Challenging Dogma - Fall 2009

Thursday, December 17, 2009

Inadequacy of Homeless Programs such as Green Doors: Lack of Ecologic Approach – Anna Zakasovskaya

Homelessness is an issue that affects all of us in many direct and indirect ways. 1 in every 200 persons in the United States experienced homelessness in 2007 (9, 11). Homeless individuals suffer multiple health problems that are not treated on time costing taxpayers a lot more money than it would be to house these people and provide preventative services (4,14). Homelessness is a major health issue since it forces people to live on the streets without proper hygiene, regular medical care, adequate nutrition and exposed to crime and abuse (1,15). These people suffer health problems such as mental conditions that cause them to become homeless or are the result of being homeless. Homeless individuals suffer higher rate of infectious diseases such as tuberculosis and STDs, often have drugs issues and are more likely to be involved in crimes or be victims of crimes.
There are many policies and programs that have been done to mitigate the issue, but it persists to afflict our country’s largest metropolitan areas. In the period of 2001 through 2007, the U.S. Department of Health and Human Services in partnership with the U.S. Departments of Housing and Urban Development, Veterans Affairs, Labor, Education, and the U.S. Interagency Council on Homelessness created The Homeless Policy Academy Initiative. The Initiative was designed to bring together state and local policy makers to address the issue of chronic homelessness. $4,670,869 was allocated for this Initiative, which was spent on developing the guidelines for successful state programs to combat homelessness. The Initiative took an ecologic approach combining perspectives and services that historically have shown to work in a fight against homelessness (11). Some states, however, either did not participate in the Initiative or did not submit a proposal that followed the guidelines suggested by The Homeless Policy Academy Initiative.
One of these states is Texas. Based on the organization of the Texas government, homelessness is not considered to be a health issue that would be approached in a comprehensive way. There are a few decentralized agencies that try to address the issue, but largely it lacks any type of comprehensive structure. One such program is in Austin, TX, and is supported by the state and the local government – Green Doors. Green Doors is an example of a traditional approach-sporadic and piecemeal - that has been used for years to deal with the issue of homelessness.
Green Doors is an initiative consisting of three programs: Transitional Veterans Re-entry housing, Permanent Supportive Housing, and Affordable Housing. The housing programs have a strong focus on single veterans, single parent families affected by a disability, and low-income individuals and families at-risk for homelessness. The program also operates a weekly food pantry and clothes distribution. Although, this program assists some homeless people that are in dire need of help, it does not address the problem in a comprehensive way to make significant steps in eliminating homelessness in Austin, Texas.
Green Doors is one example of many programs that use traditional approach to fighting homeless by segregating people into groups targeting separate individuals. Such approach lacks integration across services such as permanent housing, mental health, family maintenances and community building. It is based on Health Belief Model that emphasizes individual behavior only with no attention to social and structural factors that contribute greatly to the causes of homelessness. Homelessness is a complex issue that has to be addressed from all aforementioned perspectives.
I. Proper, Consistent and Accessible Mental Health Services are Essential to Successful Homeless Prevention Program.

First, Green Doors is lacking any kind of mental health services. There is a one-sided individualistic approach in targeting limited aspect of homelessness. As part of ecologic approach of integrated and comprehensive program, there has to be enough emphasis on proper and consistent delivery of mental health services, with appropriate access to these services. Green Doors program is concentrated strictly on the housing and food supply. The program seems to be designed based on Health Believe Model, which assumes that a person will use the services if an individual perceives homelessness as a negative condition and sees the benefits of the services. However, it fails to take into account that people with mental health issues do not perceive the threat and barriers in the same way healthy people do. Thus, basing an intervention strictly on providing housing is ineffective for those with mental illness. Mental illness afflicts anywhere from 15 to 50 percent of homeless people (2,4). Programs such as Green Doors automatically exclude these15-50 percent of homeless population and fail to address the biggest cause and issue in homelessness. State of Texas, similar to other states, has mental health services that are managed by local agencies; however, access to these services is unattainable for many homeless individuals since it would require them to make a logical and purposeful decision to seek such service. Inconvenience of access for individuals with mental illness creates a more unattainable barrier than for a mentally sound person and thus only exacerbates the issue of homelessness and mental health. These patients are less likely to adhere to medications and are more likely to use emergency medical services (4). According to a study done by Pescosolido an individual does not always make health-related decisions alone and in a rational manner. Individuals are often forced to enter the health care system after actions taken by police officers, judges, or family members (7). This fact yet again shows that mental health services should be easily accessible and should be designed in a way that promotes their use.
Furthermore, Green Doors program has stringent application process and assumes that a person will pay a small amount for the housing provided (10). This assumption is based on an individual’s responsibility to make appropriate decisions. A mentally ill person needs consistent medical evaluation and medication to keep acute episodes to a minimum in case of schizophrenia, for example. For clinically depressed individuals who already suffer from self-blame, low self-esteem and require social support, a program that concentrates on individual behavior and person perception of need is not effective.
II. Affordable and Accessible Permanent Housing Should be Part of an Intervention Program.

Second issue with the program is lack of access to affordable permanent housing. Green Doors program provides some community housing to those in need but the barriers to attaining the housing are too high. Following is a quote from what is required in order to be eligible for the housing. “To be eligible to reside at Glen Oaks Corner [Green Doors housing], residents must be a single parent family, provide disability documentation, income information and demonstrate an active desire to achieve residential stability and self-sufficiency.” This signifies that the program targets individual as being the sole source of the issue. Individual factors such as mental illness, behavioral issues, substance abuse, and family separation are big parts of homelessness, but they are not the only and not always the most sever (6). Structural factors such as housing market, economic downturn and labor market are all part of increase in homelessness as well (18,17,20). Programs that are concentrated on targeting individual factors only, are automatically excluding a large percent of the homeless society that for example lost their source of income due to loss of a job or due to their skills becoming obsolete in the modern market. These people are not necessarily going to have a disability. They also, would be suffering from destroyed self-esteem and stigma of being homeless; thus, preventing them from seeking help. Therefore, requirements such as stated above would be too high of a barrier for such individuals to seek permanent housing.
Some cities even try to expend shelters as a solution to the problem of homelessness by “glorifying” slightly improved conditions and access. For instance, Mayor Bloomberg’s plan for New York City – Beyond Shelter- is concentrated on placing people who qualify into shelters. Individuals and families that “do not qualify” for a place in a shelter, daily after insisting that they are provided some shelter, taken to emergency housing. “Sometimes they are taken to a shelter in the Bronx; sometimes they go to Brooklyn or Queens. It is different every night.”(3) True, these people do get a roof over their heads for the night and are statistically not on the street, but this hardly solves a housing issue. Such uncertainty of where to spend the next night after being subject to humiliation of asking and rejection of permanent housing violates basic human need for shelter and safety.

III. Family and Community Support are Crucial Part of Helping people to Overcome Homelessness.

Green Doors program uses a very inflexible approach to family homelessness. It only allows for single-parent families to utilize the services. Along with not using ecologic approach, it violates another social theory – labeling that leads to stigma (17,20,5). By identifying the people living in provided housing as single-parent community, the program labels them and inadvertently attaches a characteristic of being different from what is considered a normal family. Mothers/fathers are already struggling with the stigma of being homeless and having children without having a complete family; therefore, singling out these people deters them from seeking/using the services and reduces their motivation to improve their lives (17,20). Moreover, stigma affects multiple domains of people’s lives and has a dramatic bearing on the distribution of life chances/resources in areas such as job availability, housing, health and social acceptance (20,5).
In addition to stigmatizing, Green Doors does not address another even more important factor in such situation – social acceptance and support. Social factors play a large role in motivating individuals, and improving their self-sufficiency and psychological well-being. Studies have shown that people who have basic social or family support are more likely to receive help from these sources or seek additional help from the services provided (19). All of the factors that affect families’ chances of getting help in fighting homelessness and prevent them from seeking/using the services proved should be addressed in a comprehensive way as part of an ecologic approach.
What Makes a Program Addressing Homelessness Successful?
No single program has the capacity to solve the growing and complex issue of homelessness. Therefore, collaboration at the Federal, State and local levels must occur to create a true integrated system that addresses many complex causes of homelessness. Research shows that better results are achieved if a comprehensive approach with permanent housing, social support and other services is used to address homelessness (19,20,21). Therefore, policies and programs have to be designed to include all social theories that have shown to work in addressing homelessness. Ecological theory as an overarching approach along with labeling and stigma theory, social exclusion and theories based on individualistic traits should all be part of a comprehensive systematic way to address the issue.
The Homeless Policy Academy Initiative was the first innovative attempt by the federal government to design an innovative approach based on research and best evidence. Through collaboration with state and local policy makers, the Initiative was designed to improve access to mainstream services for individuals and families with children who are homeless. The Homeless Policy Academy Initiative has developed detailed guidelines outlining what should be included in the comprehensive approach (21). However, three overarching components mentioned above and discussed in more detail below have to be part of an ecologic, comprehensive system.
I. Mental Health as is an essential component of a homeless program.
Mental health whether it is a clinical depression or schizophrenia are highly stigmatized conditions that often label people as mentally ill and thus affect their lives on all levels. Therefore, mental health has to be a large component of any homeless policy/ program if it is to succeed in reducing or eliminating homelessness. A program with a solid mental health component not only will reduce the stigma, but also will help suffering people treat the disease. The services have to be integrated, accessible, non-discriminating and target chronic homelessness as well as prevention of homelessness. The policy/program should take into account special needs that homeless people have and tailor the programs to them by making it easily accessible at the shelters and permanent housing. The programs should be integrated into other social support services such as assistance with job placement and social support groups. As well as be placed in the areas where the services are needed and would be used, to minimize the barriers. Providing such services in a decentralized manner such as in Austin, TX, will only exacerbate the issue. There should be no cumbersome application process to receive mental health evaluation and help. Care not Cash – a San Francisco initiative integrates mental health services at the shelters and permanent housing residences through policy changes. Requiring all agencies that receive funding from San Francisco spend it on mental health and permanent residence (14).
II. Affordable and Accessible Permanent Housing.
“A significant barrier to participation in community life for people with serious mental illness is the lack of decent, safe, affordable, and integrated housing of their choice linked with supportive services.” (12) Accessible, affordable and permanent housing with integrated support services should be another essential component of a comprehensive system. A significant shortcoming with many policies and programs is associated with their investment into shelters instead of permanent housing. A study done by Letiecq and colleagues shows that families placed in permanent housing arrangements have significantly higher rate of social contact and receive more help and support from family and friends (19). These families are also more likely to move on from the permanent housing to more stable arrangements.
Programs that do not target permanent housing that an individual could call home, will not achieve fulfillment of the basic needs of a human being – shelter and safety. Temporary housing does not fulfill this need. As seen in the New York’s “Beyond Shelter” example above, people who live in shelters are spending every night at a different shelter and are forced to move all the time spending most of the day on the streets. This type of arrangement is not only harmful to a person’s psychological well-being, self-esteem and self-worth; it is not conducive to receiving treatment if needed or looking for employment. According Maslow’s theory of human action, individual’s basic needs such as safety, shelter and hunger need to be met first in order for this individual to be motivated to make the next step (22). By being in a homeless shelter individuals are in a state of uncertainty whether they will have a roof over their heads, which does not allow this person to seek any other “higher” needs such as self-esteem to overcome drug dependency or adhere to mental health treatment. An example of a program that attempts to put emphasis on permanent housing integrated with support services is Care not Cash program in San Francisco, CA. The policy is designed to redirect part of the money that was previously given as cash to homeless individuals to be used to build permanent housing with support services so that people can make the transition from the streets to a functioning stable life sooner (14).
III. Providing Comprehensive Services to Families with Children.
A large percent of people who are looking for permanent housing are families with children. As studies have shown ecological approach has to be used to include services and permanent housing that encompasses families with children (16). These children are in their developmental stages when security and basic needs are essential for healthy cognitive development. Often homeless pregnant mothers do not have proper nutrition, prenatal care and have chemical abuse issues that lead to delayed development of the fetus/infant. Both mother and a child at that stage need intervention that would be used and would be helpful to both. Policies and programs do not consider the seriousness of two main issues when trying to provide prenatal or mother-child services. First, the fact that children of the parents who are seeking shelter and services are in danger of being taken away by the child services and thus loosing their connection to the family. Mothers are often reluctant to seek help out of fear of losing custody of their children (2). Even though mothers often know that the services would be beneficial to them and their child, the fear of child welfare services scrutiny and potential separation from their children, keeps them from using available services. Services do not place enough emphasis on keeping nuclear families together and providing family based counseling. Additionally, substance abuse could be a cause of a loss of custody of a child or the loss of custody can lead to drug abuse. Mothers, who already have substance abuse issues, even if they know that it would be appropriate for them to seek services, consider barriers to seeking such help too high and do not have the social support to perceiver through the treatment (2).
Policies and programs should place more emphasis on the importance and accessibility to programs for mothers with children that can lead to cognitive/mental health issues for both the mother and the child. Therefore, another major component of any homeless assistance program has to be conservation of a family unit with provision of supportive services for mothers. Mayor Bloomberg’s homeless program in New York –Uniting for Solutions Beyond Shelter - has gotten this aspect of the program design right. The services are provided at the places of need so that families can be in their home communities. Most initiatives in the program are focused on keeping the family unit together and providing services to the family as a whole. Its goal is to reduce the disruption of families (13). As part of ecologic approach, a comprehensive program should also include prenatal care and domestic abuse intervention. Such services are rarely part of homeless assistance programs.
As mentioned above, homelessness is a very complex issue that has to be approached on many levels in order to address all public health issues that cause homelessness and are caused by homelessness. Mental health, accessible permanent housing with integrated support services and focus on families are major parts of addressing the issue but definitely not a complete approach. Policy makers and program designers should pay close attention to evidence from the studies done on homelessness and lessons learned from programs that failed. Human behavior is irrational in predictable way and with such deep psychological trauma as being homeless, having a mental illness, and lacking social and/or family support, accurate and ecologic approach is crucial.


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3. Kaufman, Leslie. A Challenge to New York City’s Homeless Policy. The New York Times. 2007. September 4. (
4. Gilmer, et al. Schizophrenia patients do not take medications regularly resulting in higher medical costs. Press Release. UC San Diego. 2004. March 31. (
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7. Pescosolido, BA., Gardner, CB., Lubell KM. How people get into mental health services: stories of choice, coercion and “muddling through” from “first timers.” Social Science and Medicine. 1998. 46:275–286.
8. Texas Department of State Health Services.
9. U.S. Department of Housing and Urban Development Office of Community Planning and Development. The Third Annual Homeless Assessment Report to Congress. July 2008.
10. Green Doors.
11. U.S Department of Health and Human Services. Homeless Policy Academy Initiative: Final Report. April, 2007.
12. O’Hara, Ann. Housing for People With Mental Illness: Update of a Report to the President’s New Freedom Commission. Psychiatry Services. 2007. 58:907-319.

13. NYC Department of Homeless Services. A Progress Report on Uniting for Solutions Beyond Shelter: The Action Plan for New York City. 2008.
14. Human Services Agency. San Francisco, CA. Care not Cash.
15. Fischer et. al. Mental Health and Social Characteristics of the Homeless: A Survey of Mission Users. Journal of Public Health. 1986. 76 (5): 519.
16. Haber M, Toro P. Homelessness Among Families, Children, and Adolescents: An Ecological–Developmental Perspective. Clinical Child & Family Psychology Review. September 2004; 7(3):123-164.
17. Link, et al. Public knowledge, attitudes, and beliefs about homeless people: Evidence for compassion fatigue? American Journal of Community Psychology. 1995, 23(4).
18. Lee, et. al. Public beliefs about the causes of homelessness. Social Forces. 1990. 69, 253–265.
19. Letiecq, et. al. Social Support of Homeless and Housed Mothers: A Comparison of Temporary and Permanent Housing Arrangements. Family Relations. 1996. 45(3):265-272.
20. Link, B., Phelan, J. Stigma and its public health implications. The Lancet. 2006. 367( 9509):528-529.
21. Issues for Debate in Social Policy: Selections From CQ Researcher. In re: CQ Researcher. 2010.
22. Maslow AH. A theory of human motivation. Psychological Review 1943; 50:376-396.

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