EARLIER THIS YEAR, the US Department of Veterans Affairs announced its ambitious 2023 goals toward preventing and ending veteran homelessness, including ensuring that 95 percent of veterans recently housed nationally do not return to homelessness this year.
This is admirable, and it is potentially achievable, if there is an investment in – and commitment to – providing supportive services, including behavioral health care, primary care and employment services, in equal measure to housing. Housing is the starting point; wraparound services sustain it.
In Massachusetts, an estimated 534 veterans were unhoused in 2022, representing approximately 3.4 percent of the Commonwealth’s overall homeless population. We have made significant strides in reducing the number of veterans experiencing homelessness in the last three years, seeing an overall 36 percent drop between 2020 and 2022, but those who remain unhoused are suffering from increasingly complex behavioral health and medical challenges.
At a program our agency operates, data suggests that 80 percent to 90 percent of veterans seeking services have co-occurring disorders – both a mental health condition and substance use disorder. These are interwoven illnesses that must be treated comprehensively.
We know that many of the barriers to providing timely access to behavioral health and addiction treatment services are rooted in the disparate nature of the health and human services system, siloed funding streams, persistent stigma, and resistance to change. One way of decreasing those barriers is to encourage agencies that fund housing to also provide access points to clinical services.
Stable housing has been demonstrated to improve health outcomes, just as access to care nurtures the likelihood of long-term housing success. There is no wrong door to treatment and care should be trauma-informed given the population being served.
What is trauma-informed care? It reflects a change in the approach to treatment from “what is wrong with you?” to “what happened to you and how can we help?” It acknowledges that the trauma one may have experienced – whether it is the horror of battle or childhood abuse – can have a profound, lifelong effect on one’s psychological as well as physical health, and also on how one interacts with, or why one may avoid, certain health care delivery systems.
People who have been traumatized interact with safety net systems – most notably the health care system – differently. They may avoid treatment altogether, or struggle to consistently attend all appointments or adhere to a rigid set of expectations. Trauma-informed care is about empowerment – it gives veterans a voice and a choice, and services that are available when they’re ready to engage.
Veterans are more likely to have experienced trauma when compared to the general population. Post-Traumatic Stress Disorder – or PTSD – was first identified in soldiers. There is perhaps no greater evidence of this connection between military service and trauma than in the veteran suicide rate: In 2020, there were 6,146 veteran suicides nationally. While veterans make up only 6 percent of the adult population, they account for 14 percent of all suicides. This overrepresentation is a national tragedy, and one that we must address by providing veterans with appropriate services.
Such services must be evidence-based and holistic, and would require a certain level of customization for each individual. However, the goal for all is to receive services through an approach that ensures that they are treated as a person who has happened to experience a traumatic event, rather than as someone who is solely defined by its effects.
Moreover, we must stop viewing behavioral health as separate from physical health. Mental health conditions can cause physical illness and vice versa. For instance, some untreated behavioral health conditions, data shows, can lead to diabetes. Conversely, improving one’s mental health care can reduce high blood pressure.
New housing designed for veterans must efficiently integrate both behavioral health care and primary medical care. New models of care are emerging that master this integration by locating all of these services in one setting, which increases the odds that a veteran will get comprehensive care and achieve recovery.
Housing is the place to begin, but it is not the solution. Low-threshold services that accompany housing substantially boost the odds of long-term success, marked by increased engagement in mental health treatment, as well as employment and independence.
Charles Gagnon is the president and CEO and Samata Sharma is chief medical officer of Volunteers of America of Massachusetts (VOAMASS).