♪ meet cathy, who's lived most verywhere, from zanzibar to barclay square. but patty's only seen the sight, a girl can see from brooklyn heights, what a crazy pair! ♪ cathy: oh my, patty. did you find all your files? patty: finally! who knew it would be this much work when richard and i decided to retire! cathy: well, what are you going to do first?

patty: we're heading down to brooklyn heights and start in on that social security paperwork. cathy: why would you do that? patty: what do you mean? cathy: it's so much easier to log onto socialsecurity.gov and file online. patty: what if i need to know how much money i'll be getting? cathy: online. patty: what if our address changes? cathy: online. patty: what if i want medicare too? cathy: online. patty: so, how did you get so darn smart anyway? cathy: online! ♪ when cousins are two of a kind! ♪ [music]

hello, i'm ivette torres, and welcome to another edition of the road to recovery. today we'll be talking about homelessness and substance use disorder treatment. joining us in our panel today are dr. h. westley clark, director, center for substance abuse treatment, substance abuse and mental health services administration, u.s. department of health and human services, rockville, maryland. richard cho, director of innovations and research, corporation for supportive housing, new haven, connecticut. robert kershaw, business owner and outreach worker, oxford house, incorporated, silver spring, maryland. dr. jesse b. milby, director, medical psychology, substance abuse and homeless research program, department of psychology, university of alabama at

birmingham, birmingham, alabama. dr. clark, when is a person categorized as homeless? well, the most important thing is to recognize that when a person lacks a permanent, fixed residence, they meet the category of homeless. now, there are a number of temporary arrangements that people have; for instance, it's estimated that roughly 1.6 million people are living in transitional or shelters, and they also meet the definition of homeless. so it's-we're looking for people who have permanent, fixed residence, and if you don't have that, then you're defined as homeless. and dr. milby, can you sort of take us through those categories a little bit? well, there're, there're lots of services that are provided for the homeless, from basic

emergency shelters that just provide overnight stay, and people have to leave after-usually serve breakfast and then have to leave after. there are shelters that are more permanent and give people a chance to find more permanent housing. there are shelters also for women with children, for example, so whole families can stay in a sheltered situation. so there are lots of different categories of services. and who are typically, richard, the people that are going into these and availing themselves of these services? well, i think it's important to understand that there's actually several categories of homeless persons. there's, on the one hand, people who are transitionally homeless, people who spend very short periods of time in one of the emergency systems and then who basically make it out on their own, as well as people who are chronically homeless, who spend many, many years or months in homeless shelters or on the streets.

and even among the chronically homeless, there are a number of people who spend primarily most of their time on the streets, as opposed to other people who spend a lot of time in homeless shelters. and then another category of people who cycle in and out of many different kinds of homeless services, as well as emergency services and institutions. and, robert, there are so many aspects to doing outreach to the homeless population. what are some of the approaches that one uses to really go out and identify these individuals? well, one of the approaches which we use is visit. we visit a lot of shelters. we visit a lot of shelters, we go to a lot of the rooms of recovery individuals, because you find a lot of individuals that are homeless that are seeking help. they tend to go there for that support. and that's where we find a lot of individuals in our outreach. dr. clark, one of the issues that was in our, our briefing packets was the, the whole notion that a great number of people that are homeless

have an addiction problem. talk to us a little bit about that, and tell us how the addiction then causes the homelessness. well, it's important to realize that the addiction can either be the cause of homelessness or it can result from homelessness. when you realize that, on a given night, over 700,000 individuals may be homeless, you understand that those individuals are often going through a great deal of stress. now, the stress may have been caused because the alcohol and drug use, you lose your family, you lose your job, you can't pay your rent or your mortgage, and as a result you find yourself out on the street. or if you are homeless due to the economy or due to some other reason, you resort to alcohol and drugs to self-medicate. from the perspective of the services needed by the individual, it's important for the provider to have a good understanding of both situations.

and which are the groups that are mostly affected, shall we say? are there, for example, a lot of the homeless population, are they veterans, were they veterans, for example, dr. milby? there's, there's survey data to suggest somewhere around 20 to 25% of homeless people are veterans. that's a lot of veterans. and the va has special services designed for homeless veterans, and they-and those services are expanding now. and some of these veterans, dr. clark, have families, so it really doesn't affect just the individual that is homeless, but how does it affect the entire family? well, i think for any homeless context, if the principal provider loses his or her ability to earn, whether the alcohol and drugs caused or the mental illness caused the homelessness, or whether the alcohol and drugs or the anxiety or

stress or depression was a result of being homeless, that affects the whole family. and that's a key construct. when we're dealing with veterans, we may be dealing with post-traumatic stress disorder, particularly those who have combat, and we need to recognize that that ptsd, in addition to the alcohol and drugs, also affects not only the individual but that individual's family. so, as a society, we have an obligation to our men and women who served to make sure that we're addressing the full range of issues associated with their homelessness, or their alcohol and drug use, or their post-traumatic stress disorder. and the family members who've supported the individual who served who may be affected by that sort of dislocation may need special services dealing with that. so when we're talking about services, we're talking about that full range of things. one of the, i think, fortunate things is the

amount of growth in the federal investment in programs that serve the homeless veterans. and of those, i think the most important development is the, the expansion of permanent supportive housing options for people who are veterans and who are homeless, and the veterans' affairs supportive housing program is one of, i think, the most promising models that have arisen in the past couple of years. very good. is that a recent initiative, or- it is something that actually has increased in recent years, and there many thousands of vouchers that are being provided, where the local vas are providing some of the clinical supports and are partnering with public housing authorities to provide their rental assistance. what we want to do is make sure that the safety net that is not met by the va is offered by non-va services. the va obviously has the lead. they have the resources. but sometimes there's an alienation that occurs between the va, as a government institution, and nongovernmental organizations, community

organizations, who can assist the va, because if the person's otherwise entitled to va benefits but is alienated from the va, one of the efforts is to help connect that person to va services. so community organizations, community coalitions can help function as, shall we say, expediters, moving the person from the non-va-recognized status to a va-recognized status, working with veterans' service organizations to engage that person, so if they're eligible for va benefits, they can capitalize off of that full range of benefits. richard, what other populations-are there youth or women affected by homelessness as well? absolutely, and with women in particular, there's both single women who are primarily using the set of homeless services that are tailored towards homeless single adults, as well as women with children. so many families are affected. and they face a number of challenges,

both encounters with the criminal justice system but also encounters with the child welfare system, and where their substance use often is a complicating factor with regard to their ability to keep custody of their children. so that is another, i think, challenge that needs to be met. and, you know, it's almost like a very 360 circle. the women are homeless, the children go into foster care, then the children, when they leave foster care, then become homeless themselves. is that the case that you've seen, robert? yes, that's been the case. and, and in our model, one of the things, one of the major focuses that we have are, are being able to provide housing for a, a individual, but not necessarily the family, and that's been one of our major hurdles. we're trying to work with that and create more houses for women with children in this area. robert, you yourself are, are-have experienced homelessness. you want to tell us a little bit and what got you there and what you're doing now?

yeah. well, being a, a veteran, i can certainly identify with a lot of the, the issues there and especially with some of the programs there. one of the things that got me to that point was my not being willing to accept the fact that i suffered from an addiction. and throughout the course of the, the years, it just became overwhelming, and of course the resulting consequences ended up with me being just that, homeless, with nowhere to go and no one to turn to. and it wasn't until i actually accepted the fact that i had a, a problem that i sought help. and one of the first places that i turned to was a social service agency, where they had a veteran administrator there. and they were attempting to get me into a long-term treatment program, which didn't materialize. in the meantime, i went to a social treatment agency, a 28-day program.

and that program lasted, for me, for 35 days. i actually stayed there so long, i thought that i really was teaching the program. (laughter) but what happened was just that the programs themselves are cyclic. the information just goes around. and eventually i was waiting to get to the long-term program, and through the benefit of contacts and networking, what presented itself was an opportunity to move into an oxford house, a decision which i chose, and which has changed my life dramatically, from the self-run, self-supported environment to the taking responsibility for my life and my recovery-it's unparalleled. it's unparalleled. and to that point that i'm now a business owner, and i actually work for the oxford organization. so i strongly, to anyone, would recommend that that would be one of the first opportunities to, first and foremost, seek help. seek help. well, when we come back, i want to start talking about that whole issue of seeking help.

how does one begin to identify, assess the populations, and then begin to get them into some type of stability in order to end their homelessness? we'll be right back. [music] it's important for us to realize that homelessness is a condition that is often related to substance use disorders or to serious mental illness. roughly 20 percent of individuals who are homeless have a serious mental illness and almost two thirds of the individuals who are homeless have a substance use disorder so it's important for us to keep that in mind. what supportive housing would do is to provide services in a

context to allow a person to remain clean and sober or to pursue being clean and sober and as a result of that we facilitate not only housing itself but also recovery from substance use. the hearth act is very, very helpful insofar as it has broadened the definition of homelessness substantially. in broadening the definition it includes populations who are at risk of being homeless, who may not be currently homeless in the actual moment. so, for example, someone who will not have a secure place to live within 14 days of being discharged from a hospital or an institution of any type or incarceration, would be eligible for resources through the housing and urban development department, through the continuum of care program.

also the broadening of the definition to include families and children is very, very important insofar as families and children are at greater risk of having homelessness be a problem and of having other disabilities along the way such as mental illness and substance abuse problems and other co-occurring issues. so if we can capture and take care of and house those persons who are families with children early on, we're going to be in a better position to reduce the problem of chronic homelessness later on in their lives. when you have a drug or alcohol problem, your whole world stops making sense. you can get help for yourself or a loved one and make sense of life again. for information, treatment referral, and most importantly, help, call 1-800-662-help.

brought to you by the u.s. department of health and human services. what is the cost of drug and alcohol addiction? i lost my job. i lost my home. i lost my health. i lost my self-respect. i lost my freedom. if you have a drug or alcohol problem, remember treatment is effective and recovery is possible. for information on drug and alcohol treatment referral for you, or someone you know, call 1-800-662-help and see what you can save. i got my life back. [music] the path that my life has taken, it has allowed me to be able to parallel

experiences with people. being able to talk to the homeless individual, because i've been there. i've been homeless. i've slept on concrete. i've looked for any type of shelter that i could, just for a moment, just for an hour. so i can relate to that. i have been imprisoned, you know, so i can relate to the individual fresh out of jail and, and their struggles. i can relate to veterans because i am a vet. so when you have that camaraderie, it's the same as if you're in a foxhole together. you know, as a military guy, you know, they become not just the guy in another uniform, but it 'comes your family. that's your brother, because you got to look out for each other. it's the same thing in this path of recovery. i find that i'm better able to relate to people because we have that familial sense of, hey, i've been there, brother, i know what it's like. i empathize, not sympathize, with you. so i thoroughly understand what you're going through.

it's really aided me immeasurably. dr. milby, approximately 600,000 families, including 1.35 million children, are said to be homeless. what kind of dynamics happens when, when this occurs? well, this is the fastest-growing segment of the homeless population, actually, with women and children, and women and children have increased in the last several years' surveys we've had. and, you know, addiction plays a part sometimes, the economic situation plays a part, the breakup of a marriage or a family, and then women are left to negotiate and try to provide for children by themselves, and wind up being homeless and looking to community support for emergency housing and shelter and so forth. so it's a big problem. and it's, it's a challenge for service providers. and these are some of the issues, really, the underlying.

we were talking earlier about the youth population, and i know, dr. clark, you were mentioning some of the reasons why these youth become homeless, and you had a particular insight into that. well, there are a number of reasons. clearly, there are children who are runaways, children who are so-called throwaways, there are children who have value conflicts with their families, and then there's another population of youth that often gets ignored and that is kids who identify themselves as being gay/lesbian/bisexual/trans gender who find themselves at odds with their either family or their community, so they seek refuge in the street, trying to find support and understanding, and sometimes they become victims of predators who exploit their tragic situations for their own gain. and this is, richard, i think is particularly poignant, because the youth really

do get victimized. absolutely. and i think the kind of traumas that dr. clark was referring to with families also apply to young adults who are often on the streets. there isn't the same kind of safety net for a lot of those young adults, and so they tend to form peer support networks. but life on the streets is difficult, and i think they experience a lot of trauma, which often then also leads to substance use as a coping mechanism. robert, in terms of the oxford house, at this point does oxford house offer families an opportunity to come together, or is it mostly targeting a gender definition of male and female homes? yes, mostly they are targeting male or female homes. we do have a couple. there's not many. we want to get more. funding is always an issue in regards to women with children. we're actually also looking at the model of men with children, because there's a lot of men out there that have taken the responsibility for their children. and the oxford environment obviously offers a lot of

support, and the few homes that we do have, the individuals that are there with their children thrive. they thrive tremendously, because they do have that support, and they do have their family with them, so they're better able to concentrate on their recovery. dr. clark, what have we learned in our unit, our chab unit-and you might want to explain what chab stands for-in terms of treating homelessness? i think the issue is that samhsa has several approaches to addressing the full spectrum of homelessness. there's supportive housing, and then the chab unit, the co-occurring homeless branch, deals with grants to benefit homeless individuals. so, again, we try to meet the person where they are, rather than prescribing a single model. we're fond of saying, there are many pathways to

recovery, and, as richard pointed out, there are many different individuals with many different needs in the homeless population. so we use that diversity of programming, using nonprofit organizations in the community. so you offer services for veterans as a safety net. we offer services for people with hiv, young adults-or youth or young adults who are gay/lesbian/bisexual/trans gender, people who are in transitional situations, people who meet the older criteria with what was called chronic inebriates, people who are frequently intoxicated and go in and out of emergency rooms and unstable situations. so using our limited resources, what samhsa's trying to do is address facilitating programs, housing, but meeting the person who's homeless where they are. if you offer only one model, then you're going

to miss a lot of people, and we don't want to be in a situation where we say, if you don't belong to this group, we can ignore you. the homeless situation requires support. we also want to make it clear that we, we provide services at samhsa. we don't just do the housing. we have to work with hud, we have to work with administration of children and families, work with hrsa, work with the corporation for supportive housing and other nonprofit groups, so that we're dealing with the full spectrum. and working- so that would require a very extensive assessment of that individual. we definitely prefer a case-by-case assessment of the individual. so you want outreach workers addressing the unique needs-why is that person homeless? what are the circumstances? is it a sexual orientation issue, is it a family issue, is it an economic issue, is it a chronically mental illness issue? what's going on with that person, and do they have potential access to resources or no access to resources?

if you don't do it that way, then you operate on this one-size-fits-all, and that generally doesn't work. dr. milby, we've thrown around a lot of terminology. why don't we get you to explain to our audience what co-occurring condition is? well, co-occurring condition really means that someone has a substance use disorder and in addition has a additional mental disorder. and sometimes co-occurring disorder means that they have more than one additional co-occurring disorder- which are? -and they can be psychiatric diagnoses, is usually the way we conceptualize it. additional axis 1 disorders or personality disorders. and they can cover a whole range of things. very commonly, people have a major depression, for example, or dysthymia, and, very commonly, people who are homeless have experienced lots of trauma

and have post-traumatic stress disorder. people have other anxiety-mediated disorders. so the whole gamut is-even simple phobias. people have phobias, and they interfere with their functioning. so co-occurring disorders can cover from people who have active psychoses and difficulties with reality contact to people who have stress disorders, and everything in between. and from an integrated approach, we also like to remind people that some, many individuals who are homeless also have medical conditions that are untreated, and that becomes part of the co-occurring context. so- as well. as well. so hypertension, diabetes, if you're injection drug user, you may have abscesses that need to be treated. you mention hiv. we want to make sure that a person who is hiv-positive is hooked up with ryan white,

they can get on medication. the sooner you're on medication, the better off you are. but that does mean that, indeed, those services are available and that the caseworker or case manager is able to recognize that. so it's physical health, it's mental health, and it's substance use disorder, full spectrum. when we come back, we're going to continue to talk about, now, the treatment of homeless individuals with co-occurring conditions and with addiction problems. we'll be right back. it's important to be familiar with the proper terminology surrounding addiction and recovery.

one of the terms you want to be familiar with is, co-occurring disorder. co-occurring disorders are when an individual suffers from both a substance use and mental health disorder. such as an anxiety, depression, or other mood disorders. for more information on this and other recovery jargon, visit the recovery month website. mornings used to be the toughest. before i got treatment for my addiction, it was the little things that were hardest to bear. but now that i'm free of drugs and alcohol, it's the little things that give me the most joy. recovery. it gave me back my life. now i can give back. for drug and alcohol treatment referral for you, or someone you know, call 1-800-662-help. [music]

[music] community connections has been in existence, actually, for 25 years. it was started by maxine harris and helen bergman. community connections provides a range of services. we have our community support teams, and there at least five specialties within those teams-addictions and co-occurring disorders, criminal justice involvement and recovery from the criminal justice system, wellness and recovery, and recovery from violent victimization. we also provide a host of other services. we have a psychiatric clinic, we work with