Abstract
By adhering to The Soldier’s Motto, “I will never leave a fallen comrade” the homeless veteran population may be something to add to the history books. The program proposed in the following paper will attempt to address the unique needs of homeless veterans, including mental health, substance abuse, vocational training and an evaluation of individual’s benefits in partnership with the VA.
Community needs
Addressing the unique needs of a community requires a thorough understanding of the culture involved, the strengths and shortcomings of programs that are already in place, and how to provide mental health counseling in a manner that is both cost and time effective. Much can be gleaned by observation, surveys, and interviewing both providers and those who use the services. Finding a right fit for the community is essential to increase the likelihood of individuals actually seeking out and using a new program.
A survey conducted on a cold night in January in 2011 revealed that there were 67,495 homeless veterans on the street, with almost 150,000 who had spent at least one night in an emergency shelter program during the previous year. The state of Oregon has a large homeless population, with 1,425 (or 8%) comprised of veterans (http://cms.oregon.gov/odva/info/Pages/stats.aspx).
Homelessness, defined as a lack of a fixed and regular nighttime residence, is associated with a higher incidence of both poor mental and physical health (Gordon, Haas, Luther, Hilton and Goldstein, 2010). There are current programs in place that aim to address the homeless veteran problem, but with the assistance of grants from the VA, more programs can be implemented that can better address the needs of this unique population.
Services needed
Comorbidity of psychiatric and medical disorders amongst the veteran community is a common occurrence, with addiction and generalized illness (comprised of eye problems, hypertension, COPD, liver disease and gastrointestinal problems) indicating the highest correlation (Goldstein, Luther, Haas, Gordon and Appelt, 2009). Thus, a treatment program that addresses substance abuse and mental health counseling, in conjunction with medication management, housing and vocational training may prove beneficial to the individual seeking assistance. Grants from the government, which go towards helping non-profit organizations in providing services for low income veterans can help to offset housing and operating costs, thus reducing the monetary burden.
Currently a couple of initiatives address the need to connect homeless veterans with needed psychiatric services, including domiciliary care for homeless veterans (DCHV) and homeless chronically mentally ill (HCMI). However, those who have a need for such services already outweigh the resources available, making alternatives a necessity (Stovall, Flaherty, Bowden and Schoeny, 1997).
Goals and objectives
Measurable goals, both terminal and ultimate are important in considering the implementation of a new program. Ensuring the goals are feasible, viable and pragmatic are essential to creating realistic benchmarks (Milstein and Wetterhall, 2000). Focusing on evidence-based practices may shorten the evaluation period due to the proven record of accomplishment during prior therapeutic interventions (Calley, 2009). The initial goals for the proposed program are to address acute health and mental health problems, resource-related problems (housing, employment and hygiene), and public perception problems (rejection, dehumanization and community fear of veterans), which were identified as the main contributing factors to the problems experienced by homeless veterans (Applewhite, 1997). Long-term goals of the program include treating any substance abuse or other issues documented during the initial intake, vocational training and employment opportunities, which can help to facilitate self-sufficiency.
The proposed program aims to coincide with the Six Pillars of the Homeless Initiative, as set forth by the VA, which include community partnership, income and benefit analysis, housing and support services, outreach and education, prevention of becoming homeless and treatment of medical and psychiatric needs (http://www.va.gov/HOMELESS/about_the_initiative.asp). By blending programs it will be easier to implement tactics used successfully in the past, thus reducing the amount of time needed for program research.
Program design
Prior to acceptance into the program, clients would be screened by mental health counselors regarding their present level of assistance required, the presence of any comorbidity factors (primarily those involving drug and/or alcohol abuse) and their current living situation (threat of becoming homeless, homeless, living with friends, etc.). The screening is an important aspect, as certain comorbidity relationships have an impact on behavior and functioning (Goldstein, Luther, Jacoby, Haas and Gordon, 2008), which may affect the other residents in the program. Another consideration to keep in mind during screening is that the facility will be a clean and sober living situation, which residents will have to agree to and abide by in order to remain in the program.
The ideal facility would be one of many vacant apartment buildings located within the county, purchased with funds provided by government grants. If the units are 1-2 bedrooms, there should be at least 10-12, more if they are studio apartments. Some considerations regarding facility amenities would include handicap access and proximity to loud noise generators, which may cause undue stress upon residents.
One unit would be staffed 24-hours a day and designated for treatment, including counseling, group meetings and medication management. Vocational programs may supplement staffing needs by training residents to fill the needs of the program, thus not only help to lower the operating costs, but also promote a positive self-image and foster resiliency within the clients. However, a licensed counselor and direct care providers would still be required onsite, as these positions would be solely support and clerical services.
Counselors working within the program should be familiar with the unique needs of both the military and homeless communities, and use a holistic approach when interacting with clients. A bio-psycho-social-spiritual approach is often effective in drug and alcohol rehabilitation settings, as it allows for more flexibility in therapeutic interventions. The use of motivational interviewing, which is a client centered approach with a focus on strengthening intrinsic motivation has also shown to be beneficial in improving program interaction, retention and a reduction in relapse incidents (Wain, Wilbourne, Harris, Pierson, Teleki, Burling and Lovett, 2011). A focus on psychosocial rehabilitation would also prove beneficial, as the main philosophy includes some commonalities to the Six Pillars highlighted earlier, consisting of an emphasis on teaching essential skills of community living: vocational, social/recreational, residential and educational (Juvva and Newhill, 2011).
Even the well-educated and seasoned counselor may find himself or herself amongst unfamiliar territory, as clients are individuals, and that brings a collection of unique experiences. Having an effective consultation and referral program is essential to success, for both the client and counselor alike. Some resources to consider include VA trained staff, religious or clergy members, parole or probation department specialists and those familiar with evaluating military benefits including disability payments.
Working with local agencies would also provide a way for the clients to engage in their recovery and reintegration as productive members of society. Creating a partnership between the program and vocational training centers, such as Goodwill, Salvation Army and Habitat for Humanity will assist the clients in earning both monetary compensation and employment skills that they can use after graduation from the program.
Evaluation
An important part of any program is a reevaluation after a period, to analyze the strengths and weaknesses present and to address such findings. The key aspects to evaluate would be cost-effectiveness, relapse rate, program retention, improvement (or decline) in mental health conditions and positive contributions to the program and the surrounding community by the clients. A way to address a possible cost issue is to apply the disability or SSI payments of the residents to the rent, recruit graduate students for the direct care staff, conduct fundraisers or apply for additional grants.
Allowing for flexibility in treatment delivery approaches to fit the client may assist in increased sobriety and program retention; however, if it becomes troublesome or ineffective, a reevaluation of methods is warranted. An examination of program length is important, as some clients may be staying after they have completed treatment, thus taking a spot that could be filled by another homeless veteran. However, keeping with the mission statement of “I will never leave a fallen comrade,” the program will not abandon clients, but rather refer them to other programs that will better suit the needs of the veteran.
Reporting outcomes
Public disclosure, transparency and informing the stakeholders of the strengths and weaknesses of programs can help to ensure accurate information is disseminated, rather than speculation. Such avenues include town hall forums, VA meetings, ballot measures, articles published in peer-reviewed journals and letting the positive results speak for themselves.
Conclusion
While veterans are the minority amongst the homeless population in Oregon, the fact that there is even one without consistent shelter is a concern. The influx of returning soldiers from wars and conflicts overseas may contribute to a growing need of the services proposed by the aforementioned program. By offering a one-stop veteran assistance program, combining shelter, mental health, substance abuse and veteran benefit analysis, the incidence of homeless veterans may decrease, thus showing the respect these men and women deserve.
*References available upon request
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