When you’re in and out of psychiatric wards, said Gayle Scarbrough, it’s hard to maintain a place to live. Suffering from schizoaffective disorder and a drug addiction that only made her hallucinations more terrifying, Ms. Scarbrough slept in parks, under bridges, in shelters, anywhere she could. “My family’s kind of messed up, so they couldn’t provide any support,” she explained. “As for friends, a person can only take so much when I’m having mental issues and drug problems. I didn’t really have anywhere to go.”

Then Ms. Scarbrough heard about an innovative program called Project Coming Home at Contra Costa County Health Services in nearby Martinez, CA.

Project Coming Home is 1 of 11 sites (see Initiative Grantees below) across the Nation participating in a unique collaboration among the U.S. Department of Health and Human Services (HHS)—with participation by SAMHSA and the Health Resources and Services Administration (HRSA)—the U.S. Department of Housing and Urban Development (HUD), and the U.S. Department of Veterans Affairs (VA). Launched in 2003, the 3-year Collaborative Initiative To Help End Chronic Homelessness is designed to bring a comprehensive approach to bear on the problem. (See SAMHSA News, Volume XI, Number 1.)

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Each Federal agency is tackling a different piece of the puzzle. Within HHS, SAMHSA is funding substance abuse treatment, mental health care, and related supportive services, and HRSA is funding primary health care services. HUD is funding permanent housing. The VA is offering medical services to homeless veterans. The U.S. Interagency Council on Homelessness, which coordinates the Federal Government’s response to homelessness, is helping to coordinate the $55 million effort.

“With this project, SAMHSA and its partners are providing a model at the Federal level of the kind of collaborative relationship we encourage at the local level,” said SAMHSA Chief of Staff Gail P. Hutchings, M.P.A. “Working together to help homeless people overcome their multiple problems is the only way to help these individuals move off the streets, into housing, and back into productive lives.”

Today, the 28-year-old Ms. Scarbrough is living in a subsidized one-bedroom duplex that the program’s staff found for her. She’s receiving mental health services. (She has been off drugs for 4 years now.) A caseworker calls and visits frequently to see if she needs food, make sure she’s taking her medicine, and help her tackle the new challenges of running a household.

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A Complex Problem

According to a series of fact sheets available from SAMHSA’s National Resource and Training Center on Homelessness and Mental Illness (see Federal Resources on Homelessness article), as many as 2 to 3 million Americans experience homelessness at some point each year. Most homelessness is short term. However, about 10 percent of these individuals experience chronic, long-term homelessness.

Lacking a home isn’t the only problem. An estimated 20 to 25 percent of homeless people have a serious mental illness, and up to half of those with a serious mental illness also have alcohol and/or drug problems. These problems often go untreated.

Navigating the multiple systems offering services to homeless people can be difficult even for those who don’t have a major disability like serious mental illness, said Project Officer Lawrence D. Rickards, Ph.D., Acting Chief of the Homeless Programs Branch of the Division of Service and Systems Improvement at SAMHSA’s Center for Mental Health Services.

Some chronically homeless people with mental illnesses initially may not even want treatment. Their priorities are often more concrete—housing, food, health care. “Many of these individuals are distrustful of a system that hasn’t treated them well in the past,” explained Dr. Rickards. “They may have gone through institutional treatment and been treated poorly, for example. Or they may have been treated with some of the older drug regimens that had many negative side effects or just weren’t effective. And often their substance abuse issues were not addressed at all.”

Substance abuse also plays a major role in chronic homelessness, said Project Officer Richard E. Lopez, M.A., Ph.D., J.D., a social science analyst in the Co-Occurring and Homeless Activities Branch of the Division of State and Community Assistance in SAMHSA’s Center for Substance Abuse Treatment. “When you’re on drugs, just about all your focus is on finding drugs and getting high,” said Dr. Lopez. “You start losing focus about what it takes to keep an apartment or house of your own.”

According to Dr. Rickards, substance abusers may also have cognitive problems as a result of their drug use and they can be difficult roommates, neighbors, or tenants. Family members, friends, and other potential sources of support often become alienated.

Many chronically homeless individuals also have physical disabilities like tuberculosis, heart disease, diabetes, or HIV. Treating such diseases in homeless populations can be especially challenging, said Dr. Rickards. These patients can have a hard time refrigerating medications, for example, or remembering to take them at the right time of day.

As a result of all these untreated conditions, as well as a range of systems barriers, chronically homeless people often land in hospital emergency departments, acute behavioral health facilities, or jails. Because services in these settings are costly, chronically homeless people consume more than half of the resources devoted to the homeless population as a whole.

To tackle this complex interplay of problems, grantees of the Collaborative Initiative To Help End Chronic Homelessness pull together community resources to address comprehensively the housing, mental health, substance abuse, and primary health care needs of the chronically homeless people they serve.

Although each of the 11 grantees takes a slightly different approach, all share a philosophy of housing people as quickly as possible, a goal of making it easy for individuals to get all the services they need, and a strategy of aggressive outreach.

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See Also—Article Continued: Part 2 »

See Also—Related Content:

Federal Resources on Homelessness »

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