Behavioral Health Services for People Who Are Homeless

Foreign. I'd like to welcome everybody to today's presentation on behavioral health services for people who are homeless. I AM your host, Dr. Donnelly Snipes. In this hour we have got a lot to cover, believe it or not. And this is just part one of two parts. And I want you to recognize and address homelessness as a, as a special dynamic that impacts your clients. Help prevent potential crises that result from becoming homeless. Provide preventative services for individuals and families who are service who are homeless. Be more aware of the effects of psychological trauma and co occurring disorders among people who are homeless. Provide integrative, effective services to people who are homeless. Understand and know how to utilize resources for homelessness in your community. And I'm actually have a few links that I'm going to walk you through to help get you to some very specific resources and influence the understanding of others in your community regarding the interrelationship of homelessness, substance use and mental illness. What does homelessness mean? I mean, you think homeless. Does that mean somebody who only lives on the street? Well, no, that's actually not it. Homelessness is a lot broader than that and it means an individual who lacks or is at risk of losing a fixed, regular and adequate nighttime residence. So this means we really want to focus on individuals who may be, you know, getting ready to get evicted. They may be behind in their, in their payments. They're not homeless yet, but technically they fall under this homelessness rubric. People have to have a nighttime residence that is stable of some sort. And if they're staying in a public shelter or an institution or a public or private place not designed for nor ordinarily used as a regular sleeping accommodation for human beings, they still qualify as homeless. So if they're staying in a homeless shelter, guess what, they're still homeless. If they're staying in a domestic violence shelter, guess what? Still qualify as homeless. We do want to recognize that homelessness is basically not having somewhere that is relatively permanent. In 2018, 552,830 or about 2% of the population were homeless in the United States. That's a lot of people who are homeless. 35% of those people were unsheltered. They couldn't get into some sort of, you know, homeless shelter or, you know, some sort of roof over their head in order to sleep. So they were sleeping literally on the street. To add to that, children comprised almost 111,000, 112,000 or 1 in 5, 20% of those people who were homeless on any single night. Let that sink in for a second, about 1/5 of the homeless population are children. 26.2% of all sheltered people. This includes just the sheltered people who were homeless had current severe mental illness, 34.7% had chronic substance use issues and 45% had any mental illness. Now this just accounts for the people who were sheltered. This does not account for any of the people who were not sheltered who were actually living on the street. Over 60% of people who are chronically homeless have experienced lifetime mental health problems and over 80% have experienced lifetime substance use issues. Now that doesn't mean they've used substances their whole lifetime. It means that at some point in their life they had a substance use issue or a substance abuse issue. You know, knowing all of these statistics is, isn't really important. I just wanted you to get a, an understanding of the scope of this problem. And for those of you who are in different countries, you know, your numbers are probably going to be a little bit different. This is obviously based on US numbers and in some areas the homeless population is significantly higher than in other areas. And California, Florida, New York, and I can't remember the fourth state, but there are four states that are tend to be much higher in with having a homeless population as opposed to places like North Dakota where it's probably not temperate most of the year. So homelessness is even more of a challenge. Be aware if you're in one of those states that tends to have relatively mild weather, you might have a s more significant portion proportion of the homeless population. And we need to be aware of those issues. We also need to be aware of the fact that the clients that we see, if they are mental health clients, if they are substance abuse clients, co occurring issues, they are at risk for becoming homeless. We know that there is an increased risk of a lot of things when people start to have mental health issues. So we do want to be sensitive to that when we're working with clients. Like I said, maybe when we're working with them, they currently have a house, but or a apartment, they have a roof over their head, but they haven't paid their rent or their mortgage in a month, two months, three months, they may be at risk of becoming homeless. And if they become homeless, that is just going to confound their whole clinical picture. People with substance use or mental disorders who are homeless are more likely to have immediate life threatening health conditions and to live in life threatening situations. Well, you know, let's think about where they live at. If you're talking about somebody with a substance abuse issue who's Addicted to some sort of injectable drug. You know, you have shooting galleries, which is where they live. A lot of times they're abandoned buildings where a lot of people congregate. You have people living on the street that is not safe a lot of times because they are much more vulnerable to attacks from antisocial people. They are much more vulnerable to illness. They are much more vulnerable to a variety of issues. Interestingly, it's important to remember that keeping things together while being homeless takes considerable skill and resourcefulness. Think about, you know, what you would do if you suddenly became homeless. Would you know how to get food? Would you know how to find some way to protect yourself from the elements, even if it wasn't a roof over your head? Would you know where the safe places were to go in your. In your city, in your town where you could, you know, potentially get some sleep? 20% of men and 33% of women who are chronically homeless and have substance use disorders also have ptsd. Now, which one came first? The article really didn't say. It is just something to be aware of that people who are homeless, especially if they have a substance use issue, probably or may also have post traumatic stress disorder. You know, 20%, 33%, you know, that's 1 5th or 1 3rd. That's not the majority, but that is a pretty big proportion. Prior to Covid, 78% of individuals were only a paycheck away from homelessness. They lived paycheck to paycheck, and if they missed a paycheck, if they were out of work for some reason, they guess what, they're not going to be able to meet their basic biological needs. They're not going to be able to pay their electricity, their phone, their housing, whatever the case may be. That was prior to Covid. Now think about with people being out of work for months, what that picture's probably going to look like in the ensuing weeks, months, or maybe even years. My unfortunate sense is that we are going to have a spike regardless of what country you're in. We are probably going to see a spike in homelessness because people were not able to maintain the income. Unfortunately, a lot of people design their budget around what they make. So if for some reason they aren't making that amount of money, they quickly get into arrears. Then there's also people who just don't make enough enough. They don't make a living wage. So they're always, you know, struggling to try to make ends meet and borrowing from Peter to pay. Paul, who's homeless well, there is no typical profile for people experiencing homelessness. You don't want to get something in your head that's stereotyped. Someone who has lost their job or experienced mortgage foreclosure or has been evicted along with their family members. So, you know, for whatever reason they got evicted. It could be they lost their job, it could be their. Somebody in their family got cancer, the medical bills piled up, and then they couldn't make their house payment. There are a lot of reasons that people can suddenly not be able to afford their mortgage and, or their rent payment and get evicted. We need to be sensitive to this instead of thinking, well, you know, this person just chose not to pay or they chose to leave or, or whatever. Most of the time it's not a choice. It is something that is an unfortunate consequence of a whole litany of events. Sometimes people who are homeless are loners. I don't like that word, but that's what the SAMSA tip used. Loners who sleep in the park in, in sleeping bags. There is a small proportion, not the majority, but there is a small proportion of people who don't want the hassle of taxes, they don't want the hassle of bills. They want to live a nomadic lifestyle. So that very small sliver of the homeless population may not really, you know, want to be engaged in in quite the same way. We also need to recognize some of the things that may cause somebody to be a loner. If they have schizoaffective disorder or, or some other issue, ptsd, they may not feel safe enclosed. And instead of assuming that's the first step, and I'm getting ahead of myself as I usually do, instead of assuming that getting them in shelter is a first step, we need to work with them and identify what is the first step. First step we can help them take to meet their biological needs. You know, being enclosed may not be it. Sometimes people who are homeless are those who've experienced domestic violence, sexual assault or other dangerous or life threatening conditions in a housing situation that they are leaving. They are, you know, they pack up their stuff and they're like, I deserve better than this. I need to get out for my own safety. This can be a child or an adult, a person in early recovery or recently released from jail without enough money to pay the rent or preparation. You know, there are a lot of other things that go into homelessness when we're looking at people in early recovery or just released from jail. A person with a severe and persistent mental illness who needs long term permanent supportive Housing thinking, people who have, you know, uncontrolled schizophrenia. And next week, we're going to talk about one of the unique issues with homelessness is the fact that a lot of psychotropic meds, especially your antipsychotics, your atypical antipsychotics, are very sensitive to hydration levels. And when people are homeless, guess what? A lot of times they get dehydrated. And so their medication, their blood. Blood levels of their medications may get a little bit wonky. When I worked in Florida, our CSU EV Crisis Stabilization Unit every summer would see a spike in admissions because people who were normally relatively stable on their medications would start becoming dehydrated, their medications would get out of balance, and then they would start having more prominent psychotic symptoms. And finally, a person who's kicked out of the family home, you know, maybe they didn't choose to leave, and maybe they weren't evicted. Maybe their parents or, you know, family, however that is defined, kicks them out and says, you know, until you can play by our rules, you can't live here. Any of those people may qualify as homeless. Veterans who are homeless report that three aspects of their service contributed to their homelessness. And this was kind of a surprise to me because I thought there would be other things on this list, but there weren't. Substance abuse, beginning in the military, 75% of veterans said that that was a contributing factor. Inadequate preparation for civilian employment, 68% said that was a precipitating factor. And loss of structure, again, 68% of people indicated that that was a problem. I have worked and been friends with and, you know, been related to lots of veterans. And one of the common issues I see is people who join the military when they are very young and they hear all these promises about how it's going to prepare them for a better future and give them skills and training that they can use when they get out. And a lot of times that doesn't end up happening. They don't. They develop skills, yes, they do, but they are not transferable. They are not something that is easily used or translated into the civilian world. So a lot of veterans end up leaving the military and being very disenchanted with what their options are. Some people, when they were in the military, thrived on the structure. And without having that kind of structure, they may have difficulty doing what they need to do to get along independently. Those are, you know, the three things that they identified. I could go on a whole diet tribe of other issues. But do be aware that if you're working With a veteran, you know, obviously substance use makes, puts them more at risk. But if they don't feel like they've been adequately prepared for civilian employment, we need to make sure to hook them up with job skills training with the local workforce development board in order to help them get connected. Loss of structure, that is something else we can work with people on to help them figure out how to implement structure. If they don't have somebody telling them what to do all the time, you know, how can they implement structure for themselves? And if, if they can't, if it's somebody who really needs an external source of structure, imposition, if you will, then we need to help connect them with resources that might be able to do that. They may need to be in some sort of transitional living arrangement. Criminal justice is another population near and dear to my heart. Worked with the criminal justice population quite a bit for the first, you know, 15 years of my career. People who have substance abuse or mental health issues prior to incarceration are at risk of homelessness when they get out. Well, you think, well, they're in jail, so. Or prison. So while they're in there, don't they sober up? Well, in an ideal world, yes they do. But sobering up doesn't mean finding recovery or being, being, being recovered. A lot of times they sober up and it's the first time they felt feelings in years and they don't know what to do with them. They don't have the skills to handle those feelings. So they are at high risk of relapse when they get out. Another thing that I see in a lot of jails and some prisons, I'm not as familiar with the prisons which are, are facilities that hold people for longer than 365 days, but a lot. One of the things that I see that just really drives me bananas is when people go into jail or prison and they are on some sort of psychotropic medication, whether it is an antidepressant, an antipsychotic or even methadone, you know, let's just put everything in there. A lot of times, as soon as they're admitted to that facility, they are taken off all of those medications because the jail or prison doesn't want to pay for it. And the response that I've gotten more times than not is if the person becomes a behavior issue, then we will give them their medication back. Okay? Just so many things wrong with that. However, we're talking about homelessness. So hypothetically, you have somebody who goes into jail and they were stable on their Meds or relatively stable on their meds. They go to jail for six months. All the meds are out of their system. They get discharged from jail and guess what? They are not probably in a place where we would consider them stable anymore in terms of their mood. They are at high risk of homelessness as well as, you know, potential self injury and, and other things because they haven't been on their meds. And we know that a lot of the mental health meds take four to six weeks to actually get in somebody's system. So they have this window of time from the period when they're released from prison or jail until the medication actually takes effect and they get stable again where they are at super high risk for development of other mood disorders, development of substance use, recidivism, you know, homelessness. The list goes on. So okay, that was my soapbox there. We do need to be aware and, and be more proactive at identifying things that might set people up for failure when they are leaving a quote, controlled setting. Up to 80% of people who are homeless have cognitive impairment. Now That's a lot. 20% don't, but up to 80% do. Fetal alcohol spectrum disorders. I do have videos on FASDs that are on the YouTube channel. You can watch. One of the trademarks or hallmarks of FASD is the person often can talk at a much higher level than they understand. So they may be able to Talk at a 20, the level of a 24 year old, but they may only understand at the level of an 8 year old. And people with FASDs often usually do not learn from consequences and they cannot anticipate what's coming up next. So a lot of times when you look at their rap sheet, for example, they will have committed the same petty misdemeanor over and over and over again. They don't get any better at it and they don't progress to higher things, which is, is good in a way. But people with FASD really do need a lot of structure. They also tend to be very much followers. They are very impressionable and can be manipulated very easily. You can see how this puts the somebody at high risk in a homeless type situation. Then you have people with intellectual disabilities, can be mild, can be moderate, people with traumatic brain injuries. And this encompasses veterans as well as everybody else out there who has had some sort of, you know, concussion, especially repetitive concussions or any sort of anything else that might have caused a traumatic brain injury that can cause cognitive impairment, dementia. Now we have dementia from aging. We have dementia that is associated with Parkinson's or Alzheimer's disease. And we have dementia that is associated with Weirnicki Korsakoff syndrome and that is caused by a thiamine deficiency. Now, people who are homeless often don't have the best nutrition and if, especially if they're drinking on top of it. But you know, even if they're not, if their nutrition's bad enough, the lack of thiamin can actually contribute to the development of something called Korsakoff syndrome, which the main symptoms are our dementia. We used to call it alcohol related dementia or a term I even despise is wet brain. But they found they've that the lack of thiamine is also present in people who've never drank, but who may have had bariatric surgery or who are anorexic. So they're starting to realize that Korsakoff syndrome is not just an alcohol related thing. It can be caused by a variety of factors that contribute to a thiamine deficiency. Now I say that and I go into that big explanation to point out that this is potentially a life threatening emergency. If you are working with somebody who starts evidencing dementia sort of out of nowhere, you know, that's something to be aware of. You know, maybe you're going to some of the homeless encampments and you're working with people, you're talking to people, and all of a sudden one of the people starts not making as much sense or repeating themselves, having symptoms of dementia. It is really important that they get evaluated. Korsakoff syndrome is reversible if somebody gets thiamine, but generally that means they have to go to the emergency room and get an IV infusion of thiamine to get those levels back up. It is treatable as long as it's caught early. And, and like I said, it can be life threatening if it's left unattended. We do want to be aware of that. 38% of people who were homeless and received services lacked a high school diploma or equivalent. A lot of us who are, quote, counselors were never trained or taught to consider or ways to link people with wraparound services. Now my master's was in voc rehabilitation. So, you know, that's kind of part and parcel to what we do. But a lot of counselors are not educated about those things. It is important to recognize if you're working with someone who is, you know, maybe you're in a clinic and you're seeing somebody who has major depressive disorder, but they also have, you know, low educational attainment. They haven't gotten their high school diploma or their ged and that increases their risk. They have two marks, I guess, going against them, the depression as well as the low educational attainment that put them at risk for homelessness. We want to be aware of this and help them connect with resources. One of the things that you can do super easy, doesn't take a lot of time because I know, you know, time is precious. Make a list of all of the resources that might be helpful to your clients and, and have it on a handout that you give clients. You know, you can give it to every client, like where I worked in Florida. The majority, if not all, probably 98% of the clients that we worked with were indigent. They were all either homeless already or at significant risk of being homeless. So that handout would have been appropriate to give people at, at intake. That can save a lot of time so you're not having to try to reinvent the wheel every single time and write down, you know, different referral sources. It is important to know what resources are available in your community and we will get there. Biopsychosocial needs. Solving homelessness is more than just having a safe place to live. And helping our clients who may have depression keep from becoming homeless is more than just making sure that they've got a roof over their head. Go back to Maslow. You know, I love Maslow. I finally found an infographic that kind of presents that hierarchy. If you have somebody that you're working with who is malnourished, who doesn't have a safe place to sleep, who's not getting adequate sleep, who doesn't have adequate medical care and they're in pain all the time, guess what? You're not going to probably make a whole lot of progress on developing self esteem and addressing depression until you get those basic needs met. You know, and that's where we need to start with a lot of people who are homeless, they have a lot of trauma issues, a lot of trust issues. Okay, so you're not going to tell me your whole story or just automatically come in for counseling. You know, that's, that's not on your, on your radar. That's cool. One of the first things that we can do to facilitate their recovery process or for clients that we are working with already to ensure that they are getting their needs met and have the best chance of not becoming homeless is to make sure that they have access to the resources to get their basic physiological and safety needs methods. Then we also have to consider substance abuse and Mental health issues, medical and dental problems, legal and criminal justice issues, and lack of social support. All of those things can again contribute to the development of homelessness. People who experience homelessness can be particularly demoralized. Our culture is not very welcoming to people who are homeless. They often need active and often persistent engagement. One of the things we need to think of is remembering that behavior is communication. One of their behaviors was becoming homeless. If you want to look at it that way, whether it was by choice or not, you know, whether they chose to leave a bad situation or they got evicted, whatever, something happened that precipitated this condition that they're in. And we need to be curious and explore what that might be in order to identify, you know, an entry point with that person. In order to identify an entry point and engage that person. People are not going to get engaged until they feel respected and until they feel like you understand what they might need and you've got something to offer them. So we need to be flexible. We want to be person centered. What do they want or need from you and how do they want or need it? A lot of people, you know, they may need housing, they may need shelter, but they don't want to go to a homeless shelter or residential treatment. They don't want to be confined in some sort of environment where they don't feel, feel safe for some reason. They could, maybe they were victimized in a setting like that before or, you know, it's hard to know what could prevent people from wanting to, you know, go to a shelter or, or get into treatment. If they are homeless. We need to ask. They may not tell us that. There may be too much shame around it, but we need to be sensitive, you know, okay, you're not ready for a shelter yet. How can I help you? Maybe you need blankets, you know, so you can stay warm because it's going to get cold tonight. You, you don't want to go to a shelter, let's get you blankets. We will start developing rapport, we will start developing engagement, and they will start to trust us once they recognize that we are not going to force them or push them and into something that they don't want to do. Once they recognize that we are empowering them to take the steps that they feel are most appropriate for them. We want to identify strengths. We want to help them identify personal goals for a rich and meaningful life. My goal for a rich and meaningful life may not be the same as, you know, anybody else. I want to know what their goal is for a rich and meaningful life and then we can work backwards and figure out how to make that happen. You know, maybe they want to reconnect with their family, maybe they don't. Maybe they want to get sober, maybe they don't. You know, we need to meet the person where they are physically, emotionally and cognitively. We also want to recognize what they perceive as the benefits to homelessness. And I say benefits and I don't mean that they think it's all well and rosy. Most of the time they don't. But if they are resistant to some of the interventions and some of the services that are available, we need to look at, you know, what is that behavior saying a lot of people who are homeless join loosely associated communities of other homeless people and they develop a sense of friendship, a sense of structure, a sense of family, if you will. And if they leave that and go to treatment or whatever they feel, they may feel like they're abandoning that family or they may be concerned that that family will abandon them. Some people like or are afraid of giving up homelessness because they're afraid of losing their freedom. They're afraid of being committed maybe to a long term care facility if they've got schizophrenia. They may be afraid of losing their freedom because they came from a violent, domestically violent environment and they're afraid that they might go back into something like that. You know, it's hard to say, but we do want to recognize and start thinking, be curious. You know, when you look at somebody who is homeless, when you're engaging with them, continue to ask yourself how, what happened that they ended up here? What is their perception of this situation and what is it that they think that they need? And safety, believe it or not, may actually be something that the person who is homeless sees as in homelessness. Because when they've been in the system, when they've been in jail, when they've been in treatment, when they've been in homeless shelters or even at home, for example, they may have been victimized and they may have found a group of people who aren't abusing them and they feel safe with this group of people, even if it means they're living in a tent under a bridge somewhere. We do need to recognize their trauma triggers, and this is true for everybody. But you know, we're going to talk about it in terms of people who are homelessness, social workers, counselors, you know, those of us who come out there who are typically focused on mental health. We may be seen as a threat. Maybe prior social workers or doctors or well meaning people had them involuntarily committed in the past. And so they see us and they're like, oh, no, don't want to talk to you because I don't want to be committed again. Hospitals and law enforcement may also represent times when they've had their power taken away or times when they felt victimized. Rules in general, if somebody comes from an environment that was traumatic to them, especially if it had a, a lot of rules, they may not want to go back into a situation where a lot of rules because they're afraid of punishment or rejection. Think about somebody who comes out of a domestically violent relationship. There a lot of rules there, and you know, they, they often change a lot. So somebody may be afraid to go back into another situation in which there are rules that they're afraid that they'll get punished if they break. Communal living, as in shelters, like I said earlier, in and of themselves, can be a trigger because they may have been victimized in those environments before. And we may represent someone or something that traumatized them in the past, aside from our job title. You know, just being a, you know, 50 year old white female, that might trigger some sort of transference reaction from a client. And it's important for me to recognize that just my presence may trigger trauma in some people. I came up with an acronym that can help you remember some things that we need to do when working with people who are homeless. And it's Restore respect is the first thing. Meet clients where they are and understand behavior as communication. If they are, quote, resistant, that's communication. That's the person saying, that's too scary. I don't have the skills or tools to do it. Or there's something else that's preventing me from going there. A lot of people who are homeless, not the majority, but a lot have pets, for example, and that animal, especially dogs, those dogs have served as their sentry to help them sleep safely. They've served as the sole source sometimes of unconditional positive regard, and maybe the only unconditional positive regard that person's ever gotten. Animals are huge for people and they may be threatened or fear that they're going to have to give up their dog. And if they go to a shelter or if they, you know, go somewhere, we need to work with them with that. Obviously, in public housing, we can work on getting the dog certified as an emotional support animal. You know, there are some loopholes that we can work with. In some cases when it comes to, you know, homeless shelters, we may not be able to work with with that. We may not be able to get the dog admitted there. So that may be one reason why someone who's homeless, who has a dog, doesn't want to go into a shelter, so to speak, because they feel safer with Fido. E stands for empathy and curiosity. Change can be super overwhelming and scary. A lot of times people who are living on the streets are already overwhelmed and the thought of everything that they need to do to, you know, be able to have a home is, is just mind boggling to them. And if they're depressed or abusing substances on top of that, you know, that's probably more than they can even conceptualize. So we need to break it down into very small steps. If we're working with somebody who is, you know, has depression and they're not quite living on the streets yet, we still need to use empathy and curiosity to understand, you know, if they're continuing down toward a path of homelessness. What is that behavior saying? What do they fear they will lose by engaging with us and, and, you know, engaging with the treatment plan? Support, you know, that's just basic stuff. Providing the support that people need. And this, this can include resources. We need to be out there to help support people in their journey if they need questions answered, if they need resources, not to force them somewhere, but to serve as that, you know, safety net. Treatment, and that's kind of a garbage term, may not be actual treatment. Sometimes it's support groups, sometimes it's intensive outpatient, sometimes it's residential. But for people who have a mental health or substance abuse issue, or even for people who are grieving, which doesn't actually have a diagnosis, so they may need to access resources. And this can even be connecting with clergy. Treatment isn't always necessarily a licensed, you know, clinician or a licensed psychologist. It could be a pastoral counselor or just a pastor. Opportunities. We need to help them identify opportunities for housing and employment. They may not be ready to take them, but we need to help them see that those opportunities are out there for the picking whenever they're ready. We need to recognize them for their worth as human beings and as they make progress, recognize their achievements. We also want to look back, learn about the people you're working with. Because my guess is they've had achievements up until now, and we want to highlight those achievements to increase self esteem. And the final E stands for encouragement. Sometimes you just got to be a cheerleader, you know, see them, encourage them, you know, tell them, all right, today was a bad day, tomorrow's going to be better. What can we do? To improve the next moment, Whatever you need to do so respect, empathy, support, treatment opportunities, recognition of worth and encouragement. Screening we need to screen for substance use or mental disorders, current and past traumas, medical and dental issues including the risk of and treatment for hiv, AIDS and other communicable diseases. We need to explore the onset and course of homelessness and how it relates to other symptoms. How does it relate to their substance abuse or their depression or their trauma. We want to explore their current skills and ability to maintain stable housing, current and or pressing criminal justice issues, social functioning in terms of social supports, literacy, education, job skills, employment, income, immediate stressors and the client's interest in services. If they're not interested in services, then we're going to be dancing by ourselves. We do need to explore what they're interested in, if anything. Secondary prevention keeps problems from getting worse and tertiary prevention prevents the development of additional problems. When we're working with people who are homeless, you know, primary prevention is keeping it from happening in the beginning. If they're already homeless, you know, we missed the boat on that one. But we can keep it from getting worse and keep them from developing additional issues. Help them identify permanent supportive housing. Explore your community to identify consumer directed recovery oriented services. And this can include that's kind of the everything out there, whatever it is they need for wraparound services, access to Social Security and other benefits, medical, psychiatric and dental care. Teeth are really important. People feel self conscious if their teeth have fallen out, if they have abscesses, if they have bleeding gums, if they have dental issues that can contribute to other physiological problems as well as systemic inflammation and depression. Nutrition, child care, animal and pet care. Sometimes one of their biggest issues is figuring out where to get food for fido. A lot of pounds animals, animal centers, animal control centers will donate food. A lot of places that sell pet food will donate the bags that are open that got returned for some reason because somebody else's foo foo dog didn't like the food. So there are places you can get food donations and being aware of that is really important. Legal assistance, civil and criminal. A lot of lawyer boards, licensing boards will provide will allow lawyers to claim continuing education credit for providing a certain amount of pro bono services every year. Check with your state board for attorneys and job placement, job assistance and job coaching can all be really important. A lot of times people who are homeless have not had a great run in the employment area. Income stability is goes along with jobs. We need to make sure people can pay their bills. The federal bonding program provides no cost Fidelity bonds that protect the employer against losses caused by fraudulent or dishonest acts of the bonded employee. To encourage hard hiring, hard to place persons. Now it doesn't pay the employer anything, but it basically protects them. Because a lot of times we hear this excuse of, well, I don't want to hire this person because they are a liability. Well, this kind of takes the wind out of that one. And this can be used for people who are involved in criminal justice, who are in recovery from substance use disorders, who are on public assistance, people who have poor credit records, people who are economically disadvantaged or lack work histories, or who are dishonorably discharged from the military. In order to help people connect with these things, the first thing you need to do is contact your state bonding coordinator. That person will tell you the steps that you need to take when you have a client who is wanting to get employed. But maybe one of the hard to place persons, the person at the state bonding coordinating center will tell you all the steps you need to take in order to help this person get employed and help that employer get that bond, which again is free to the employer. Goals for best practices, they need to be specific, measurable, achievable, relevant, and time limited. Okay, Our smart goals, we want to make sure they're specific, like how many days the person actually took their medication, attendance at medical appointments, whether they went to certain groups, anything that you want them to do. Try to make it measurable in a way that's verifiable. They have a something signed when they go to a group or you can count their pills. I mean, none of those is foolproof, but you know, it gives you something to go on. We need to make sure that the goals are tailored to the individual's level of functioning and resources to make sure they're achievable. You can't take somebody who has an intellectual disability in the severe category and expect them to get a high paying job and enroll in community college. That's not realistic. So we do need to be realistic. Goals should also be relevant and restorative. Helping the person gather the resources and tools that they need in order to achieve what they define as a rich and meaningful life, which is where the relevant part comes in. And time limited goals, you know, especially people are who are homeless. You may not have a long period of time where you actually are in contact with them. So keep goals short, no more than a week at a time and then at the end of the week they've accomplished it or they haven't. But their treatment plans or Service plans, whatever you want to call them. Those can be longer and ideally you put one of those together working with the client at the beginning of your interactions and you give a copy to the person. So even if they leave, even if they drop out of interactions with you, they still have that. They still have a go by guide. So when they're ready they can start taking that next step. Finding services United Way 211 is a great resource. It doesn't have everything by any means, but it is a great place to start for everything from child care to housing to food to dental care, you name it. United Way probably has a connection that they can give you a referral to. The National Health Care Homeless Council. Oh my gosh, this is a treasure trove. They have tons of resources that can help you connect with places in your local area that provide medical and dental care for people who are homeless or indigent. State departments for housing and homeless services. Just Google, look online for whatever your state name is. Like here it's Tennessee, Tennessee Department of Housing and Homeless Services. And that will help you identify some of these state funded resources that are available in your area. I don't like the term indigent, but it is the buzzword. You can also search online for indigent services and then again put your area. So I would do indigent services Nashville, Tennessee and it would help me find resources, you know, for anything I could possibly think of. The SAMHSA treatment locator will help you connect with guess what? Mental health and substance abuse treatment services. You can even search or filter by the payor. So if you have somebody who has TANF or Medicaid you can find treatment centers that accept TANF or Medicaid. If you have somebody who is a male that has no dependent children, they probably aren't going to qualify for a lot of programs. So they may fall in the indigent or state funded category. But you know, again you can sort by that and find treatment centers in your area. And there's at least one in your area that gets state funding to provide services to people who can't afford it. Medicaid, you know, make sure you know what the rules are for Medicaid in your, in your state. Because Medicaid rules vary a little bit from state to state based on waivers and different things that your state has applied for. Many states Medicaid can, can be used for housing related services and which goes into just about everything but paying rent. So that, that's an interesting little thing there. Section 8 housing or public Housing, you know, every county has it. So look in your local county. So for example, here would be Wilson county and I would put Wilson County Housing Authority and it would come up and I could find the application for Section 8 housing or public housing. Section 8 housing is a voucher that people get and they can take it anywhere to use. And I think there are some limitations on it, but they can use that, you know, in a lot of different places that will accept Section 8, Section 8 vouchers. Public housing, on the other hand, is the, the dwelling is actually owned by the state. So there's a slight differences. Section 8 people have more choices. The list and the waiting list for these things is long. And a lot of times they only open for maybe a week or two. Every year you get on the waiting list and then you gotta wait and then it opens again the next year or when they have, when they've whittled down the list. It is really important that people, you know, kind of stay on top of that. And if you work with this population, you want to be aware of what the opening and closing dates are in your locale. PATH grants come from SAMHSA and behavioral health organizations like, you know, the one you work for. Probably they can apply for PATH grants. Now a lot of times this has to go to a non profit or a religious organization. But if you're in a for profit, you can partner with a non profit in order to try to apply for one of these if you don't have one in your area. PATH grants provide funding for outreach, screening and diagnostic treatment of people who are homeless, habilitation and rehabilitation services, referral for primary health care, job training, educational services and housing. And it actually will also provide housing services as specified in section 522B of the Public Health Services Act. So path stands for something. It's a Homelessness Prevention Grant. I can't remember what the acronym stands for, sorry. Personal issues. When you're working with people who are homeless, even if they're coming to treatment or if you're going into a, you know, an enclave and you are working with people where they are, you know, under the bridge behind the Walmart, wherever it is, there can be a certain amount of frustration and other feelings. Other issues that come up. And some of them that we need to, you know, really talk about and notice so we can address them, include considerable anxiety regarding clients, dangerous situations like clients who refuse shelter on frigid nights. It may break your heart. But if they are competent, then they are able to make that decision. And the Best you can do is, is figure out how to mitigate that. Okay, you won't go to shelter. Where can we find you a. Where, where can we find you some extra socks or a blanket? Repeatedly trying to persuade someone to go to treatment because you were concerned about his or her recovery, you know, sometimes people just, that's not where they're going to go. So instead of continuing to try to persuade them, which is often going to push them away, we need to meet them where they are. If you have strong urges to use involuntary commitment despite no clear risk of imminent danger, you know, it may seem like the easiest way, but when we involuntarily commit someone, and if you've done it, you know, you've probably taken ethics classes on it anyway, it totally disempowers the person. It takes away their, a lot of their rights, and a lot of times it completely, completely obliterates the relationship and their trust in you because, you know, all of a sudden they were having to do something against their will. So we do want to not enter into involuntary commitment lightly. Anger over family members reactions to the person. Given their experience with the individual's past behavior. We haven't lived in their heads. We have not lived with the person. Person, you know, they feel how they feel. They perceive the situation how they perceive it, and their reaction is their reaction. And they have to own that we can't take that from them. We need to deal with our own sense of frustration and powerlessness when maybe we see something different in, in the person than what the family does and the family is just unable to see it. Feeling overwhelmed or frightened by the person's irritability, anger or frustration. You know, irritability, anger and frustration are signs of fight or flee. That indicates to me the person is perceiving a threat, they're feeling unsafe in some way, and we need to recognize what our part is in that Struggle to understand and appreciate the strengths and survival skills of a person who is homeless, particularly when their choices and behaviors create barriers to receiving services. Remember, choices and behaviors are communication, guilt about going home at night while a client is sleeping on the street. It's hard, it really is. And the best we can do is continue to try to connect them, connect with them in meaningful ways. Anger or frustration about missed appointments, which indicate resistance to engagement. Remember, resistance means what we're offering, they either perceive as too hard, maybe too scary, or ineffective. Maybe we're missing the point, we're not understanding what their needs are. It's likely there will be a surge in people who are homeless after a major negative economic or pandemic event. Most people who are homeless desire safe, stable housing. Secondary prevention should focus on helping the person develop a safer living situation and prevent worsening of any current medical, dental, or psychiatric issues. Tertiary prevention should focus on preventing development of additional problems like addiction, hepatitis, Covid, you know in Part two. Coming up next week, we will discuss unique issues for those who are homeless and unsheltered and the prevalence and impact of homelessness on children. 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