«DiscoVeriNg HomelessNess Volume 13, Number 1 • 2011 U.S. Department of Housing and Urban Development | Office of Policy Development and Research ...»
State budget cuts have affected services at both respite care and detoxification centers and have reduced options for referrals from respite care and detoxification programs. Long waits for longer term services and housing have made referrals from respite care and detoxification programs more challenging, and they are discouraging for consumers. One former street dweller explained that a sense of hopelessness contributed to his returning to the streets after his health status had improved at respite care.
It’s easier [to go back to the streets]; it’s because of low self esteem; it’s because you feel like it’s never going to get better. People feel hopeless and helpless. Sometimes you feel like, ‘what’s the difference.’ It’s not a big deal, you know. ‘I am not going to get any help; I am not going to get any housing.’ That’s when you end up not doing anything. (former street dweller) Consequently, CoC, either in the treatment system or the system of care available after respite care fell apart with detrimental effects for homeless street dwellers.
As respite care and detoxification providers indicated, many programs do not accept homeless individuals, which further limits the number of available referral options. Barriers to access include past criminal records and medical needs that program professionals feel ill equipped to manage.
In addition, the types of programs available for homeless street dwellers often do not address their service needs, such as providing medication and supportive services, or do not admit individuals who have been homeless for long periods of time.
Another barrier to leaving the streets is the lengthy housing application process, including the long waits until a housing placement becomes available. Successful housing placements most often occurred among those interviewed when consumers stayed at the respite care program for extended periods of time and were then able to move directly to housing. Both respite care provider interviews and the quantitative analyses supported this contention. Providers stated that housing placements were most successful when exceptions were made regarding length of stay at respite care and individuals were allowed to stay much longer.
I ended up in [respite care]; I was there for 14 months…. From [respite care] I went straight to … housing. They got my name in when I was at [respite care]. It took them about a year before I got housing. (current street dweller) There are some special circumstances with patients that we give one-on-one attention that do actually go from here into housing. (service provider) One avenue to achieve housing for the high-risk cohort is to connect those eligible with Massachusetts DMH or DMR housing services, thereby presenting an alternative to the long waits imposed by applying for Section 8 housing vouchers, which are available to all low-income individuals. The recent addition of three psychiatric outreach workers to the BHCHP street outreach team raised hopes for better access to the various DMH housing programs, such as DMH shelters, Safe Haven and Housing First projects, and more traditional DMH housing options.
Detoxification programs successfully referred a few high-risk street dwellers to long-term treatment. Most of those who were sober at the time of the interviews reported having stopped abusing substances on their own, without going through detoxification and substance abuse treatment programs. For the most part, they attributed attaining sobriety to having reached a point of experiencing severe medical problems and facing the possibility of death.
From most interviews, it was apparent that the linear service model ingrained in most CoCs, including the CoC model for homelessness, does not work for many. Of the former street dwellers now in housing, only one individual went from short-term to long-term treatment to housing. Some former street dwellers explicitly stated that the stepwise CoC model would not have worked for them.
There [at the shelters] they want you to go to a program before you get housing. That would have not worked for me. (former street dweller) Those providers who were more critical of the current service system also shared their concerns that the system is too inflexible and has inadequate options. In addition, previous negative experience in shelters, hospitals, and other programs can function as a barrier to service use and the accompanying linkages to housing. Both providers and consumers cited many instances in which homeless individuals were treated disrespectfully when accessing mainstream services, or, even worse, were denied care.
Although the service system poses great challenges for placing homeless street dwellers in housing, many respite and detoxification providers attributed psychosocial factors, and not solely program factors, as causes of street dwellers remaining on the streets. Respite care providers cited untreated mental illness and substance abuse as factors, as well as the inability to take on the responsibilities that come with housing placements. Other providers spoke of fear of the unknown and not wanting to leave friends on the streets as major barriers to successful housing outcomes.
Consumers had a different view. When prompted for reasons that people cycle between respite
care and the streets, one consumer said the following:
But it’s a mess, it’s confusing. … I want a home. I just need to get going. I don’t know what am I going to do. … I need to be walked through the whole process. I am thinking someone needs to listen to me; but no one really is paying attention to where I am going next, and that’s why I am back on the streets. (current street dweller) Providers also presented the lack of housing skills as a barrier. Skills that were important for survival on the street were considered maladaptive for indoor living.
I think that for some people living inside is too difficult to manage because they don’t have the skills to do it, like if they get any income and can’t manage the income on their own, or being inside and not losing connections with the outside world.
So that they just isolate themselves and can’t figure out how to go grocery shopping, or get a phone, and actually connect with people outside. So I think that there are a bunch of skills that need to be in place for somebody to stay in. (service provider) Consequently, preparation for placing street dwellers in housing needs to include relearning the skills necessary to successfully make the transition to and retain housing.
Some were able to use the long waiting period at respite to get accustomed to indoor living.
Current and former high-risk street dwellers disagreed that training and developing more skills would be useful. Although consumers acknowledged the need for continuous support during their transition to housing and during their initial period in housing, they did not support the need for long-term training to relearn housing skills.
Many street dwellers also stressed the importance of sufficient time to successfully make the transition from the streets to housing.
It’s a slow process. You can’t expect immediate results, which is what people want to see. You can’t transform a homeless person into this clean sober person, that doesn’t work. It takes time. Homeless people don’t trust people. It takes a long time for homeless people to start to trust people. (former street dweller) Depending on the nature of consumer-provider relationships, respondents thought these interactions could serve both as facilitators and barriers to continued service use and housing. As presented earlier, trusting relationships can be major facilitators of successful service delivery and can promote movement off the streets. On the other hand, both consumers and providers talked about staff who were not responsive to their clients’ needs, thereby hindering the process of helping individuals to move off the streets.
What strikes me dealing with the homeless population is how powerless they are in the system. How the system is not responding to any of their needs. … But when push comes to shove, I think the homeless are being kicked to the curb. And our services are lacking, there is a general sense from the people who come in here and talk about … [that] … There are very few [services they trust] in the system overall.
Consequently, that makes our job much more difficult to lead them onto further treatment, hook them up with services. (service provider) The impetus for contemplating moving off the streets most often was sickness and the possibility of death.
I got tired of it. Tired of being out there drunk, punched up, sick. And because of my liver problems. (former street dweller) Those people who have had so much suffering come to a point where they realize that they cannot take it anymore, and they are more ready to get into treatment programs. (service provider) At such low points, life on the streets was no longer an option, and long-term treatment became a necessity. Supportive, continuous relationships with service providers and the willingness of programs to keep individuals for longer periods of time is what enabled street dwellers to successfully make the transition into housing.
Implications for Changes in the Homeless Service System Interview respondents shared a variety of suggestions for improving homeless services and for housing chronically homeless street dwellers. These suggestions ranged from structural changes geared toward increasing the affordable housing stock to addressing more interpersonal issues, such as educating service staff and the larger public about homelessness. Current and former highrisk individuals focused on the need for affordable housing and more client-centered services, but providers spoke more of the need to create service programs tailored to the high-risk cohort.
As discussed previously, street-based service delivery is successful in engaging high-risk street dwellers and attending to their short-term needs, such as food, clothing, and medical care. Building on this successful model of engaging difficult-to-reach street dwellers in services, services should take on a more active role in addressing the housing needs of the street population. In
addition, the inclusion of housing assistance at detoxification programs and expansion of housing services at respite care may help limit repeated cycles between these services and the streets. Of course, adding a credible housing focus to these programs hinges on the production of affordable housing for street dwelling individuals and a commitment of resources toward this end.
The need for a variety of program and housing options for street dwellers became evident in the interviews. The linear CoC model in homeless, medical, and substance abuse services has not worked for the high-risk street population, and many providers discussed the need for more flexible programs addressing specific needs of street dwellers. As the linear CoC is ingrained into the current service provision models, however, most providers thought of it as the only model of change; very few spoke of the necessity of changing this service approach.
There are halfway houses, and those are wonderful things. They can be a great place for skill building. Folks who make it through an entire detox, who make it through a 28-day program or even 90 days, make it to the halfway house. All the challenges they are presented with, by the time they finish that halfway house, they may at that point be able to make enough money to be able to afford a room. (service provider) The belief that substance abusers cannot succeed, and thus should not attain housing, was widespread among service providers.
Contrary to the views of respite care providers and detoxification staff, street outreach providers thought that all high-risk cohort members would be ready for housing. Most street outreach team members thought of the high-risk street cohort as being ready to be housed, along with sufficient support and housing that matches their needs, backing a Housing First approach. Respite care providers, for the most part, noted that by adapting to years on the streets, chronically homeless individuals lack the ability to live indoors and follow rules. As such, these individuals would need to relearn daily living skills in addition to attending to substance abuse and psychiatric problems before moving into housing. According to respite care providers and detoxification staff, this skill development can be achieved only in long-term treatment programs. Consequently, changing to a Housing First approach would require focusing on staff education and garnering support for such an approach.
The need for continuous service support after moving to housing was documented in the many stories of former street dwellers’ failures to maintain housing and by those individuals who made the transition successfully. Some members of the street outreach team took on responsibilities beyond providing medical care, such as regularly checking in with former street dwellers and helping them with basic chores in their new home. Support services during the transition to and throughout housing, if necessary, should be developed to increase the chances of high-risk homeless street dwellers finding success in housing.
Another suggestion derived from the interviews was to provide more education on the issues of homelessness for staff in both homeless and mainstream programs. A better understanding by staff of the issues that homeless individuals face would contribute to alleviating some of the often negative service experiences that hinder street dwellers’ future engagement in care. In addition, clients’ input into their own treatment and service plans can support passage to more independent living.
For example, this former street dweller describes empowerment of homeless people and unconditional support by staff as key elements to a successful transition from the streets to housing.