Homelessness in Older Adults: Examining the Layers

We create experiences that transform the heart, mind, and practice.

The Academy is a project of San Diego State School of Social Work.

Serving over 20,000 health and human services professionals annually, the Academy’s mission is to provide exceptional workforce development and learning experiences for the transformation of individuals, organizations and communities.

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We create experiences that transform the heart, mind, and practice.

About APSWI & The Academy

• Adult Protective Services Workforce Innovations (APSWI)
• Training program of the Academy for Professional Excellence, a project of the San Diego State University School of Social Work.

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• APSWI provides innovative workforce development to APS professionals and their partners.

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• The Academy provides workforce development and learning experiences to health and human service professionals.

We create experiences that transform the heart, mind, and practice.

Academy Programs include:

Housekeeping

• Video camera
• Option to hide “self view”
• Mute, unmute
• Display name
• Correct name
• Pronouns if desired
• Chat box
• Hand clap/thumbs up
• Raise hand icon
• If you must step away briefly…

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• Potential technical glitches

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Poll Activity

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• Poll 1
• Poll 2

Where Are We Going?

This is workshop one of a series.

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Learning Objectives for today:

• Define common language and terminology use when working with people who are at risk of, or experiencing homelessness
• Explain risk and contributing factors to becoming homeless and identify protective factors
• Recognize how implicit and explicit biases impact the way APS professionals work with others
• Apply a trauma-informed approach that is specific to those who are at risk or are experiencing homelessness

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Today is about laying a foundation, finding some common ground.

• **Its okay to feel conflicted today

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Additional workshops in series will focus on skill-building opportunities.

Trivia Activity

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1. When did Homelessness first become a problem in America?

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2. Which profession set the stage to begin researching and analyzing?

A. Medical field C. Social Workers

B. Sociologists D. Human Resources

3. In which time frame did this research start?

A. 1880-1900 C. 1920-1940

B. 1900-1920 D. 1940-1960

4. There have been five major episodes of homelessness in America.

Name an event you believe began one of those episodes.

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5. In which decade do you think our current, 5^th episode of homelessness

began?

Solving Homelessness: Two Models

Treatment First:

• Established by the McKinney-Vento Act.
• Transitional (temporary) help if expectations/conditions met.
• Based on belief that temporary assistance allows individuals to work on their obstacles and create self sufficiency.
• Cons: Often inadequate, particularly for older adults whose barrier is unaffordable housing

Housing First:

• Prioritizes permanent housing quickly.
• Based on Maslow’s Hierarchy.
• Meeting basic needs provides a foundation/motivation to meet one’s needs and advance themselves.
• “No barrier” approach
• 2016- Senate Bill 1380
• Cons: Lack of Social Services, Housing programs rule out (e.g. credit, criminal history, etc.)

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“In order to help another effectively, I must understand what he understands. If I do not know that… my greater understanding will be of no help to him... instruction begins when you put yourself in his place.”

- Soren Kierkegaard

Understanding the Path

of Homelessness

ACES = Study on Adverse Childhood Experiences. Done in 1995 by the CDC and Kaiser Permanente Health Care to study outcomes on the health of individuals who had a high ACES score.

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Outcomes:

• Juvenile/Young Adult incarceration
• Early substance use
• Unstable work history
• Mental health issues
• Traumatic brain injury

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These outcomes create a higher rate of poverty and homelessness at an early age.

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Homeless Before 50: Common Factors

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Homeless After 50: Common Factors

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Why it Matters to the APS Professional

Homeless Before 50

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Strengths:

• Survival skills; networking, knowledge how to find and use resources.

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Needs:

• Social service supports; substance use programs, mental health help.
• Life skills training.
• Permanent Supportive Housing (Often eligible for Social Security income at an earlier age.)

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Homeless After 50

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Strengths:

• History of functionality in basic

life needs; paying bills, making appointments, etc.

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Needs:

• Functionality can often be restored by housing help.
• Grief over losing the life they expected to have.

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Homelessness in CA

The next 20 years:

• Households w/ people 80+ y/o will be the fastest growing group.

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• The # of older adults who rent will double.

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• A growing number will pay 50% or more of their income for rent/mortgage aka “Precarious Housing.”

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Layers of Bias

It is doubtless impossible to approach any human problem with a mind free from bias.

- Simone De Beauvoir

• Explicit Bias: conscious/deliberate.
• Ex: The belief that many people named Karen are middle-aged, racist white women. Are they?

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• Implicit Bias: Often based on thoughts and feelings that become part of a belief system without awareness.
• Affect judgement, decisions and behaviors.

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• Systemic Bias: a system operates on a biased foundation

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Bias Happens

• Samuel is 18 years old (Gen Z), identifies as bisexual, BIPOC, and spent six months in a juvenile detention facility for selling stolen prescription drugs when he was 15. Samuel has a substance use disorder and has received treatment from three different rehabilitation centers in the past two years and is currently living in his car.
• Choose two identities and list as many biases that go with those identities as possible.

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Identity Activity

• On a single night in CA, January 2020:
• 161,584 people were homeless
• 113, 666 were unsheltered homeless, which is 51% of the unsheltered population in America

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• Demographic Breakdown:
• 65% male, 33.4% female, 1.2% transgender, 0.4% gender non-conforming
• 13% are Veterans
• Overrepresented in proportion to their percentage of the population:
• Black/African American,
• American Indian/Alaska Native,
• Native Hawaiian
• Other API and Multiple races
• LGBTQIA

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Who is Homeless in CA?

Holistic Health

". . . Well-being is holistic; physical health, mental health and cognitive function can influence each other."

- Xianghe Zhu, Ph.D

Health Differences in the Sheltered and �Unsheltered�

Unsheltered homeless individuals experience major health challenges which increase in severity and more quickly than sheltered individuals.

Why do you think there is a difference? (type your answer but WAIT to press enter in chat box)

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• Survival based thinking
• Prioritize conditions that are uncomfortable/noticed
• Adherence to medical interventions can be difficult

A Layer of Bias: Homeless people are severely mentally ill.

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Living with severe mental illness vs. mental health concerns originating from homelessness

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What % of homeless people do you believe live with severe mental illness?

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APS professionals work with individuals who have mental health issues.

• Use your skills to consider how a client’s mental health may be impacting their ability to function.

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Mental Health and Homelessness

• Which mental health disorder do you think = a higher risk for homelessness?
• Bi-polar, severe depression, and any mental health disorder with an element of psychosis, possibly including PTSD.
• How to interact?
• Psychosis brings fear (paranoia) anxiety and a confusing disconnect. Build rapport and go slowly.
• Bipolar: Mood swings, irritability and risky behaviors. Listen to what is behind the behaviors. Expect progress with extreme slide backs.
• Severe Depression: Can bring challenges due to experiencing symptoms like lack of motivation. Break tasks into small steps and validate any effort.

Encourage/Aid access to mental health help.

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Mental Health and Homelessness:

Risk Factors

Mental Health Issues Due �to Homelessness

Depression:

• Major depressive disorder higher among older homeless individuals due to the multiplicity of stressful issues.

Anxiety:

• Constant fear due to lost of stability and security. This can lead into learned helplessness and apathy

Trauma:

• Overwhelms individual’s coping ability. (Will be discussed more).

Unique Needs of Homeless Older Adults �with Mental Health Concerns.

Five Categories of Unique Needs:

• Dynamics of aging/ Therapeutic Needs
• Subpopulations:
• Veterans
• History of Justice Involved
• Co-occurring disorders
• Medication Management
• Outreach and Engagement

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Cognitive Health and Homelessness

Cognitive Health: Ability to think, to learn and to remember.

• Poor cognitive health = a risk factor for and an outcome of homelessness.
• Stress decreases the ability to maintain good cognitive health.
• Cognitive impairment can be hidden
• Implications for service planning
• Older adults who are homeless may not prioritize cognitive engagement due to the need to prioritize basic survival

Physical Health and Homelessness

• Homelessness results in a decreased lifespan of 10-20 years, which makes 50 the new 70 for a homeless individual. There are:
• Higher rates of impairments with basic ADL’s:
• Compliance with Medical treatment is difficult:
• Medications
• Diet
• Adaptive equipment
• Getting to medical care
• Freedom can be a causality of homelessness.
• Hospital > nursing facility > shelter > street > hospital…

Homelessness and Substance Use

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“I’m not addicted to Alcohol or Drugs. I’m addicted to escaping reality.” - Anonymous

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Substance Use and Homelessness

A Layer of Bias: Homeless Individuals have substance use disorders.

• Research estimate: 35% of homeless adults struggle with substance use.
• Common challenges
• Co-occurring/Dual disorder.
• Lack of trust in authority figures.
• Appropriate treatment and follow up.
• Return to homelessness.

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Older Adults, Homelessness & �Substance Use

• Higher rate of use in the “homeless before 50” population.
• Alcohol is most common substance with older adults

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How does Substance use differ for an older adult?

• Metabolic changes
• Liver function is less efficient
• Medication interactions are more likely
• Substance abuse treatment programs are typically geared towards a younger population

How APS Professionals Can Help

• Increase their social support network
• Component of recovery and something frequently diminished in older adulthood.
• Realize that any substance use may simply not feel like an important issues to an individual who is homeless. Housing is.
• Collaboration with other social service agencies is important.
• Resource for the APS Professional:
• Tip 55: https://store.samhsa.gov/product/TIP-55-Behavioral-Health-Services-for-People-Who-Are-Homeless/SMA15-4734

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The Ostracizing Impact of

Homelessness

“Being excluded or ostracized is an invisible form of bullying that doesn't leave bruises, and therefore we often underestimate its impact." 

- Kipling D. Williams

Homelessness and Stress, �Stigmatization and Ostracism

• Older homeless individuals frequently have a minimal support system.
• What does additional ostracism do? What perceptions drive stigmatizing and ostracizing this population?
• What is the outcome of these perceptions?
• Inadequate solutions.
• Laws that cost $, but do not help.
• Dehumanizing an individual.

Unconscious thoughts and feelings.

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Implicit Bias

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Labels/ Dehumanization

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Stigmatizing/Ostracizing

Lack of Empathy

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Ineffective Solutions & Increased Costs

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The Reality of the Perceptions

• Can seeing homelessness create negative internal responses in others, including APS professionals?

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• Take a minute and think what those are.
• Helping them increases my taxes—and it’s not like the government uses the money right.
• They could hurt someone.
• I don’t want them around my house. They steal.
• They are filthy, who knows what a person could catch.

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• Used as scapegoats

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Despair, Trauma and the �APS Professional

“I’m getting more and more used to the idea that my life is a complete waste. I do not have a family. I do not have a career. I’m not a productive human being. It’s day after day of wasting my time... I am a walking dying woman. I walk until I can’t walk anymore, and then I sit. The busses pass me by… We are the untouchables.”

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- 78 y/o female participant in a homeless study

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Aligning Values, Principle and Action

• What is the focus of APS values and principles?
• Words are powerful tools.
• Dialogue
• Respect.
• Empowerment.
• Narrative
• Identity beyond “the homeless person.”
• Validation of strengths and person.
• Affirming their humanity (“Rehumanizing.”)

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Trauma Informed Care

• Existentialism and Trauma Informed Care both create resiliency, which is a protective factor.
• Homelessness is traumatizing due to constant stress and risk.
• Hypervigilance is a sign of trauma. For homeless individuals it is a survival skill.
• Trauma Informed Care (TIC) provides service in a way that does not retraumatize, rather promotes empowerment.
• Trauma informed care aligns with APS guidelines.

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TIC and APS

• Trauma Informed Care Principles.
• Safety: Ensure they have emotional and physical safety.
• Choice: Give the individual a part in choice and control
• Collaboration: Shared power in decision making.
• Trustworthiness: Build with consistency and boundary setting.
• Empowerment: Prioritize empowerment and skill building when necessary.

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Refer to your APS guidelines and type in chat box what aligns with these TIC principles.

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Putting it All Together

• Teaching A Person How to Fish:
• Requires knowing where they are.
• Some might need the purpose of a fishing pole explained.
• Some might only need the outfitted pole and “ask questions as needed.”
• In between are many other levels individuals can be at.
• How do you correctly assess and collaborate w/ individuals without overestimating, or underestimating their strengths and needs?
• Read the vignette and determine:
• Risk factors?
• Protective factors?
• How do you engage this individual?
• How do you collaborate with them? (Tasks, strengths, needs, etc.)
• Areas of health they may want to first address?

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Activity Debrief

What did you come up with?

• Risk Factors
• Protective Factors
• How do you engage?
• How do you collaborate with them?
• Areas of health they may want to address first?

Closing and Evaluations

• This was workshop one of series
• Humans have multiple layers and each bring bias
• Person-led interventions

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• Questions?
• Thank you for participating in this training.
• Thank you for your commitment to all individuals in our communities.
• Evaluations

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Thank You!

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We envision a world where the quality of life for individuals, organizations, and communities is transformed to a healthier place.