Homelessness and Mental Illness: The Vicious Cycle

1. Homelessness and Mental Illness: The Vicious Cycle Rhonda Thissen, M.S.W. Executive Director NAMI Virginia

2. About NAMI Virginia We are a national, state and local advocacy and support movement that works on behalf of individuals and families affected by mental illness. Our mission is to promote recovery and improve the quality of life of Virginians with serious mental illness and their families through support, education, and advocacy. We envision a world where all people affected by mental illness get the help, hope, and support that they need.

3. Mental Health vs. Mental Illness • Without mental health there is no health • More than the absence of mental disorders • “A state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.” • Mental illness is an impairment of an person's normal cognitive, emotional or behavioral functioning, which can be caused by social, psychological, biochemical, genetic, or other factors.

4. The Problem • On the average, more than a third of homeless adults in the US suffer from a serious mental illness (SMI) • There is a vicious cycle between SMI and homelessness • Many adults with SMI are chronically homeless, in part due to their mental health challengesOn • Many also suffer from substance addiction and other serious health conditions • Homelessness can impact the mental health of anyone who is experiencing it, regardless of their mental health

5. What is “Serious Mental Illness”? • Severe and persistent mental/emotional disorder that seriously impairs the functioning of adults age 18+ in primary aspects of daily living: • Personal relationships • Self-care skills • Living arrangements • Employment • SMI is assessed on three dimensions: Diagnosis, Disability and Duration

6. SMI on Three Dimensions • Diagnosis: Major mental health disorder such as Schizophrenia, Major Depression, Bipolar Disorder, organic or other psychotic disorders, personality disorders, or other disorders that may lead to chronic disability. • Level of disability due to the disorder: • Difficulty maintaining employment • Need for public assistance • Difficulty maintaining relationships and managing daily life • Mental health crises leading to institutionalization (jail/prison, hospital) • Duration of illness: Individual needs or has received services of an extended duration

7. Prevalence Rates • 18% to 20% of adults have any mental disorder • Estimated 45% of homeless adults • 4.2% of adults have a SMI • Estimated 25% among homeless adults • 30.1% of adults in national 2018 PITC data; 24.6% in Virginia 2018 PITC • 50% to 80% of adults with SMI have a co-occurring substance use disorder • Officially, 11% of inmates in Virginia jails have a mental illness, and more than half of those have a SMI • This percentage is likely an undercount

8. Homelessness in Hampton Roads

9. Virginia Homeless Adults with SMI, PIT Count

10. “Diagnostic Impression” of PATH Participants, 2010-2012

11. Homelessness Reductions Not as Dramatic for SMI Population

12. Mental Illness Can Lead to Homelessness. Why? • Systemic issues leading to increased risk of homelessness among people with SMI • Sociological and illness-related factors

13. Systemic Risks - Historically • Historically, people with SMI were frequently committed to long-term hospitalization • With deinstitutionalization in the 1970s and 1980s, many people were discharged into the community with inadequate treatment and supports • The Baby Boom generation was reaching the age of onset of some SMIs during this time – service providers could not keep up with the need • Many ended up homeless and on the streets

14. Systemic Risks - Now • Poverty and lack of health coverage impacts people’s ability to obtain consistent MH treatment • In studies, there is a direct correlation between missing medication and psychiatric hospitalization • Homeless individuals themselves identify affordable housing, education and job training as top unmet needs • “Trans-institutionalization” - the cycle of hospitalization, homelessness and incarceration - is not uncommon. In recent studies: • Approx. 40% of people with SMI have been in jail at least once • One study suggested that 10x more people with MI are now in jails and prisons than in state psychiatric hospitals • More than 5,000 people in Virginia have been identified in this population

15. The Cycle of Exclusion

16. Sociological Risks • History of childhood abuse • Emotional • Physical • Sexual • Poverty • Poor or conflicted social relationships • Substance use/abuse • Lack of an advocate to help identify resources or assert their rights

17. Risks Related to SMI • SMI can negatively affect people’s functioning through: • Distorted perceptions of reality • Disorganized thought processes • Hallucinations, delusions • Impaired or poor self-control • Impaired ability to care for or to protect oneself • Impaired ability to hold a job, pay rent, manage a household or maintain a home • Ability to form and/or maintain relationships with others due to discomfort, stigma, paranoia, fear

18. Maslow’s Hierarchy of Needs: How does it match up?

19. Thissen’s Hierarchy of Needs WiFi Internet Access

20. Mental Health Issues You Might Encounter • Psychotic Disorders: • Schizophrenia • Schizoaffective Disorder • Affective/Mood Disorders • Depression • Bipolar Disorder • Anxiety Disorders: • Post-Traumatic Stress Disorder • Panic Disorder • Obsessive-Compulsive Disorder • Social Phobia, Social Anxiety Disorder

21. Mental Health Issues You Might Encounter • Substance Use Disorders: • Alcoholism • Drug Addiction • Smoking • Personality Disorders: • Borderline • Anti-Social • Narcissistic • Cognitive Disorders: • Dementia • Amnesia

22. Cognitive Impairment and TBI • Traumatic Brain Injury (TBI) is a leading cause of disability in the US • Most common undiagnosed medical condition among homeless individuals • Can cause • Memory problems • Challenges learning new information • Problems with recall of previously learned information • Impairments in language, movement, or recognizing things • Problems with planning, organizing and sequencing • Mild intellectual disability is also often missed

23. The Cultural Impact of Incarceration • Sometimes people with SMI who are incarcerated develop behavioral adaptations to help them survive in prison which can impact their treatment after release • Shelter/service staff may interpret these behaviors negatively without understanding their rationale

24. Options for Behavioral Health Services • Community Services Boards • PATH Homeless Assistance Programs at Norfolk, HNN, Portsmouth and Virginia Beach • Community Health Centers • Federally-qualified primary care providers operating in medically underserved communities • Provide services on a sliding scale; cannot turn anyone away for inability to pay • To find a location: Virginia Health Care Foundation – www.vhcf.org • Medical schools with Psychiatry departments (e.g. EVMS, MCV, etc.) • Not-for-profit CBOs – some provide sliding-scale therapy services (e.g., United Methodist Family Services, Commonwealth Catholic Charities) • SAMHSA Treatment Locator – http://findtreatment.samhsa.gov

25. Questions? Rhonda Thissen, MSW NAMI Virginia rthissen@namivirginia.org 804-285-8264, ext. 200