HOUSING CHRONICALLY HOMELESS VETERANS: EVALUATING THE EFFICACY OF A HOUSING FIRST APPROACH TO HUD‐VASH

Rapidly placing homeless Veterans with severe mental illness into permanent housing is one important goal of the U.S. Department of Housing and Urban Development‐Veterans Affairs Supportive Housing (HUD‐VASH) program; however, no research has tested whether an explicit organizational alignment of this goal with revised practices could improve outcomes. A demonstration project initiated in 2010 to reform housing placement practices in a metropolitan area enabled researchers to compare an explicit “Housing First” program—offering immediate permanent housing without requiring treatment compliance, abstinence, or “housing readiness”—with a treatment‐first program for 177 homeless Veterans. The Housing First initiative successfully reduced time to housing placement, from 223 to 35 days, housing retention rates were significantly higher among Housing First tenants, and emergency room use declined significantly among the Housing First cohort. The results suggest that a national Housing First model for the VA would be associated with improved outcomes for Veterans experiencing homelessness.     

HOUSING FIRST AS AN EFFECTIVE MODEL FOR COMMUNITY STABILIZATION AMONG VULNERABLE INDIVIDUALS WITH CHRONIC AND NONCHRONIC HOMELESSNESS HISTORIES

Housing First (HF) is an effective intervention for reducing homelessness and service utilization among vulnerable adults and is most often focused on individuals experiencing chronic homelessness. This study explored the effectiveness of a single‐site HF program for 2 groups of people with serious mental illness: those experiencing chronic street homelessness, and those whose homelessness was limited but had high psychiatric service needs, often experiencing multiple hospitalizations or residential treatment. A sample of 91 HF and 91 matched usual care comparison participants were obtained from administrative records. Those in HF spent significantly less time homeless and psychiatrically hospitalized compared to usual care. Ninety percent of HF residents were housed after 1 year compared to 35% of the comparison group. Homelessness and hospitalization outcomes were unrelated to homelessness history. This study provides initial evidence for HF's effectiveness for promoting community stability among a population previously requiring a high level of intensive psychiatric care.     

Intrapersonal and social–contextual factors related to psychological well‐being among youth experiencing homelessness

Homeless youth are adolescents and young adults who do not have stable dwellings but instead live on the streets, in shelters, or in other unstable situations. Although researchers have begun examining well‐being among this population, little is known about components of well‐being that are relevant to homeless youth or which factors predict differences in well‐being. This study examined psychological well‐being and its associations with demographic characteristics, intrapersonal factors (mental health, optimism, and self‐esteem), and social–contextual factors (social support, sense of community, and empowerment) among 100 youth experiencing homelessness. All of the intrapersonal and social–contextual variables were associated with well‐being at the bivariate level. In the full regression model, only self‐esteem and psychological distress remained significant. Findings inform future research and program development at homeless service centers.     

Agreement between self‐report and archival public service utilization data among chronically homeless individuals with severe alcohol problems

Public service utilization data are often used as key outcomes in studies on homelessness. Although self‐report data on these outcomes are accessible and cost‐effective, various factors may affect retrospective recall in homeless populations. It is therefore necessary to establish validity of self‐report to ensure the integrity of studies involving such populations. Participants (N=134) were chronically homeless individuals with severe alcohol problems who participated in a housing first effectiveness trial (Larimer et al., 2009 ). The authors compared 30‐day and 3‐year retrospective self‐report data on sobering center, jail, and hospital use with archival records corresponding to the same timeframes. Analyses indicated good category‐specific agreement for 30‐day self‐report and archival data on sobering center (82%; κ=.58) and jail use (89%; κ=.60). Hospital use, however, was self‐reported significantly more frequently than indicated by archival data (78%; κ=.30). Three‐year data showed inadequate agreement across all three variables. © 2011 Wiley Periodicals, Inc.     

Stressful life events among homeless people: Quantity,types, timing,and perceived causality

This article describes the stressful life events suffered by a multicenter, randomized sample of 262 homeless adults in Madrid, Spain. Subjects were interviewed with the List of Threatening Experiences (Brugha and Cragg, 1990), supplemented by nine additional items specifically related to homelessness. Participants then rated each life event in regard to its causal contribution to their homeless situation. Findings showed that homeless people have suffered a mean of 9.1 important stressful events in their lives. Most of these events occurred Before (45% of the episodes), or During (39%), the first homelessness episode. In regard to the perceived causality of the stressful events, we found that homeless people have a multicausal view of their own problems. In fact, three categories of events were subjectively related to their current homeless condition: economic problems, breakdown of social ties, and mental illnesses. We discuss the implications of these data in light of Daly's (1994) typology of causal factors involved in homelessness: Economic, Affective/Relationship, Personal, and Institutional. © 1999 John Wiley & Sons, Inc.     

Risk of mental ill-health among homeless women in Madrid (Spain)

Several studies have revealed that homeless people suffering from mental health problems are more vulnerable than homeless without those mental health problems. Nevertheless, there is a lack of evidence describing the real circumstances of homeless women. This paper explores the differences between homeless women at high risk of mental ill-health compared with those who do not present this risk. The sample consisted of a group of 120 homeless women in Madrid (Spain). For this study, we collected data on background information (trajectory of homelessness and stressful life events experienced) and current aspects (living conditions, physical health, and social support). The risk of mental ill-health has been measured by the short version of the General Health Questionnaire (GHQ-28). The results showed that homeless women with higher risk of mental ill-health had become homeless at a younger age, had experienced more stressful life events in their lives, had a poorer physical health, felt less happy, had less social support, and a greater feeling of loneliness when compared with homeless women who did not present risk of mental ill-health. Improving knowledge about the risk of mental ill-health among homeless women is essential for the design of specific psychological interventions within this population.

     

THE ASSOCIATION BETWEEN HIV STATUS AND HOMELESSNESS AMONG VETERANS IN CARE

Veterans seeking care in the Department of Veterans Affairs Health Care System (VA) are more vulnerable to HIV infection and homelessness. However, there is little scholarship on the association between serostatus and homelessness among VA veterans. We examined this association in the Veterans Aging Cohort Study, a sample of 6,819 HIV‐positive and HIV‐negative veterans attending 8 VAs across the country. We utilized logistic models regressing shelter use in the last month on correlates. HIV and homelessness prevalence was higher than in general veteran populations. Being HIV‐positive was protective against homelessness. Substance use, hazardous alcohol use, depression, schizophrenia, and being African American and male increased risk of homelessness. HIV‐positive status reduced the homelessness risk posed by substance use, especially among African American substance users. However, women veterans with HIV were at higher risk of homelessness than noninfected women veterans. Implications for policies on veteran homelessness and housing for people with HIV are discussed.     

Homelessness and health: challenges for health psychology

Homelessness can be seen as a challenge for health psychology in research and practice on several levels: analysing the risks of becoming homeless; the living conditions of being homeless and their impact on health risks and problems; homeless youth as a specific phenomenon; health problems in the context of homelessness; service utilization and barriers and effects of interventions in the context of homelessness. With these levels, a framework is outlined for the contributions to this Special Issue. In the end, homelessness is discussed as an issue for prevention in three respects for a comprehensive approach in health psychology.     

Social networks of unaccompanied women experiencing homelessness

This study explored strengths, barriers, and role of social networks among unaccompanied women experiencing homelessness. Twenty women from two local shelters participated in semistructured, face‐to‐face interviews. A constant comparative analysis revealed 4 themes: support as a coping mechanism, loss of support as a path to homelessness, support as a drain, and support as a way to give. Almost universally, women experienced considerable barriers to housing, including physical health, mental health, substance abuse, or domestic violence. Despite precarious circumstances, women showed optimism, interest, and readiness to move forward and exit homelessness. Most women utilized social networks to cope with their difficult situations. Their networks, however, were limited such that abusive relationships and substance abuse commonly contributed to homelessness and delayed entrance into secure housing. Together with identifying unaccompanied women as a subgroup in the homeless population, targeted interventions can help women capitalize on healthy relationships to promote housing security and well‐being.     

LIFE AFTER SUPPORTED HOUSING: A CASE SERIES OF FORMERLY HOMELESS CLIENTS IN THE DEPARTMENT OF VETERANS AFFAIRS‐SUPPORTIVE HOUSING (HUD‐VASH) PROGRAM 20 YEARS LATER

This article presents a case series of three formerly homeless clients who were in the Housing and Urban Development‐Veterans Affairs Supportive Housing (HUD‐VASH) program 20 years ago and describes their progress since. Clients were identified from a 1992 client roster at one of the original HUD‐VASH sites. Clients were interviewed and their medical records were reviewed. The case studies were characterized as “sustained involvement in subsidized housing,” “successful discharge followed by re‐engagement,” and “case management more important than the voucher.” These cases illustrate that, first, long‐term success in supported housing has not been defined, but perhaps social integration and self‐sufficiency should be a focus. Second, mental health and substance abuse treatment appear to be important in long‐term client success, but when and how they should be promoted remains unclear. Last, case management services may represent a crucial and necessary form of support for clients in supported housing programs.     

Mental health services for homeless: patient profile and factors associated with suicide and homicide

This study aimed to establish a profile of users of the mental health service for homeless in Cork, comparing this group with those attending a General Adult Service. The homeless group were significantly more likely to be male (89% v. 46%o), unemployed (96% v. 68%), unmarried (98% v. 75%) and under 65 (94% v. 83%). Diagnostically, there was a significantly higher prevalence of schizophrenia (50% v. 34%); personality disorder (37% v. 11%) and substance dependence (74% v. 19%) in the homeless service users. They were more likely to have a history of deliberate self harm (54% v. 21%) and violence (48% v. 10%). Severe mental illness has a high prevalence in the homeless population, with particularly high levels of factors associated with suicide and homicide. Poor compliance and complexity of illness lead to a requirement for significant input from multidisciplinary mental health teams members.     

The prevalence and determinants of antepartum mental health problems among women in the USA: a nationally representative population-based study

Mental health problems disproportionately affect women, particularly during childbearing years. We sought to estimate the prevalence of antepartum mental health problems and determine potential risk factors in a representative USA population. We examined data on 3,051 pregnant women from 11 panels of the 1996–2006 Medical Expenditure Panel Survey. Poor antepartum mental health was defined by self report of mental health conditions or symptoms or a mental health rating of “fair” or “poor.” Multivariate regression analyses modeled the odds of poor antepartum mental health; 7.8% of women reported poor antepartum mental health. A history of mental health problems increased the odds of poor antepartum mental health by a factor of 8.45 (95% CI, 6.01–11.88). Multivariate analyses were stratified by history of mental health problems. Significant factors among both groups included never being married and self-reported fair/poor health status. This study identifies key risk factors associated with antepartum mental health problems in a nationally representative sample of pregnant women. Women with low social support, in poor health, or with a history of poor mental health are at an increased risk of having antepartum mental health problems. Understanding these risk factors is critical to improve the long-term health of women and their children.     

Escaping homelessness: anticipated and perceived facilitators

One study with two distinct sections was conducted to identify factors facilitating escape from homelessness. In Section 1, 58 homeless individuals rated possible facilitators of escape (factors they believed would help them become more independent and self‐sufficient). In Section 2, 80 participants who had already exited homelessness rated the same facilitators (factors that would have helped them become more independent and self‐sufficient) and the importance of actual factors that facilitated escape. When rating factors in the hypothetical, both groups rated obtaining housing as being particularly important for facilitating movement toward independence. People formerly homeless who reported perceived facilitators of escape, however, also reported that their escape was facilitated by realization of their own abilities and potential to offer something to the world. The findings have implications for the design of community interventions helping individuals who are homeless. © 2009 Wiley Periodicals, Inc.     

Public exposure and attitudes about homelessness

In this study, we conducted a survey among a large sample of U.S. adults to assess attitudes and beliefs about the causes of homelessness, policies to address homelessness, and programs for homeless individuals. In 2016, we surveyed a national sample of 541 adults from 47 different U.S. states using Amazon Mechanical Turk. Of the total sample, 78% reported that homelessness was a problem in their communities and 60% believed homelessness would increase in the next 5 years. The majority expressed compassion for homeless individuals and endorsed structural, intrinsic, and health factors as causes of homelessness. Most participants (73%–88%) believed the federal government should dedicate more funds and policies for homeless individuals. These attitudes were substantially more likely to be reported by participants who were female, lower income, Democrat, and personally exposed to homelessness. Most Americans care about homelessness as a major problem but there are divergent perspectives on solutions to address homelessness based on gender, income level, and political affiliation.     

CHILDHOOD MENTAL HEALTH: AN ECOLOGICAL ANALYSIS OF THE EFFECTS OF NEIGHBORHOOD CHARACTERISTICS

Research on childhood mental illness traditionally examines risk factors most proximal to the child. However, current trends reflect growing interest in how broader contextual factors contribute to psychopathology risk. In this study, we examined neighborhood‐level indicators as potential sources of chronic strain in a sample of 156 mother–child dyads; children were 8 to 12 years old. For most neighborhood indicators, data were collected at the level of census tracts using publicly available data sets. We hypothesized that these indicators would be both associated with greater overall mental health symptoms and specifically predictive of childhood symptoms of depression. We also examined potential mediators (maternal functioning and family cohesion) and moderators (maternal depression). Neighborhood indicators correlated with parents’ ratings of children's overall mental health problems, but did not correlate with children's self‐report of depression symptoms. Maternal functioning mediated neighborhood effects on children's overall mental health problems. Implications and directions for future research are presented.     

How do homeless adults change their lives after completing an intensive job‐skills program? A prospective study

Among people experiencing homelessness, difficulty securing housing is often compounded by concurrent challenges including unemployment, chronic illness, criminal justice involvement, and victimization. The Moving Ahead Program (MAP) is a vocational rehabilitation program that seeks to help adults facing these challenges secure competitive employment. We prospectively studied how MAP graduates (N = 97) changed from the beginning of MAP to about 6 months after graduation. We observed a variety of positive outcomes in not just employment and housing but also health, substance use, and criminal justice involvement. However, these gains were not universal; for instance, participants were less likely to report positive outcomes at follow‐up if they started MAP with a serious mental illness, made relatively small gains in work skills, or did not seek mental health treatment during the 6 months after they completed MAP. These findings might encourage program staff to devote additional resources toward supporting at‐risk students.     

UNDERSTANDING THE ATTAINMENT OF STABLE HOUSING: A SEVEN‐YEAR LONGITUDINAL ANALYSIS OF HOMELESS ADOLESCENTS

Stable housing provides a solid foundation for youth development, making it an essential topic of study among young homeless people. Although gains have been made in research with adolescents and young adults experiencing homelessness, few longitudinal studies of this population exist, clouding the long‐term housing outcome picture. The current study examined the course and risk factors for homelessness in a sample of 243 homeless adolescents followed over a 7‐year period. The vast majority of youth returned to stable housing quickly; however, early experiences of homelessness, even at this young age, were observed to have a substantial negative effect on future housing. Participants from poorer neighborhoods and those identifying as ethnic minorities also took longer to achieve stable housing. The data suggest that family reunification interventions may serve this population well. Preparing youth for returning home may not only prevent subsequent homeless episodes but also improve their overall functioning.     

Mental health change in the transition to permanent supportive housing: The role of housing and social networks

Aims: Permanent Supportive Housing (PSH) may improve homeless adults’ mental health via housing stabilization and/or improved relational factors, however, the role of housing and social networks on PSH residents' mental health change is minimally understood. Methods: Interviews were conducted with a baseline sample of adults experiencing homelessness ( N = 421), across their initial year in PSH (3‐months, 6‐months, and 12‐months). Generalized linear mixed models assessed changes in positive past‐month psychiatric disability screenings (Modified‐Colorado Symptom Index [MCSI]) and probable posttraumatic stress disorder (PC‐PTSD) in controlled models, and between and within‐subject effects of time‐varying social network correlates on mental health changes. Results: Compared with baseline, positive MCSI screens continuously decreased over time (56%, 54%, and 50%) while PC‐PTSD screens declined initially (40%) with marginal decreases at remaining follow‐ups (39% and 38%). These differences remained significant in controlled models. Gaining a romantic partner was associated with a longitudinal increase in a positive MCSI screening. Between subjects, emotional health counselors and conflicting network members were associated with an increased likelihood in positive screenings, while doctors and case managers were protective. Conclusion: Housing may facilitate positive changes in PSH residents' mental health, yet positive screenings remain high. Social network interventions that increase residents’ positive interpersonal exchanges and prosocial relationships are warranted.     

SELF‐CONTROL AND ADOLESCENT INTERNALIZING AND EXTERNALIZING PROBLEMS: NEIGHBORHOOD‐BASED DIFFERENCES

Self‐control may act as a protective factor against the development of internalizing and externalizing problems among adolescents. However, little research has examined how self‐control functions within and across different types of communities. Using two cohorts from the Project on Human Development in Chicago Neighborhoods (N = 1,072; 51.40% female), we examined how self‐control and neighborhood characteristics were independently and jointly associated with these behaviors. Using latent profile analysis, we categorized neighborhoods based on several characteristics known to be associated with youth outcomes, including violence, concentrated disadvantage, and collective efficacy. Then we examined how self‐control was associated with youth internalizing and externalizing problems within and across neighborhoods. Results suggest that self‐control was a protective feature in only some types of disadvantaged and dangerous neighborhoods. We discuss findings in terms of implications for programs and policies to support youth mental health.     

Could worry and rumination mediate relationships between self‐compassion and psychological distress in breast cancer survivors?

Many breast cancer (BCa) patients experience clinically significant anxiety and depression in survivorship. Self‐compassion offers a bulwark to anxiety and depression in nonclinical, mental health, and some chronic physical health populations. We examined whether self‐compassion predicted lower anxiety and depression symptoms in survivors and whether this might be mediated by lower worry and rumination. The design was a cross‐sectional survey using self‐report measures. Female adult BCa survivors of mixed stages who had finished primary surgical, radiotherapy, or chemotherapy treatments completed self‐compassion subscales and worry, rumination, and anxiety and depression scales. Higher self‐compassion subscale scores were negatively associated with anxiety and depression. Depressive brooding and worry mediated any effects of self‐kindness and mindfulness on depression and anxiety, whereas common humanity directly predicted lower depression scores. Findings are consistent with the view that self‐compassion reduces threat‐related rumination and worry in BCa survivors, consequently reducing anxiety and depression. This may form a basis for prevention and treatment.