R.I. tracking and treating its chronically homeless

The numbers of homeless people in Rhode Island did what everyone hoped when volunteers fanned out across the state one night in January 2014 to count how many people were living in shelters and on the street. They went down.

What the U.S. Department of Housing and Urban Development called its annual “point in time” estimate counted 1,190 homeless people, 20 of whom were unsheltered. That represented a 14 percent drop over 2013 when 1,190 homeless people were counted with 117 unsheltered and an overall decrease of 13.3 percent since 2007.

But the numbers can get complicated. The Rhode Island Coalition for the Homeless Management Information System tracks the total number of individuals who use an emergency shelter or transitional housing program shelter system each year. Its data show homelessness increasing until 2013 when the shelter system was used by 4,447 people, an 8.6 percent decrease from 4,868 people in 2012.

Things get even more complicated when it comes to tracking the numbers of mentally ill homeless people in the state. The Homeless Management Information System identified 1,332 people with a disabling condition who used an emergency shelter bed for at least one night in 2013. Of those, 533 individuals, or 22.3 percent, said they had a mental health condition.

Eric Hirsch, Ph.D., a Providence College sociology professor who oversees the data collection, says the screening process changed in 2003 when the system switched to an electronic database. Previously, shelter system users were asked whether they had mental health issues. The change meant screeners first asked clients if they had a disability. If they said yes, then they were asked what type.

“From that date forward, the percentages of homeless people experiencing mental health issues appeared to decline because we asked first if people had a disability,” Hirsch explains. “So now we’re getting only people who define themselves as disabled due to a mental health issue.”

Even so, Hirsch believes the percentage of mentally ill homeless people in Rhode Island is very stable year to year. “But of course that means the number has declined as the total number of homeless people has declined,” he says.

Clinicians who work with the homeless may find very complicated territory too. Aurit Lazerus, Psy.D., a Providence-based clinical psychologist who conducts disability evaluations for the U.S. Social Security Administration and has evaluated individuals who are homeless and formerly homeless, has found that many have histories of disorganized attachment as well as abuse or trauma, all risk factors for substance abuse problems.

“PTSD and other trauma work often involves people learning how to create pockets of safety in their life,” Lazerus says. “When someone is homeless, this type of treatment may not be appropriate because they are often getting re-traumatized over and over again on streets, in shelters, or staying with people they know for a few days at a time. In other words, the threat is real and they cannot feel safe. And teaching them to let their guards down can be really dangerous.”

Engaging the chronically homeless – defined by the federal government as those who have a disabling condition and who have been homeless for one consecutive year or for four episodes over three years and have a disability – is challenging. ACCESS-RI, a program of the Mental Health Association of Rhode Island, attempts assertive outreach to coax people off the streets and provide them with what’s been called “low demand” services that ease requirements and conditions upon which they can be received. The ACCESS-RI staff team includes a psychiatrist, case managers and outreach workers offering blankets, food, toothbrushes, clothing, and other basic need items, a clinical supervisor, and the program director.

“We really do our best to be person-centered and meet people where they are in their journey to housing and recovery and wellness,” says Jessica Mowry, LICSW, the association’s senior director of program services. “Sometimes folks are engaged quickly and they will come in and shower and we’ll get them to eat and participate in developing their goal plans really quickly and then other times they’re more distrusting of service providers and reluctant to engage so it takes us a little while.”

The Providence Center’s Home Base program has secured permanent supportive housing for 140 single adults diagnosed with a co-occurring mental health and substance use disorder since it was launched in 2011 with $1.5 million in funding over three years from the federal Substance Abuse and Mental Health Services Administration (SAMHSA). Median age was 49 with 71 percent male and 29 percent female, said Vickie Walters, the Providence Center’s associate director of housing, residentials and Home Base.

Home Base followed the “housing first” model which declares a homeless person’s primary need as obtaining stable housing before other issues can be addressed. Affordable rental housing is combined with supportive services such as case management, health care, substance use services and employment on a voluntary basis in contrast to programs that mandated participation in psychiatric treatment or sobriety in exchange for housing. The National Alliance to End Homelessness calls the housing first approach the most successful model for housing people with a history of chronic homelessness.

Research has found that housing first programs lead to higher rates of housing retention, even among those with the most severe psychiatric disorders. A 2007 HUD study found participants who entered a housing first program from shelters, jail or a psychiatric hospital, crisis houses or living with friends were far more likely to stay in housing after a year than those who entered from the streets.

The Providence Center recorded an 87 percent retention rate after two years of clients still housed compared to the typical rate of 80 percent, Walters says.

“They’re not very trusting of individuals. They’ve had their pockets picked many times, things stolen from them. It’s important to build their trust before you really try to have them engaged in services,” Walters says.

“When you provide them housing first, they have a place to lay their head, they can sleep, they can get rest, they have a place to put their medication so they’re not stolen from them so they can actually take medication on a regular basis,” she adds.