BEHAVIORAL HEALTH SERVICES FOR PEOPLE
WHO ARE HOMELESS
Introduction
According to the Department of Housing and Urban Development’s (HUD) 2020 Annual Homeless
Assessment Report (AHAR) to Congress, on a single night in 2020, there were approximately
580,000 individuals experiencing homelessness in the United States. People experiencing
unsheltered homelessness (e.g., those sleeping outside or in places not otherwise meant for
human habitation) were typically concentrated in large cities, followed by suburban areas. Thirty
percent of homeless people were members of a family with at least one adult and one child under
18 years of age, and most homeless people in families were sheltered. Twenty-seven percent of
those who were homeless and residing in shelters were children under the age of 18, while 87.8
percent of unsheltered people were aged 24 or older. Over 60 percent of all people experiencing
homelessness in 2020 were males while African Americans comprised nearly four in 10 homeless
individuals, and 37,252 people experiencing homelessness were veterans (HUD, 2021).
Ending homelessness is an important public health issue in the United States. Many experiencing
homelessness have high rates of chronic and co-occurring health conditions, mental and
substance use disorders. Individuals who are homeless also may be dealing with trauma, and
children experiencing homelessness are at risk for emotional and behavioral problems (Perlman
et al., 2014). Additionally, research has shown that individuals who are homeless have a risk of
mortality that is 1.5 to 11.5 times greater than the general population (Gambatese et al., 2013).
Preventive services, including mental health, substance use, medical care, and social supports,
are needed for people who are homeless, irrespective of whether they present with diagnosable
conditions.
According to data collected as part of the 2015 AHAR, over half of adults living in permanent
supportive housing either had a mental disorder or co-occurring mental and substance use
disorder (HUD, 2016). Further, people experiencing homelessness are at high risk of overdose
from illicit drug use (SAMHSA, 2020). To further compound these already signicant problems,
data show that adults aged 65 and older who are homeless also have a higher prevalence of
unmet needs for substance use and mental disorder treatment compared with their younger
adult counterparts (Kaplan et al., 2019). Providing housing to people experiencing homelessness
can help prevent the exacerbation of substance use and mental disorders; however, separate
treatment and housing considerations must be accounted for when working with this population.
1
ADVISORY
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SAMHSA’S mission is to reduce the impact of substance abuse and mental illness on America’s communities.
1-877-SAMHSA-7 | (1-877-726-4727) • 1-800-487-4889 (TDD) • WWW.SAMHSA.GOV
This Advisory is based on SAMHSA’s Treatment Improvement Protocol (TIP) 55, Behavioral Health
Services for People Who Are Homeless. It addresses the fundamentals of how providers and
administrators can eectively employ approaches to address the complex challenge of providing
comprehensive, integrated, and trauma-informed treatment services to clients experiencing
homelessness.
Key Messages
● People who are homeless are at elevated risk for experiencing substance use disorders
(SUDs), mental disorders, trauma, medical conditions, employment challenges, and
incarceration.
● People experiencing homelessness present unique treatment challenges, as both
treatment and housing needs must be concurrently addressed for treatment to be most
eective.
● Preventive services for people experiencing homelessness, including mental health,
substance use, medical care, and social supports, are critical for mitigating risks of SUDs
and mental disorders and improving health outcomes.
● Treatment providers must be knowledgeable about and help clients identify available
housing resources.
● Person-centered prevention and trauma-informed treatment practices are essential when
working with people experiencing homelessness and help prioritize and address the
complex issues clients face.
● Providers should work with federal, state, and community-based agencies to secure
permanent supportive housing placements for their clients.
● Clinicians must know how to help individuals access federal or local benets to improve
housing stability.
Dening Homelessness
Homelessness exists on a continuum and is categorized in three ways (Burt, Aron, Lee, &
Valente, 2001; Gabrielova & Veleminsky, 2015):
1. Transitional homelessness: ranges from weeks to months, but less than a year, and includes
people recently leaving prison or jail.
2. Episodic homelessness: refers to periods where individuals enter and leave homelessness
repeatedly and is common among those with unstable housing situations.
3. Chronic homelessness: refers to a period of homelessness lasting at least a year—or
occurring repeatedly—while struggling with a disabling condition such as a serious mental
illness (SMI), SUD, or physical disability (HUD, 2015).
ADVISORY
3
SAMHSA’S mission is to reduce the impact of substance abuse and mental illness on America’s communities.
1-877-SAMHSA-7 | (1-877-726-4727) • 1-800-487-4889 (TDD) • WWW.SAMHSA.GOV
Environmental and Individual Risk Factors for Homelessness
Poverty and high housing costs that exclude individuals from the local housing market, the
removal of institutional supports for individuals with SUDs, and decreased job options for
individuals with only a high school education are just some of the environmental factors identied
as contributing to homelessness (Burt, 2001; Tuller, 2019). Individual contributors that increase
the likelihood of experiencing homelessness include: cognitive impairment, preexisting medical
conditions, unemployment, and family instability (Giano et al., 2020). Additionally, traumatic
experiences early in life have been identied as a pathway into homelessness (Woodhall-Melnik
et al., 2018).
Of people who are homeless and in substance use treatment, 68 percent of men and 76 percent
of women reported experiencing a trauma-related event (Christensen et al., 2005; Jainchill et
al., 2000). Cognitive impairment also increases the risk for homelessness. Up to 80 percent of
people who are homeless show some signs of cognitive impairment, which impacts their ability
to learn new skills (Spence, Stevens, & Parks, 2004). Co-occurring medical conditions like HIV/
AIDS, hepatitis B and C, cardiovascular conditions, dental problems, asthma, diabetes, and other
medical problems are more prevalent among people who are homeless and individuals with SUDs
compared to those who are housed (Fazel et al., 2014; Noska et al., 2017; Bagget et al., 2018;
Kolla et al., 2020; Mejia-Lancheros et al., 2020).
Preventive Services for People Who Are Homeless
Preventive services may include medical care, housing support, and other social and supportive
services (e.g., employment, educational supports for children). These services help a client work
toward housing stability and support retention in substance use and mental health treatment and
long-term recovery.
Preventive services can be categorized as:
● Universal: targeting entire populations (e.g., community, state, or country)
● Selective: targeting subsets of the population considered at risk
● Indicated: targeting and delivered to individuals exhibiting early signs of problem behavior
Preventive services are often provided in clinical settings, such as primary care, hospitals,
or counseling centers. They include life skills development, stress and anger management,
anticipatory guidance, parenting programs, and screening and early intervention. These programs
may be designed to directly prevent substance use and/or promote mental health and may
strengthen individuals and families and enrich quality of life to build resiliency. Providing housing
and other preventive services to people experiencing homelessness can help prevent the
exacerbation of substance use and mental disorders or transition from normal functioning to the
rst phases of problem development.
ADVISORY
4
SAMHSA’S mission is to reduce the impact of substance abuse and mental illness on America’s communities.
1-877-SAMHSA-7 | (1-877-726-4727) • 1-800-487-4889 (TDD) • WWW.SAMHSA.GOV
Update on Housing First
Housing First programs place individuals experiencing homelessness into permanent housing and
makes supportive services available throughout the housing placement process. Per the Housing
First philosophy, housing placement is not contingent on use of available services or engaging in
treatment for substance use and/or mental disorders. Beginning in the early 2000s, the Housing First
model was widely adopted by various federal, state, and local government agencies to reduce the
number of individuals experiencing homelessness and provide substance use, mental health, and
medical services through the use of case managers and multidisciplinary teams (Tsemberis, Gulcur,
& Nakae, 2004; Tsemberis, 2011). However, recent research suggests that Housing First programs
prioritizing housing placement without concurrent treatment engagement and adherence have not
been eective in reducing homelessness (Tsai, 2020; U.S. Interagency Council on Homelessness,
2020). To eectively reduce homelessness, the U.S. Interagency Council on Homelessness (USICH)
states that programming models should engage and assess people experiencing homelessness
using a trauma-informed approach to address the root causes of their homelessness.
Screening and Evaluation
In general, the rst step in providing preventive services to an individual experiencing homelessness
involves initial observations and decisions about care. It is important to determine if the client is in
imminent danger to health or safety and requires immediate help. Providers should collect primary care
records and information on the following: substance use and SUD, mental disorders, eects of specic
symptoms, co-occurring disorders, and exposure to trauma. They should also evaluate the onset of
homelessness, current ability to maintain stable housing, and criminal justice involvement.
Client retention and continuity of care is a signicant challenge to address among individuals
experiencing homelessness. For those living with chronic homelessness, the task of addressing
health care, nancial needs, criminal justice issues, and housing security is daunting. Therefore,
client retention requires the development of short-term, realistic treatment and prevention goals.
Goals should be set collaboratively with clients to include specic milestones within a dened time
period and rewards (contingency management) to increase retention.
Relapse prevention and recovery management present unique challenges for providers, as
clients with mental and/or substance use disorders are at a higher risk of relapse (Andersson,
Wenaas, & Nordfjærn, 2019) and subsequent loss of housing (Pringle, Grasso, & Lederer, 2017).
Common strategies to manage recovery and prevent relapse eectively include:
● Wellness self-management/Illness self-management: supports the management of disease and
development of skills related to health and wellness (Mueser et al., 2006; Parsell et al., 2018).
● Assertive community treatment: provides intensive and integrative community-based
mental health services for high-risk individuals (Coldwell & Bender, 2007; Morse et al., 2017).
● Motivational interviewing: counseling approach focused on achieving behavioral change by
determining and increasing an individual’s motivations to make positive choices (Berk-Clark et
al., 2015; Robinson et al., 2016).
● Contingency management: therapeutic approach based in the principles of operant
conditioning that rewards positive behaviors while withholding privileges when negative
behaviors are exhibited (Munthe-Kass et al., 2016; Rash et al., 2019).
ADVISORY
5
SAMHSA’S mission is to reduce the impact of substance abuse and mental illness on America’s communities.
1-877-SAMHSA-7 | (1-877-726-4727) • 1-800-487-4889 (TDD) • WWW.SAMHSA.GOV
For more information on the use of motivational strategies when working with clients with SUD, please
refer to SAMHSA’s TIP 35, Enhancing Motivation for Change in Substance Use Disorder Treatment.
Housing Considerations
Housing services are a vital component of treatment for individuals with substance use and/or mental
disorders who are experiencing homelessness. For example, immediate access to housing and support
from a mental health team has been shown to decrease inpatient days for homeless individuals with
schizophrenia or bipolar disorder (Tinland et al., 2020). Housing services can come in the form of
emergency shelters or temporary and transitional housing placements, with the needs of each client
being dierent based on the severity of their illness and the client’s readiness to change.
For clients with SUDs, three housing types are utilized based on the individual’s readiness to change:
● Wet housing permits the use of legal substances and is suited for pre-contemplation or
contemplation stages and includes engagement in treatment services.
● Damp housing meets the basic needs of a safe shelter and increases the client’s readiness
to accept services; it is suited for contemplation and pre-preparation stages.
● Sober housing includes group housing options and is best suited for clients in the action or
maintenance stages of change.
Permanent Supportive Housing
Permanent supportive housing is a housing placement and support model widely used for
individuals experiencing homelessness who have an SMI or other disability. It provides additional
supports, as needed, to help individuals live stably in the community. This type of housing oers
a combination of housing and services, and is an established solution for clients experiencing
chronic homelessness (Aubry et al., 2020). The ultimate goals of permanent supportive housing
models are to oer housing choices, de-emphasize institutional care, prevent relapse, and
reduce discrimination and stigma of people with mental and substance use disorders. SAMHSA’s
Permanent Supportive Housing Evidence-Based Practices (EBP KIT) lists 12 elements of
permanent supportive housing programs that form the core guiding principles of these programs
and dierentiate them from other forms of housing assistance:
1. Leases are in the tenants’ names and provide full rights, including protection from eviction.
2. Leases have the same provisions held by people without psychiatric disabilities.
3. Participation in services is voluntary, and refusal does not result in eviction.
4. If there are house rules, they are similar to those for people without psychiatric disabilities.
5. There is no time limit on housing with a renewable lease.
6. Tenants are oered a range of housing choices that would be available to others at the same
income level.
7. Housing is aordable—no more than 30 percent of the tenant’s income.
8. Housing is integrated, allowing the opportunity for tenants to interact with neighbors.
9. Tenants are given choices in the support services they are provided.
10. Support services are dynamic and can change as needs change over time.
11. Support services are focused on recovery to help tenants choose, obtain, and keep housing.
12. Housing and support services are delivered separately.
ADVISORY
6
SAMHSA’S mission is to reduce the impact of substance abuse and mental illness on America’s communities.
1-877-SAMHSA-7 | (1-877-726-4727) • 1-800-487-4889 (TDD) • WWW.SAMHSA.GOV
Recovery Housing
Recovery housing is an intervention that addresses a recovering individual’s need for safe housing
while providing the requisite recovery and peer support (SAMHSA, 2019). In 2018, the Support Act
was passed, which requires the development of best practices for the operation of recovery housing.
The resulting report includes ten guiding principles:
1. Have a clear operational denition that delineates the types and intensity of the services provided.
2. Recognize that SUDs are a chronic condition that require a range of recovery and supports.
3. Recognize that co-occurring mental disorders often accompany SUDs.
4. Assess applicant (potential resident) needs and the appropriateness of the residence to meet
these needs.
5. Promote and use evidence-based practices to best support recovery.
6. Develop written policies, procedures, and resident expectations in a resident handbook to
ease transition and ensure compliance.
7. Ensure quality, integrity, and resident safety by making safety the chief priority in all recovery houses.
8. Learn and practice cultural competence so sta can work with individuals on a personal basis
and respect diering beliefs and backgrounds.
9. Maintain ongoing communication with interested parties and care specialists, including
resident’s family, vocational programs, and criminal justice professionals.
10. Evaluate program eectiveness and resident success to assess how each house is
performing in delivering quality care to residents.
Addressing the Needs of Special Populations
Some groups experience homelessness at higher rates than the general population, and may need
to be considered dierently when receiving homeless services. Veterans are at increased risk for
experiencing homelessness, but are also eligible for additional programs oered by the Department
of Veterans Aairs (VA). While it is often assumed that single adults in urban areas are the most
common population experiencing homelessness, families and rural populations are also at risk, and
often need, but may not have access to, mental health, substance use, and homelessness services.
● Veterans: Individuals experiencing chronic homeless are more likely to be veterans than
those residing in shelters or with stable housing (Levitt et al., 2009) and often have worse
treatment outcomes (Buchholz et al., 2010). In one study, 60 percent of homeless veterans had
a diagnosed SUD (Tsai et al., 2014). Another study found that 77 percent of veterans entering
transitional housing had a least one previously diagnosed co-occurring disorder (Ding et al.,
2018). The VA operates a number of homeless programs for veterans to determine benets
eligibility, provide temporary shelter, and secure permanent housing placements. The VA also
houses the National Center on Homelessness among Veterans, which was developed to
identify, evaluate, and promote recovery-oriented care models for veterans who are homeless or
at risk for homelessness.
● Families: Families who are impacted by homelessness face additional challenges that include
an increased risk of traumatic experiences and interpersonal diculties. Special services and
resources for families are available, such as family-only shelters and child-specic healthcare
options. The vast majority (98 percent) of homeless families are sheltered but in need of
ADVISORY
7
SAMHSA’S mission is to reduce the impact of substance abuse and mental illness on America’s communities.
1-877-SAMHSA-7 | (1-877-726-4727) • 1-800-487-4889 (TDD) • WWW.SAMHSA.GOV
stable housing (HUD, 2020). It is important to treat families as a separate subpopulation
with their own specic needs. For additional information and resources regarding family
homelessness, please refer to the HUD Exchange for a number of available resources.
● Rural Populations: Available housing and treatment centers can be limited in rural areas
(Robertson & Myers, 2005). Individuals experiencing homelessness in these areas are typically
less visible, so outreach and engagement eorts may require a dierent approach than eorts
deployed in urban areas. The availability of job opportunities, shelters, health services, and
social programs are often limited. The National Health Care for the Homeless Council has
collected a number of available resources for working with rural homeless populations.
Considerations for Program Administrators and Senior Sta
Developing Services for People Experiencing Homelessness
Homelessness represents a signicant case management challenge for treatment program
administrators and other sta members who are responsible for nding housing resources. Some
considerations that must be addressed include:
● Limited resources for housing people in early recovery from substance use and/or mental disorders
● Time required to nd and evaluate potential resources
● Collaboration eorts involved in working with other community agencies
● Limited funding available for housing services
In addition to addressing these considerations, administrators and treatment providers will
need to ensure that individuals who are homeless are able to participate and remain engaged
in ongoing services and care. They will need to work with clients to manage transportation,
mental health, SUD, healthcare, nancial, criminal justice, and employment issues complicated
by homelessness. However, the reality is that an individual who is homeless is in crisis and has
immediate housing needs that must be addressed in a limited period of time. For more information
on the use of eective case management strategies when working with clients with SUD, please
refer to SAMHSA’s TIP 27, Comprehensive Case Management for Substance Abuse Treatment.
Intraorganizational Needs Assessment
To determine the treatment organization’s ability to assist clients experiencing homelessness,
a number of initial questions must be addressed. An intraorganizational needs assessment is
a process that includes sta and stakeholder discussions at an organizational level to better
understand the program’s ability to assist this special population. Key steps in the process include:
● Evaluating the basic demographics of the target population. This includes gender, ethnicity, racial
makeup, criminal justice experience, family status, language, and the nature of homelessness.
● Determining if these demographics and characteristics are reected in the frontline sta
providing services.
● Identifying gaps in the continuum of care. This requires the organization to ask basic questions
about client retention, referrals from other services, client access to primary care providers and
medication, and program diculties working with clients who have substance use or mental illness.
● Identifying
organizational policies and procedures that contribute to the gaps identied in the
continuum of care. Policies that aect client eligibility for services is an example of a policy
that could be changed to better meet client needs.
ADVISORY
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SAMHSA’S mission is to reduce the impact of substance abuse and mental illness on America’s communities.
1-877-SAMHSA-7 | (1-877-726-4727) • 1-800-487-4889 (TDD) • WWW.SAMHSA.GOV
●
Identifying larger community-level issues to be addressed. These issues could include
legislation that handles homelessness through arrest, lack of aordable housing, and
insucient mental health, substance use, or medical care services in the community.
● Identifying potential opportunities to partner with other providers in the community and
leveraging resources to improve services for people experiencing homelessness.
Integration of Substance Use and Mental Disorder Treatment with Homelessness
Services
Throughout the continuum of care and services, clients experiencing homelessness will likely
engage with multiple care providers. It is important that all programs have shared goals and
standards of quality of care with the understanding that addressing homelessness in the
community requires strategic coordination on the part of all providers. Use of a coordinated and
integrated approach to care and service delivery is recommended throughout each phase of
rehabilitation from homelessness and is described below.
Outreach and engagement
This rst phase includes building relationships with individuals with substance use and mental
disorders who are also experiencing homelessness. Administrators can assist by establishing
collaborations with community organizations, forming interdisciplinary teams, increasing sta
availability o-site, ensuring proper training of sta, developing outreach tools, and providing
funding for practical goods that can be oered to potential clients.
Transition to intensive care
After a client agrees to accept care, housing, and other services, an administrator can support
this phase in several ways. This includes formalizing recordkeeping policies, providing tangible
benets, assigning case managers, oering supportive services like employment and nancial
benets, ensuring sta are familiar with local community housing resources, and developing
protocols from transition planning.
Intensive care and treatment
When an individual engages in a clinic, shelter, outpatient, or residential treatment program, they
begin the intensive care phase (McQuistion et al., 2008). In this phase, developing a memorandum
of understanding (MOU) with housing resources, providing screening by behavioral health
professionals, increasing engagement and retention, and developing strategies to improve treatment
compliance are essential steps an administrator can take. Comprehensive healthcare services are
also required in this phase of rehabilitation for clients who meet the criteria for outpatient treatment.
Transition to ongoing rehabilitation
This phase occurs gradually and has the highest risk for dropout or relapse. Building recovery
skills, encouraging community involvement, and providing transitional housing until a permanent
housing placement is identied are all strategies to utilize in this phase. This includes programs
like recovery education centers in mental health treatment that have been successful in
supporting recovery to transition out of homelessness (Khan et al., 2020).
ADVISORY
9
SAMHSA’S mission is to reduce the impact of substance abuse and mental illness on America’s communities.
1-877-SAMHSA-7 | (1-877-726-4727) • 1-800-487-4889 (TDD) • WWW.SAMHSA.GOV
Ongoing rehabilitation
The nal and open-ended stage occurs when the client is no longer identied as homeless and
actively works to maintain recovery (McQuistion et al., 2008). Administrators can support sta as
they provide ongoing rehabilitation and the means for clients to contact the organization if there
is a relapse of substance use or an increase in the severity of mental disorders. This ongoing
support can include regular follow-up in the form of meetings or phone calls.
The Health Care for the Homeless program provides additional resources and funding to
health centers to better serve individuals experiencing or at risk for homelessness. Maintaining
Independence and Sobriety through Systems Integration, Outreach, and Networking (MISSION) is a
trauma-informed, time-limited treatment intervention that integrates co-occurring disorder treatment,
Critical Time Intervention (CTI) case management, and peer support programming for homeless,
veteran, and justice-involved populations. A number of MISSION manuals and workbooks are
available for providers and administrators to use when working with these populations.
Resources
● Substance Abuse and Mental Health Services Administration
- Homelessness Programs and Resources
- Permanent Supportive Housing Evidence-Based Practices (EBP KIT)
- Recovery Housing: Best Practices and Suggested Guidelines
- TAP 21, Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of
Professional Practice
- TIP 27, Comprehensive Case Management for Substance Abuse Treatment
- TIP 35, Enhancing Motivation for Change in Substance Use Disorder Treatment
- TIP 55, Behavioral Health Services for People Who Are Homeless
- TIP 59, Improving Cultural Competence
● Corporation for Supportive Housing (CSH)
● Center for the Advancement of Critical Time Intervention (CTI)
● Maintaining Independence and Sobriety through Systems Integration, Outreach,
and Networking (MISSION)
● National Alliance to End Homelessness
● National Association of Community Health Centers
● National Health Care for the Homeless Council
● U.S. Department of Housing and Urban Development (HUD)
- HUD’s Denition of Homelessness: Resources and Guidance
- HUD Exchange
● U.S. Department of Veterans Aairs (VA)
- Homeless Programs
- VA Health Benets
- Housing Navigator Toolkit
- HUD-VASH Resource Guide for Permanent Housing and Clinical Care
● U.S. Interagency Council on Homelessness (USICH)
- Expanding the Toolbox: The Whole-of-Government Response to Homelessness
ADVISORY
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SAMHSA’S mission is to reduce the impact of substance abuse and mental illness on America’s communities.
1-877-SAMHSA-7 | (1-877-726-4727) • 1-800-487-4889 (TDD) • WWW.SAMHSA.GOV
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ADVISORY
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SAMHSA Publication No. PEP20-06-04-003
1-877-SAMHSA-7 | (1-877-726-4727) • 1-800-487-4889 (TDD) • www.samhsa.gov
ADVISORY
SAMHSA Publication No. PEP20-06-04-005
Acknowledgments: This Advisory, Behavioral Health Services for People Who Are Homeless,
was written and produced under contract number HHSS283201700001/ 75S20319F42002 by
Abt Associates for the Substance Abuse and Mental Health Services Administration (SAMHSA),
U.S. Department of Health and Human Services (HHS). Donelle Johnson served as the
Contracting Ocer’s Representative (COR), Tanya Geiger served as the Alternate COR, and
Christine Cichetti served as Product Champion.
Nondiscrimination Notice: SAMHSA complies with applicable Federal civil rights laws
and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
SAMHSA cumple con las leyes federales de derechos “civiles aplicables y no discrimina por
motivos de raza, color, nacionalidad, edad, discapacidad o sexo.
Recommended Citation: Substance Abuse and Mental Health Services Administration.
(2021). Behavioral Health Services for People Who Are Homeless. Advisory.
Publication No. PEP20-06-04-003
Published 2021
1-877-SAMHSA-7 | (1-877-726-4727) • 1-800-487-4889 (TDD) • www.samhsa.gov
