Homelessness–Questions and Answers

By Lance Chilton

If you read last week’s column on health and those experiencing homelessness, the following questions will be easy for you; if not, the answers will probably not be surprising:

  1. Which of the following is associated with being homeless:
    1. Increased physical illness
    2. More behavioral health problems
    3. More substance use disorders
    4. None of the above
    5. All of the above
  2. Which condition leads to which?
    1. Homelessness leads to increased illness
    2. Illness leads to increased homelessness
    3. Both of the above
    4. Neither of the above

If you answered “all” and “both,” you win.

People who are suffering homelessness rarely win. Speaking with a psychiatric nurse who has long worked with and volunteered to work with people experiencing homelessness (she declined to allow me to use her name), I learned a bit about behavioral health disorders that are very common in that population.

My informant noted the high prevalence of a history of trauma among the people experiencing homelessness that she serves. Many, she said, have had traumatic brain injuries, and many have suffered other forms of trauma throughout their lives. As has been made clear through not-entirely-sympathetic articles in the Albuquerque Journal about Coronado Park, physical, sexual, and emotional violence in a concentrated population of those who are homeless is very common. My informant wanted to be sure that we did not artificially separate substance use disorders from other behavioral health problems. “Substance use disorders are very much behavioral health problems; they may be more difficult to treat than schizophrenia.”

We may think of PTSD – post-traumatic stress disorder – as being related to wartime trauma, but other forms of trauma, such as those faced by a homeless population nearly every day, are equally likely to cause PTSD symptoms. Bipolar disorder, schizophrenia, anxiety disorders, personality disorders and substance use disorders are also much more common than among the general population. People who are homeless have even more difficulty accessing behavioral health care than other New Mexicans (remember ex-governor Susana Martinez’s destruction of our mental health system?), so illnesses worsen despite the best efforts of people like my interviewee.

She also feels that our overworked behavioral health system is full of people who do not fully understand or have empathy for their patients who lack permanent homes. Case managers often are unschooled in all that can or must be done to help their unfortunate clients. On their side, people experiencing homelessness often mistrust authority figures like health care practitioners, government agencies, and mental health providers, based both on previous negative experiences and also on shame and stigma surrounding their behavioral health disorders, their possible involvement in illegal activity, and the shunning common among the housed public.

My informant volunteers with a program through the federal SAMHSA (Substance Abuse and Mental Health Services Administration) called SOAR (SSI/SSDI, Outreach, Access, Recovery, where SSI stands for Supplemental Security Income and SSDI for Social Security Disability Insurance), which helps people experiencing homelessness apply for benefits and achieve stability and recovery.

All of those I interviewed for these articles would agree that having a steady income and having stable housing are necessary but not sufficient. They looked with a wary but positive eye at the many innovations brought forward in Albuquerque by the Keller administration, including the Gateway Center services and the teams from Albuquerque Community Safety. More can be done, perhaps on models already in place in such diverse locations as Tucson, Madison (WI), and Seattle.