Description of Target Population and Geographic Area Served
The project proposes to serve at least 30 homeless individuals with co-occurring disorders living in Los Angeles, particularly in areas of high concentration of homelessness. As demonstrated below, this is a fairly large, diverse, high-risk population in need of significant intervention.
To date, there is a significant lack of prevalence data on individuals with co-occurring disorders and even less data on those who are also homeless specifically in Los Angeles. The only existing national data available are two extensive surveys, the National Co-Morbidity Survey (NCS) and Epidemiologic Catchment Area (ECA) Survey, which were conducted and analyzed over the past two decades. Estimates from both studies report that during a 12-month period, 22 to 23 percent of the U.S. adult population (44 million people), had a diagnosable mental disorders (U.S. DHHS, 1999b). Of this population it is estimated that 15 percent (6.6 million) adults also have a co-occurring substance abuse disorder.
Much like the lack of prevalence data on the national level there is very little existing data on the prevalence of homeless individuals with co-occurring disorders in the geographic region of Los Angeles. Estimates of the number of people who are homeless in the Los Angeles County vary, in large part due to the various methodological variables such as various definitions of homelessness, time frames, and location. Despite these limitations in data collection, several studies have reported that Los Angeles does have higher rates of homelessness than the nation as a whole (SAMHSA, 2002). Recent research estimates that approximately 80,000 men, women, and children are homeless in Los Angeles County each night (Institute for the Study of Homelessness and Poverty, 2004). Of this population local data suggests that 13-16 percent have co-occurring disorders (Institute for the Study of Homelessness and Poverty, 2004; City of Los Angeles’ 2003-2008 Consolidated Plan, LAHSA, 2001)
In addition to the available data regarding the number of homeless individuals with co-occurring disorders in Los Angeles, there is some local demographic data that describe characteristics of our target population. A recent demographic profile compiled by the California Department of Mental Health found that the following characteristics of individuals with co-occurring disorders in Los Angeles: they are primarily individuals; men (64%), African American (54%), U.S. citizens (86%), and between the ages of 25-45 (57%) (DMH, 2003; Institute for the Study of Homelessness and Poverty, 2004). In addition, it is also estimated that veterans represent approximately 14% to 20% of the homeless population, with Vietnam veterans composing the largest subgroup of this population. Many of the veterans have experienced at least three serious psychiatric symptoms during their life. Given the available local demographic data on homeless individuals with co-occurring disorders, it is important to note that due to the limitations in data collection, as mentioned above, the existing demographic data may not accurately capture our target population of homeless individuals with co-occurring disorders.
Given the available data and its limitations, the following can be summarized regarding the ethnic and language profile of our target population of homeless individuals with co-occurring disorders. Recent data suggest that homeless African Americans/Blacks in Los Angeles are disproportionately represented among the homeless population, with estimates that range anywhere from 17% to 50%. When you compare these rates to the national percentage of African Americans/Blacks at 10% it appears that this population is disproportionately affected by homelessness. In contrast to the number of homeless African Americans/Blacks reported, it appears that other ethnic groups are under-reported. For example, the Latino homeless population appears to be under-reported when you compared the reported number of Latino homeless in comparison to national data suggesting an increasing number of Latinos that are living at or below the poverty line. In addition, to ethnicity available data suggest that the majority of our target population, are U.S. citizens who are English proficient. Estimates show that only 6% of the overall homeless population in Los Angeles, have limited English proficiency.
Recent socio-economic data on our target population of homeless individuals with co-occurring disorders suggest that approximately 16% to 20% of the homeless adults who are currently employed are living well below the poverty line (Institute for the Study of Homelessness and Poverty, 2004). This same data also suggests that people residing in shelters find employment in low-end service or sales industries, including security guards, janitors, food service workers, etc. Those living on the streets typically earned money by taking short-term employment, collecting recycling goods, and panhandling. Studies also show that homeless individuals commonly underutilize public benefits, due to their lack of knowledge of their eligibility or their inability to successfully navigate the application process (Institute for the Study of Homelessness, 2004). Studies have found that as many as 42% to 77% of homeless individuals who are entitled to benefits do not receive them. Of those who are able to successfully obtain benefits, local data suggests that 46% of the Los Angeles Homeless population reside in our targeted geographic region of South and Metro Los Angeles (SPA 6 and 4) (2003 Economic Roundtable).
Despite the cultural differences in ethnicity and language one primary value and belief that is shared among our target population is the element of survival. Concentrated areas of homeless with histories of substance abuse, mental illness, and criminal behavior tend to be intense, chaotic, and potentially dangerous environments. Individuals living in these areas have to not only provide for their basic necessities with few or no resources, but also have to protect themselves from harm. This environment can influence choices that are otherwise antisocial such as theft or prostitution. Individuals in such a survival mode thus need treatment that is nonjudgmental and that focuses on constructive survival skills and on increasing legitimate access to resources.
Nature of the Problem and Extent of the Need for the Target Population
The proposed project seeks to address three significant problems our target population commonly face: co-occurring disorders, homelessness, and limited self-sufficiency.
Currently there is a growing body of knowledge of the nature of co-occurring disorders. According to the SAMHSA’s Treatment Improvement Protocol (TIP), “co-occurring disorders” can be defined as “the presence of a combination of at least one mental health disorder as well as an alcohol or drug use disorder.” Co-occurring disorders may also vary among dimensions of severity, chronicity, and degree of impairment in functioning (SAMHSA, 2002). Some common examples of co-occurring disorders include major depression with cocaine addiction, alcohol addiction with panic disorder, alcohol and polydrug addiction with schizophrenia and borderline personality disorder with epidsoidic polydrug use (CSAT, 1994). With 13-16% of Los Angeles’ homeless population being affected by co-occurring disorders the need for an integrated system of care that effectively treats both disorders clearly supports the need to target this population for intervention (Institute for the Study of Homelessness and Poverty, 2004; City of Los Angeles’ 2003-2008 Consolidated Plan, LAHSA, 2001).
The second significant problem our target population faces is the risk of homeless. Individuals with co-occurring disorders comprises a particularly vulnerable group who are at greater risk for homelessness and are more likely to remain homeless than other groups (SAMHSA, 2002). Studies have found this particular population appears to be at greater risk for homelessness due to the presence of more severe symptoms of mental illness, abuse of multiple substances, denial of both their illnesses, and refusal to comply with treatment plans (SAMHSA, 2002; SAMHSA, 1998). There are also several additional contributing factors to homelessness for this population including: the presence of severe medical conditions, financial/legal problems, inability to maintain stable housing, behavioral problems, skill deficits, and a loss of social support systems (SAMHSA, 1998; Drake et al., 1997, SAMHSA, 2002). Homelessness is a significant problem for our target population because homelessness can significantly compromise the chances of recovery from either or both disorders, and it may also contribute to the exacerbation of symptoms (SAMHSA, 1998).
The third significant problem facing our target population is limited self-sufficiency. Individuals with co-occurring disorder commonly face multiple barriers to self-sufficiency including poor independent living skills and social function; limited vocational skills; low or no income; disruptive, antisocial and criminal behavior; histories of trauma; poor coping skills; and loss of connections with meaningful support systems (SAMHSA, 2002). These multiple barriers ultimately compromise this population’s efforts toward recovery. In order to effectively address these multiple barriers, treatment interventions should promote self-sufficiency through the development of vocational and life skills training that will enable this population to regain a sense of their own ability to effective positive changes in their lives. These interventions will also further recognize this problem by: developing an individuals’ motivation to change; developing effective coping strategies and behaviors; stabilizing their psychiatric symptoms, and attain sobriety (SAMHSA, 2002).
Hence, typical target participant will enter homeless, abusing substances, exhibiting symptoms of mental illness, with low or no income, and with limited independent living skills and social functioning levels. Given the complex nature and interplay of the problems of co-occurring disorders, homelessness, and limited self-sufficiency, we propose to serve this target population at multiple levels of intervention. The need to effectively address the complex and diverse needs of our target population is made even more immediate due to the lack of integrated services currently available. In an effort to address this demonstrated need, our proposed program will address the existing fragmentation of mental health and substance abuse services by providing a comprehensive and integrated system of care that will address the diverse needs of this population.