the HUD-VA
Supported Housing Program (HUD-VASH)”. All statistics and data that were used to
analyze the HUD-VASH program come from this published report. The original study
35
collected data on sociodemographic characteristics including age, gender, race, days
employed, income, receipt of public support payment, duration of the current episode of
homelessness, housing status during the 90 days prior to the interview, clinical status,
community adjustment, childhood history and mode of first contact (Rosenheck, 2002).
Baseline and follow up assessments were conducted every 6 months. In addition
the VASH clinicians would document their efforts to assist their clients to obtain
vouchers and apartments during the initial housing search (Rosenheck, 2002).
Instruments Used
Instruments used in the original study included Addiction Severity Index (ASI),
Brief Symptom Inventory (BSI) and the Lehman Quality of Life Interview; as well as
baseline assessments, follow-up assessments, assessments of quality of the veteran’s
residence.
Data Analysis
In the original study analysis of housing and clinical outcomes were based on
interview data. All original analyses was conducted using SAS ® version 8.0 with an
alpha level of p<.05. The original data reviewed many different variables of the HUDVASH program in comparison to case management and standard care models of
treatment. This study is focused on sociodemographic characteristics and three variable
outcomes 1) housing characteristics 2) clinical status and 3) community adjustment
measures. This data analysis will compare baseline outcome measures of HUD-VASH
participants to the outcomes measures that were averaged for a 3 year time period.
Comparing baseline and outcomes measures of housing, clinical, and community
36
adjustment will allow for a better understanding of whether or not the HUD-VASH
program is an effective program at ending homelessness among the veteran population.
By comparing baseline and outcome numbers the analysis is able to show the average
level of change after being in the program for an extended period of time (3 years).
Protection of Human Subjects
The original study was done with veterans and approved through each medical
center; however, the secondary data analysis conducted by this researcher did not include
human subjects. All veterans in the primary study provided written informed consent to
participate in the study and the protocol was approved by the Human Investigation
Committees at each medical center. Veterans received $20 for their participation in each
interview. This researcher completed the human subject application and submitted it to
both this researcher’s thesis advisor and the California State University, Sacramento
Committee for Protection of Human Subjects. On March 17, 2011 the application was
approved by the Committee for Protection of Human Subjects, approval number 10-11101 with an expiration date of March 17, 2012. The committee found that this project
was “exempt” due to the research comprising secondary data with no human subjects.
37
Chapter 4
FINDINGS
This chapter explains findings regarding the outcomes in the effectiveness of the
HUD-VA Supported Housing Program (HUD-VASH). Information was originally
obtained from a report published that was interested in understanding the costeffectiveness in several homeless programs. Information obtained for this report
consisted of 1) sociodemographic variables 2) comparison of HUD-VASH baseline
outcomes to experimental HUD-VASH outcomes. The findings focus on the data
collected for the 182 HUD-VASH participants whose baseline demographics and
variables were examined as well as how the outcome of being a part of the experimental
HUD-VASH program.
38
Sociodemographic Characteristics
Figure 1 shows that 96.1% of the HUD-VASH sample was male and 3.9% of the
sample were men.
Figure 1. Gender
Gender
Female
Male
3.9%
96.1%
39
Table 1 provides information regarding the racial and ethnic characteristics of the
participants. 31.2% (n=57) of the participants were White, 63.6% (n=116) are Black, 4%
(n=7) are Hispanic, and 1.2% (n=2) are other racial or ethnic groups that do not fit into
the other three categories.
Table 1
Race/Ethnicity
Frequency
Percentages
Cumulative Percentage
White
57
31.2%
31.2%
Black
116
63.6%
94.8%
Hispanic
7
4.0%
98.8
Other
2
1.2%
100%
Total
182
100%
Table 2 shows that the highest percentage of participants were divorced 38.2%
(n=70), 37.2% (n=68) were never married, 17.8% (n=32) were separated, 4.4% (n=8)
were married, and 2.2% (n=4) were widowed.
Table 2
Marital Status
Frequency
Percentages
Cumulative Percentage
Married
8
4.4%
4.4%
Widowed
4
2.2%
6.6%
17.8%
24.4%
Separated
32
Divorced
70
38.3%
62.7%
Never Married
68
37.2%
99.9%
Total
182
100%
40
Table 3 shows how veterans first made contact with the Department of Veteran
Affairs. The majority made first contact through VA Community Outreach 43.7% (n=78),
Self-Referred 19.0% (n=35), Referral from VA program 18.6% (n=34), Other 12.1%
(n=22), and 6.9% (n=13) were referrals from Non-VA homeless programs.
Table 3
Mode of First Contact
Frequency Percentages
VA Community Outreach
78
43.7%
Cumulative
Percentage
43.7%
Referral from Non-VA homeless Pgm
13
6.9%
50.6%
18.6%
69.2%
Referral from VA program
34
Self-referred
35
19.0%
88.2%
Other
22
12.1%
100.3%
Total
182
100%
41
Table 4 provides information on the duration of homeless episodes that the
veteran had prior to entering the supported housing program. The majority were homeless
for less than 6 months 43.8% (n=80), 23.9% (n=43) were homeless for more than 2 years,
18.8% (n=34) were homeless for more than 6 months and less than 1 year, 13.1% (n=24)
were homeless for more than one year and less than 2 years, and lastly .6% (n=1) veteran
was not literally homeless at the time of being accepted into the program.
Table 4
Duration of Homeless Episode
Frequency
Percentages
Not literally homeless
1
.6%
Cumulative
Percentage
.6%
< 6 months
80
43.8
44.4%
6 months-1 year
34
18.8
63.2%
1-2 years
24
13.1
76.3
>2 years
43
23.9
100.2%
Total
182
100%
42
Figure 2 presents information on the clinical diagnosis that the HUD-VASH
participants were diagnosed with at the time of their assessment before entered the
experimental program. 66.1% (n=120) were diagnosed with Alcohol abuse/dependency,
68.9% (n=125) with drug abuse/dependency, 5.8% (n=11) with schizophrenia, 1.7%
(n=3) with other psychosis, 4.6% (n=8) with bipolar disorder, 29.3% (n=53) with
depressive disorder, 14.9% (n=27) with PTSD, and 3.1% (n=6) with other anxiety
disorders.
Figure 2. Clinical Diagnosis
Clinical Diagnosis
140
120
100
80
60
40
20
0
Clinical Diagnosis
43
Figure 3 compare number of days homeless at baseline and after being in the
HUD-VASH program. Baseline was 25.1 days in the past 30 and HUD-VASH was 13.05
days homeless.
Figure 3. Number of days homeless: baseline vs. HUD-VASH experimental group
30
25
20
baseline
15
hud-vash
10
5
0
days homeless
44
Figure 4 compares the variables that are associated with substance abuse
including days intoxicated, alcohol index score, and drug index score. At baseline the
number of days intoxicated was 4.7 and after being in the HUD-VASH program the
number of days of intoxication decreased to 1.46. The alcohol index of the group at
baseline was .20 and the score after being in the HUD-VASH program was .12. The drug
index shows that at baseline the score was .10 and after being in the HUD-VASH
program the score was .061.
Figure 4. Substance Abuse Variables baseline HUD-VASH vs. HUD-VASH
experimental group
5
4.5
4
3.5
3
Baseline Outcome
2.5
HUD-VASH Outcome
2
1.5
1
0.5
0
Days Intoxicated
Alcohol Index
Drug Index
45
Figure 5 compares both the baseline outcomes to the HUD-VASH participant
outcomes and shows both psychiatric index and medical problems index. The psychiatric
index shows that at baseline and after being in the HUD-VASH program the score started
and stayed at .25%. The medical problems showed that at baseline the score was .41 and
after being in the HUD-VASH program the number decreased to .26.
Figure 5. Clinical Status Medical Problems Index (ASI) & Psychiatric Index (ASI)
0.45
0.4
0.35
0.3
0.25
Baseline Outcomes
0.2
HUD-VASH Outcomes
0.15
0.1
0.05
0
Psychiatric Index
Medical Problems Index
46
Figure 6 shows the community adjustment scores and compares the baseline
outcomes to the HUD-VASH outcomes for three different community adjustment
measurements. The first is social network people with a 9.78 at baseline and 11.6 after
being in the HUD-VASH program. The second is social contacts with a baseline number
of 29.84 and then a number of 39.1 social contacts (average) after being a part of the
HUD-VASH experimental group. The last community adjustment score is the social
support score at baseline participants scored 6.96 and after being a part of the program
showed an improvement to 7.85.
Figure 6. Community Adjustment (baseline outcome vs. HUD-VASH experimental
outcome)
45
40
35
30
25
baseline outcome
20
hud-vash outcome
15
10
5
0
Social Network people
Social Contacts
Social Support
47
Figure 7 compared the baseline participant outcomes to the outcomes after being
involved with the HUD-VASH program in regards to community adjustment variables
including legal index, arrest for major crimes, and arrests for minor crimes. The legal
index tool shows that at baseline, the participants scored .05 average and the HUDVASH outcomes shows a score of .061. The arrest for major crimes number for the
baseline participant outcomes 1.27 compared to the HUD-VASH participant outcome of
.23. The last variable is the arrest for minor crimes at baseline the number of arrests on
average was 1.23 versus after being in the HUD-VASH program average of arrest
declined to .22.
Figure 7.
Community Adjustment: Legal Index and Arrest (baseline outcome versus HUD-VASH
experimental outcome)
1.4
1.2
1
0.8
baseline outcomes
0.6
hud-vash outcomes
0.4
0.2
0
legal index
arrests: major crimes
arrests: minor crimes
48
Figure 8 shows the reasons why veterans were terminated from the HUD-VASH
program. 31% (n=56) of participants were terminated due to losing their housing
voucher, 50% (n=91) were terminated due to substance abuse replace, 47.5% (n= 86) did
not tolerate closeness of case management, 12.1% (n=22) left to pursue treatment
elsewhere, 24.5% (n=45) of the veterans accomplished goal of limited improvement,
24.7% (n=45) showed significant improvement.
Figure 8. Reasons for Termination
reason for termination
100
90
80
70
60
50
40
30
20
10
0
reason for termination
49
Summary
Chapter 4 presented the data of the sociodemographic characteristics of the
participants as well as the results of the data analysis in three categories including
housing variables, clinical status variables, and community adjustment variables; in
which we compared data of baseline outcomes versus outcomes of the same participants
who were in the HUD-VASH program.
In the following Chapter 5, the researcher discusses the findings of the data and
how this supports the literature review findings, the implications for social work practice
and policy, and recommendations for future research. Further, Chapter 5 discusses the
limitations of this study.
50
Chapter 5
CONCLUSION & IMPLICATIONS
This chapter will discuss the findings of the secondary data analysis that
examined characteristics and variables of participants who were selected for the HUDVASH program. The study examined baseline measurements of the participants and
compared them with the averages of all time-periods of outcomes. The original study
compared the HUD-VASH program to two different models of care including case
management only, and standard care and evaluated participants at 6,12,18,24, and 36
months. This project was intended to compare HUD-VASH at baseline to HUD-VASH
outcomes averages to identify specific variables that supported the idea that the HUDVASH program effectiveness in getting homeless veterans housed and into long term
permanent housing.
Findings
This was a secondary analysis of the outcomes for the HUD-VA Supported
Housing Program participants. This study provides a thorough review of the literature
focused on the causes of homelessness in order to identify if those causal factors were
addressed with participation in the HUD-VASH program. The causes of homelessness
were compared with outcome measures in the HUD-VASH program in order to make
these connections clear. For example; the literature indicated that alcohol abuse was a
common cause of homelessness; it was part of this study’s aim to show that these
behaviors were reduced by participating in the HUD-VASH program.
51
The analysis yielded the following data that offered specific measureable
outcomes. The three variable outcomes consisted of: 1) housing characteristics; 2)
clinical status; and 3) community adjustment measures. The specific housing
characteristic examined included information on numbers of days homeless at baseline
and averages after three years in the program. Clinical status measurements are related to
substance abuse and how many days the veteran was intoxicated (out of a 30 day period),
alcohol index, and drug index. Community adjustment was measured by legal problem
index, social network people, social network contacts, social support, and arrest for both
major and minor crimes.
The data analysis confirms the hypothesis that the HUD-VASH program is an
effective program in getting homeless veterans off the street and into permanent housing.
The demographic of this sample is consistent with the literature and showed this sample
is a fairly accurate representation of the population.
The female homeless veteran
population was about 3% of the total population (National Coalition for Homeless, 2009)
and the study consisted of 96.1% male and 3.9% female (Table 1). The literature
confirms what this data set shows in regards to the majority of the population of the
homeless veterans being African American (Table 2).
There are several factors that are associated with homelessness including
alcohol/drug dependence and mental illness therefore the first measure examined was
clinical outcomes. The data on clinical diagnosis (Table 6) at baseline were much lower
than percentages that were seen in the literature; when examining the percentage of
people who were diagnosed with alcohol abuse; the literature indicates that comorbid
52
drug abuse/dependence have ranged from 40-44% among the homeless population.
However, this study showed that nearly 89.9% had some form of substance abuse
(Stewart et al. 1999).
The literature also indicated that 20-25% of the homeless
population have a serious mental illness whereas this study indicated that 40.8% of the
sample had any serious psychiatric disorder (Greenberg & Rosenheck 2009).
The second area of review was the measure which identified number of days
homeless at baseline versus days homeless after entering the program. The data analysis
of the reported means for days of homelessness reveal a decrease in the number of days
that the veteran experienced homelessness after entering the HUD-VASH program
making a drastic change from 25.1 days at baseline and 13.05 days after being in the
program (Table 7). The data analysis also indicates a decrease in the number of days the
veteran drank to intoxication; at baseline the mean was 4.7 days out of 30 and at the
outcome the mean number of days dropped to 1.46 days. The alcohol and drug index
scores also showed a modest change going from .20 to .12 for alcohol index, and .10 to
.061 for the drug index (Table 8).
The next area of analysis was community adjustment measures. Although there
was no change in the psychiatric index there was a significant decrease in the medical
problems index decreased from .41 to .26 after entering the HUD-VASH program. Other
positive outcomes involve community adjustment measures. Veteran’s amount of social
network, social contacts, and social support improved after entering the HUD-VASH
program. At baseline the social network was 9.78 and the participant’s outcome mean
improved to 11.6. The amount of social contacts also improved from 29.84 to 39.1 and
53
the mean of social support improved from 6.96 to 7.85. Another variable that is
associated with community adjustment is legal index, arrest for major crimes, and arrests
for minor crimes. The amount of arrests after being housed decreased from 1.27 to .23
and the amount of arrest for minor crimes decreased from 1.23 to .22.
The last area of review was the reasons veterans terminated from the program.
This information is important to have in order to understand what may cause the veteran
to potentially become homeless again or on the opposite spectrum what helped the
veteran be successful enough to exit the program due to significant improvement. The
most interesting of the variables was that over 50% exited the program after substance
abuse relapse; one of the main causes of homeless among the veteran population is
substance abuse and relapse and this proves to be the highest cause for losing the
voucher. This indicates that the program was not able to effectively implement a plan to
help veterans who were dealing with substance abuse/use issues while they were in the
program to keep them in permanent housing. The second most common reason (47.5)
were the veterans who terminated due to inability to tolerate closeness of case
management. The next reason is the general “lost housing voucher”; which could be the
result of many issues 31%. There was 12.1% of the veteran’s exiting the program who
left to pursue treatment elsewhere. And the two least likely categories where the veteran
left due to limited improvement (24.5%) and significant improvement (24.7).
Implications for Social Work Practice
At a macro level, the supported housing program proves to be an affective
program in working with those who have a mental health issue and are homeless and
54
moving them into permanent housing. This program is an example of harm reduction,
housing first approach, and an integrated care program. Applying this type of program to
other homeless/housing programs may prove to be an effective approach at a more macro
policy level. The shift from offering services through many different providers and
location to the more integrative care approach and working in collaboration may help
reduce the amount of homeless individuals there are in this country. This approach can
be applied to other settings which may also be dealing with system fragmentation. Social
Work Code of Ethics indicates that social workers develop and enhance their profession
expertise. Social workers must continuously increase their knowledge and skills and stay
current in evidence-based and best practice models.
At a micro level, there are several factors that were cause for termination that
could be potentially changed in order to work with veterans and homeless individuals
which may help to maintain housing. One of the top reasons, 47.5% (n= 86), for
termination was the veteran did not tolerate closeness of case management; issues
surrounding this may be addressed in the program and by the veteran and the case
manager as a team. Case management should be a helpful part of being a part of the
program not a reason to terminate from the long-term permanent housing program, it is
the recommendation of this writer that goals are set in the beginning of the relationship
and if the veteran is not in need of intensive case management then the case manager
would then have the ability to be flexible enough to work with this veteran on a less
regular basis.
55
Implications for Social Work Education
This study has shown clear implications for social workers and social work
practice. Social workers are often educated on mental health issues and social issues;
however, what this study shows the need for implementation of substance abuse
treatment as it is one of the leading causes of homelessness; and, more specifically, the
top reason for termination from the supported housing program. Social work education
programs may consider implementing a required course on substance abuse in even
generalist social work programs. Social Workers may be better equipped to work with a
variety of populations who may be struggling with substance/drug abuse issues and/or cooccurring disorders.
Limitations and Future Research
Although the secondary data analysis was unable to prove statistical significance
due to lack of original data, the data results have a high social validity. When explaining
that a veteran went from being homeless 25 days out of the month to 13 days (average of
three year outcome measurements) shows that the program was effective in getting
veterans into housing (more days then without the program) even though there was not a
statistical test to prove the significance. This study was very limited due to the fact the
original raw data was unavailable. Having a more recent study with original data would
allow the researcher to test for statistical significance when comparing the baseline
characteristics with outcome characteristics. Having access to both baseline (initial
interview) assessment outcomes and the same variables after a 6 month, 12 months, 18
months and 24 month period, instead of an average of the months combined would be
56
beneficial in being able to truly understand if this program is effective in not only getting
veterans housed but the veteran remaining housed in permanent supportive housing
programs.
A future study may want to look at what characteristics are commonly associated
with being able to sustain housing; the study that was used for this secondary data
analysis did explore the reasons for termination but it would be valuable to understand
race/ethnicity components, substance abuse/use, age, amount of contact with the case
manager and how they specifically correlate with the individuals characteristics and the
reasons for termination.
It would be interesting to also explore how the Iraq and
Afghanistan veterans are doing in the HUD-VASH program compared to other veterans
that may have not been engaged in combat as well as comparing Vietnam Era veterans
with the Iraq and Afghanistan veterans.
Summary
This Department of Veterans Affairs and the Housing and Urban Development
Agency have joined together with a commitment to end homeless among veterans in 5
years. This study demonstrated that the HUD-VASH program is effective in reducing the
amount of days a veteran is homeless, helps increase community adjustment and decrease
leaves of criminal activity. This study also gave insight into issues with substance abuse
and relapse that may need to be addressed to increase the amount of days they are
housed. By acknowledging that 50% of veterans dropped out of this program due to
substance abuse, case managers and program administrators can better target this specific
problem. Although this study was very limited it proved successful in providing
57
information on the causes of homeless and how this issue may be addressed. The ultimate
goal, stated by presented by President Obama and Secretary Shinseki in 2009, is to end
homeless among veterans in the next 5 years. Shinseki stated, “Those who have served
this nation as Veterans should never find themselves on the streets, living without care
and without hope” (Department of Veterans Affairs, 2009).
58
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