The Continuum of Care: Is It an Effective Way of Helping Homeless People with Mental Illness/Substance Abuse Recover? - Feng-Hang Chang

Introduction
Homelessness is a growing social and public health problem in developed countries (1). In the U.S., approximately 3.5 million people experience homelessness, and the number is steadily increasing every year (2). Most people who are homeless have suffered severe hardship, including physical and sexual abuse, childhood trauma, poverty, disability, and disease (3). Moreover, homeless people showed a higher prevalence of mental disorders, such as schizophrenia (54.8%), bipolar disorders (19.8%), and substance-related problems (60.5%) compared with people who were not homeless (4).
Helping homeless people with mental illness/substance abuse go back from the street to a stable and independent life is a big challenge. To help them improve and maintain their health and well-being, the intervention does not only have to aim on housing situation, but also have to stress on the treatment of improving their mental health or/and drug abstention(5).
The Continuum of Care is a nationwide standard homelessness intervention strategy recommended by the Department of Housing and Urban Development (HUD) (6). It is a community plan which organizes and delivers housing and services to meet homeless people's needs, especially for those with mental illness and/or substance abuse disorders. The components of a Continuum of Care model include: 1) outreach, intake, and assessment, 2) emergency shelter, 3) transitional housing, and 4) permanent housing and permanent supportive housing (See figure1).


Figure 1 Components of a Continuum of Care Homeless System

This approach includes two key characteristics: 1) the provider determines when a client is "housing ready," and 2) the participants are required to get psychiatric and substance abuse treatment. Additionally, two assumptions are contained in this model: 1) homeless adults need transitional and permanent housing in order to develop the daily living skills they either lost or never had; 2) housing readiness depends on a period of sobriety and compliance with psychiatric treatment if deemed necessary. If the individuals demonstrate more compliance with treatment and sobriety, they can get less restrictive residences; if they fail to comply or relapse, they will return to a more restrictive environment (7).
Although the Continuum of Care is a linear process as stressing on restoring clients' mental health and stop using substance, the effect is not as good as we thought. First, clients report a lot of frustration and dissatisfaction in this program since the "journey" of graduating from the program is very long and complicated, which lead them to give up (8). In addition, comparing with other programs (i.e., Housing First or Pathways to Housing program), the Continuum of Care program shows lower effect on many aspects such as psychiatric symptoms, psychiatric hospitalization, substance use rate, and residential stability (7,9,10). Especially for homeless people with addiction, the Continuum of Care presents less than ideal result (11). These results indicate the program and the factors that contribute to its low effect need to be examined.

The criticisms of the Continuum of Care
1. Disobeying Maslow's Hierarchy of Needs
One of the most likely reasons that the Continuum of Care intervention does not work as well as expected is that it ignores the point that housing is one of the basic needs of human beings that need to be satisfied.
Based on Maslow's Hierarchy of Needs, the fulfillment of the lower level needs is a prerequisite to addressing the higher needs (12). In Maslow's hierarchy, the first level of needs, we call it the physiological needs, including food, drink, shelter, sleep, and sex, is the foundation of human beings' motivation. The second level is safety, including security, stability, and protection. The third level of need is belonging and love. The fourth level is esteem needs, which are fulfilled by mastery of the environment and the prestige of social recognition. The fifth level is the need for self-actualization, is to maximize one's unique potential in life. Once the lower needs are satisfied, the higher needs can be pursued (12).
For homeless individuals, apparently, the basic physiological and safety needs can hardly to be satisfied without stable housing. Stable housing forms the foundation on which an individual can establish daily routines and begin to address other issues (13). Contrarily, living in an unstable or bad environment may expose one to the cold, promote sleepless, and cause food shortage and cooking difficulties. Moreover, living on the street or temporary shelters can expose one to dangerous situations, which hardly offers security and stability, the safety needs. If those basic needs are not satisfied, how can we expect homeless people to pay attention on the mental health and substance abuse treatment?
Many studies support this statement. Studies showed that Homeless people perceive the basic needs of food, shelter, and safety as higher priority needs than health issues (14-16). Gelberg and Gallagher (1997) found that competing priority is an important nonfinancial barrier to the utilization of health services homeless people tend to pursue the housing and necessity prior to anything else. Kyle and Dunn (2008) also found empirical evidence that stable and appropriate housing situation can benefit mental ill people's health and quality of life.
Nevertheless, the Continuum of Care regards housing as an outcome, like employment, of therapeutic intervention rather than a precondition before healthcare (17). People cannot get permanent houses if they fail to comply with mental health/substance abuse treatment. However, this process disobeys the Maslow's Hierarchy of Needs and the empirical evidence. In fact, it seems to put the cart before the horse. If we want those people to comply with treatment, we have to let them see the value of treatment. But how can we expect them to value the treatment if their basic needs are not satisfied? The housing should not be seen as a "result" or "reward," but a necessity and human right.
2. Inducing the reactance
The reactance theory can also explain the limited success of the Continuum of Care. The reactance is the psychological response that people may experience when they perceive their freedom is threatened (18). It motivates people to restore the threatened freedom by adopting or strengthening a view or attitude that is contrary to the threatening message (18).
As an intervention focusing on recovery from disease and substance abuse, the Continuum of Care does not provide much autonomy to homeless people. First, the homeless people are "required" to attend treatment and have to "graduate" from the program. If they fail to show their capability of engagement and attendance in the treatment, they cannot get a permanent house (7). In the process, the treatment is like a mandate and requirement, which can probably become a freedom-threatening message to those individuals who want a house. Second, the providers are the ones to decide whether a client is "housing ready" or not. The client does not have much opportunity to get involved in the decision-making process but only wait for the judgment like a student or prisoner. This process may increase the sense of losing control. Some research supports this statement. Owen, Rutherford, and Jones (1996) found that clients feel dissatisfied and frustrated with a system that provides what it thinks they need, rather than what they say they need. Third, in the intervention process, if the clients relapse, they will be sent back to a more restrictive environment, such as a collective shelter, which may deprive their freedom and independence. Actually, most of emergency shelters and transitional housing are dirty, dangerous, disempowering, and associated with a range of negative outcomes such as negative affect and lowered independent functioning (19). It leads some clients to drop out of the system to resume their "normal lives," independently, on the street (8).
As a result, the Continuum of Care may not only induce the clients' reactance by threatening their freedom, but also influence their independence and satisfaction. Further, the clients may choose to go back to the street due to fail to follow the "rules" and fear of losing their independence. These can all cause the intervention to fail.
3. Fail to address other factors which may influence the compliance with treatment
Finally, the model regards the adherence to prescribed treatment and sobriety as the capacity of housing readiness. The client who is not able to maintain the compliance at any level or relapse into alcohol and drug use will be seen as lack of capacity. However, even if compliance with treatment is one indication of understanding whether a client is able to maintain his/her life, this postulation overlooks other factors which may influence a client's healthcare use, including taking prescribed medication and visiting the psychiatric clinic regularly.
In fact, a lot of factors can influence one's healthcare use. Based on Andersen's Behavioral Model, the factors including demographic factors (such as age and gender), social structural factors (such as education, ethnicity, and culture), health beliefs, community and personal enabling resources (such as transportation, income, insurance coverage), illness level, and many other environmental factors (such as stigma, policy, and prevailing norms of the society) may all affect an individual's healthcare use and health behaviors (20). Although having a disadvantage on any of these factors may contribute to ones' difficulty of using healthcare, homeless people could be even more vulnerable on several aspects than others. For example, they are usually lack of health insurance, health related knowledge, and social resources like family support and community support, income, and are usually stigmatized (21). Among these factors, stigma is one of the biggest barriers that we need to highlight (3).
Some researchers contend that homeless people face tremendous stigma in life and healthcare due to the stigma on poor and mental illness (4). The stigma may not only come from the social public, but also come from health providers. A phenomenological study shows that homeless people encounter serious barriers while entering healthcare services. These barriers include being labeled or stigmatized, being treated with disrespect, and feeling invisible to healthcare providers (3). Applying the knowledge to the adherence of treatment, the failure to comply wider treatment may due to the negative experience during the process of healthcare. While homeless individuals are facing stigmas and disrespects from the healthcare providers, it becomes extremely hard for them to seek help continually. Further, homeless people with mental illness tend not to consistently seek mental health care due to the fear of facing social reject (22). All these factors can affect a homeless individual's willingness and compliance with psychiatric/substance abuse treatment. As a result, while they fail to comply with treatment, it is unfair to postulate they lack "readiness" regardless of other personal and environmental factors.

Intervening program: A Home with Rehab
To develop a more effective intervention program for the recovery of homeless people with mental illness/substance abuse, we have to avoid making the same mistakes as the Continuum of Care does. The new intervention program I recommend is “A Home with Rehab.” This program has several new characteristics. First, when a client enters in the program, we help him/her get a home first by providing a safe apartment and necessities. The “home” is free for the first month, but after that, the client needs to pay for at least 30% of the rent and expenses, which can motivate him/her to manage his/her money or find a job. Second, if the client has mental illness/ substance abuse that needs treatment, rehabilitation will be offered after the client settles into the housing. A case manager will develop a relationship with the client, and discuss the rehabilitation plan with him/her in an empowering way rather than in a forcing way. Family members, if there is any, will also be invited to join the meetings. After completing counseling, the client can decide whether or not he/she wants to participate in psychiatric/substance abuse rehabilitation. Third, each client is cared for by a strong professional health team, including a case manager, physicians, psychiatrists, occupational therapists, nurses, rehabilitation counselors, and social workers. If the client has any health or life needs, he/she can seek help from the case manager, and the manager will call for the required personnel. For example, if the client wants to find a job, the case manager will gather the clients’ occupational therapist and rehabilitation counselor to discuss the issue with the client, make a job search or work skills training plan, and help him/her find a job. Fourth, health education group activities will be provided to the clients in the apartment. The health education goals include improving personal health behaviors, enhancing necessary health services use, and increasing their seeking and participating in psychiatric rehabilitation and substance cessation. The communication will decrease the reactance among the clients by sending unthreatened messages. Last but not least, the program stresses “anti-stigma” education for health providers. To make sure all of the health providers in our program have indiscriminate attitude and respect toward the clients, all of the providers need to take the anti stigma training and be evaluated before and after entering the program.
To attain these goals, the execution of the program is very important. I will now elaborate the details of this program and discuss how this intervention avoids the flaws of the Continuum of Care. First of all, based on Maslow's Hierarchy of Needs, the basic needs should be fulfilled prior to other needs. Therefore, we will help the clients settle into the stable housing and get necessities before conducting psychiatric or substance abstention rehabilitation. After satisfying the basic needs, we can expect that clients will have more motivation to improve their health, well-being, and other higher level needs. Some studies have shown that homeless individuals with mental illness who are placed directly into permanent housing first are more likely to stay engaged in a program and be residentially stable compared to those who get treatment first (2). Furthermore, the types and conditions of housing should also be considered. A dirty, crowded, and disordered shelter may not make clients feel secure. To satisfy the clients' needs for safety, the program will offer an independent, comfortable, or at least well-organized, apartment.
Next, the intervention will avoid inducing clients' reactance. The "mandate" of complying with treatment before getting a house will be eliminated since it threatens the clients' freedom of choice. Our message will not stress the need to complete rehabilitation before getting housing. On the other hand, we will let the clients know that they have the freedom to decide whether or not to engage in their treatment services. We will send positive messages such as "Wanna get rid off the pills? It's time to make your own decision." "The door to AA group is open for you anytime." "Wanna find someone to listen to your feelings? The Psych clinic welcomes you." These messages will be put in the flyers posted on the walls where clients can see easily, and in the health education groups that people can get when they participate in the activities. The healthcare providers will also provide those messages to clients during the meetings.
Additionally, to increase the power of persuasion, we will invite some successfully recovered homeless people to speak to the clients, or show videos about their own recovery stories. Based on the study, the similarity between the communicator and the clients can increase the power of persuasion and decrease resistance (18). The modeling theory also asserts that people tend to imitate the behaviors from those whom they identify as models (23). Therefore, it is important to build up those "models," for example, those successful homeless people, and demonstrate their engagement in rehabilitation. If engaging in rehabilitation could be shown as problem-solving and rewarding, such as bringing a more independent life, more people may like to adopt this behavior (23). As a result, clients will more likely to comply with treatment.
Finally, to encourage homeless people with mental illness/substance abuse to keep seeking treatment, we will aim to remove barriers that they may face in the healthcare system. The case managers will meet with the clients regularly and explore if they have any difficulty of using health services. If there are barriers which interfere with the clients' health services use, for example, the client is lack of knowledge about when and where to seek for rehabilitation; we will help them to eliminate the barriers, for example, by using health education.
In addition, based on the problem I addressed before, one big challenge for homeless people is the stigma from healthcare providers. According to the stigma theory, a stigma is an attribute that is socially defined as “deeply discrediting,” spoiling one’s identity and disqualifying one from full social acceptance (24). The homeless population has been facing a public stigma for a long time based on people's negative perceptions related to the poor, the mentally ill, and substance abusers (24). Moreover, many people's perception of homeless people is influenced strongly by the media or by the unsavory behaviors of a few but highly visible homeless people (4). Unfortunately, healthcare providers show the similar negative attitudes toward homeless people when homeless people walk in and seek help (25, 26). Because of that, our primary task is to remove the stigma from healthcare providers. Ways to change attitude include education and direct contact, which both focus on increasing healthcare providers' familiarity with the homeless population and decreasing the unknowns (6). In addition, interaction with the stigmatized population is regarded as a key to reducing discrimination and prejudice (6). Based on that, delivering adequate knowledge about the homeless population to health providers is very important, as is helping them get in experience with treating homeless people (25). These are all effective ways of removing the barriers and helping homeless people enter and continue following the treatment.
In conclusion, in helping homeless people with mental illness/substance abuse recover and return to the community, we should help them settle in a stable and safe house first in terms of satisfying their basic needs. Next, the health services should be provided in an acceptable way. We can offer abundant information and services and encourage them to comply with treatment by using some persuasive techniques, but the clients should have the right and autonomy to make treatment decisions. Even if they fail to comply with treatment, their needs and barriers need to be understood rather than blamed. One of the biggest barriers, stigma, especially needs to be addressed and removed to help clients comply with treatment. Therefore, education for health providers and increased opportunity for them to interact with homeless people is important.
It is never easy to help homeless people recover from illness and return to their lives. That is why it is so important to develop an effective intervention program and make relevant policies. We may not be able to build up a "perfect" program; however, we can always improve the programs by examining the problems of the ones we are using. The process will help us find more possibilities in the future.








References
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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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