Victimization, safety, and overdose in homeless shelters: A systematic review and narrative synthesis

Bridging the Gap: Implementing Consultation-Liaison Psychiatry for Mental Illness in Unhoused Populations

BACKGROUND AND OBJECTIVES

California has one of the largest unhoused populations in the United States, a crisis compounded by the prevalence of untreated mental illness among those living on the streets. In this Perspective, we elucidate the critical importance of addressing mental illness within California's and other states' unhoused populations, who often are overlooked and not connected to psychiatric services.

METHODS AND RESULTS

We propose the consultation-liaison (C/L) psychiatrist as a bridge between community outreach teams and psychiatric services, in addition to their traditional roles in inpatient and outpatient psychiatry. Drawing upon clinical experience, literature review, and community insights, we underscore the urgent need for comprehensive mental health interventions to mitigate the profound impact of psychiatric disorders on unhoused individuals and consider the C/L psychiatrist to be particularly skilled in this endeavor.

DISCUSSION

We highlight the safety concerns, improved quality of life, and other benefits of timely recognition and treatment of mental illness in unhoused populations.

Exploring the Role of Racial Microaggressions in the Association Between Depression Symptoms and Drug Use and Related Harm Among Women of Color Experiencing Intimate Partner Violence

Objective: Drug use and related harm among women of color who experience intimate partner violence (IPV) is a serious clinical concern. Depression symptoms have been identified as an important risk factor for the development of drug use and related harm among women of color with a history of IPV. The current study advances this research by examining the roles of distinct domains of racial microaggressions in the relation between depression symptoms and drug use and related harm in this population. Method: Participants were 103 women of color experiencing IPV (Mage = 40.39, 51% Black/African American). Results: Results indicated an indirect effect of depression symptoms on drug use and related harm via racial microaggression domains of Assumptions of Inferiority, Second-Class Citizen and Assumptions of Criminality, Microinvalidations, Exoticization and Assumptions of Similarity, and Environmental Microaggressions. Conclusions: Findings provide preliminary support for the role of racial microaggressions in the association between depression and drug use and related harm among women of color experiencing IPV.

Antecedents and Consequences of Violence in Homeless Shelters: Perspectives and Experiences of Service Users and Shelter Staff

Violence is a critical issue in homeless shelters that affects service users and staff, yet there is limited evidence on how shelter-based violence occurs. The objective of this qualitative study was to investigate the antecedents and consequences of shelter-based violence from the perspectives of service users and staff. Purposive sampling was used to recruit individuals experiencing homelessness and shelter staff in a large metropolitan city in Ontario, Canada. Data from in-depth interviews with 56 individuals experiencing homelessness and 30 shelter staff were analyzed. Findings showed that shelter-based violence toward service users and staff was perceived to manifest in response to three interacting factors: (a) burden of homelessness and shelter living, (b) individual histories and marginalization, and (c) interpersonal conflict. These antecedents had a hierarchical structure in that each subsequent factor exacerbated the risk of previous ones and culminated with the most proximal factor for violence. There were three primary outcomes of shelter-based violence reported by service users and staff: (a) health and environmental harms, (b), procedural enforcement, and (c) avoidant behaviors. Avoidance was often a subsequent impact following health harms, as was procedural enforcement to a lesser extent. Overall, the study findings demonstrate that shelter-based violence is a complex and dynamic problem that is perceived to be the result of interacting structural, environmental, programmatic, interpersonal, and individual factors, with similar consequences for service users and staff. Implications for preventing violence through shelter design and service delivery are discussed.

Developing a comprehensive inventory to define harm reduction housing

BACKGROUND

The City of Boston has faced unprecedented challenges with substance use amidst changes to the illicit drug supply and increased visibility of homelessness. Among its responses, Boston developed six low threshold harm reduction housing (HRH) sites geared towards supporting the housing needs of people who use drugs (PWUD) and addressing health and safety concerns around geographically concentrated tent encampments. HRH sites are transitional supportive housing that adhere to a "housing first" approach where abstinence is not required and harm reduction services and supports are co-located. Despite the importance of HRH, the specific characteristics and operations of these sites are not well understood. This study sought to address this gap by cataloging the common features of Boston's HRH sites to generate a comprehensive inventory tool for evaluating implementation of harm reduction strategies at transitional housing locations.

METHODS

We collected data between June and September 2023 and included semi-structured qualitative interviews with HRH staff (n = 19), ethnographic observations and photos at six HRH sites. Candidate inventory components were derived through triangulation of the data. Two expert medical staff unaffiliated with data collection reviewed a draft inventory measuring awareness and utility of HRH inventory components. We then pilot tested the inventory with three HRH residents across two sites for readability and reliability. Awareness, frequency of use, and perceived helpfulness of key inventory items were further tested in a survey to 106 residents.

RESULTS

HRH staff identified best practices, resources, and policies in HRH sites that were further contextualized with ethnographic field notes. Common to all were overdose prevention protocols, behavioral policies, security measures, and distribution of harm reduction supplies. The initial 44-item inventory of services, policies and site best practices was further refined with expert and participant feedback and application, then finalized to generate a 32-item inventory. Residents identified and valued harm reduction services; medical supports were highly valued but less utilized.

CONCLUSION

The HRH inventory comprehensively assesses harm reduction provision and residents' awareness and perceived helpfulness of HRH operational components in staying safe from drug-related harms. Characterizing the critical components of HRH through this tool will aid in standardizing the concept and practice of HRH for PWUD and may assist other cities in planning and implementing HRH.

Towards a "trauma-informed spaces of care" model: The example of services for homeless substance users

While clinical practitioners have long recognized the importance of trauma-informed models of care, geographies of care scholars have been slow to engage with and address trauma in its methodologies for better understanding environments that support, or hinder, care for people. Marrying the conceptual contributions of geographies of care, trauma geographies, and geographies of addiction, this paper aims to advance the inquiry of trauma-informed spaces of care. Drawing on the example of the homeless substance user, we present a novel theoretical imperative for considering trauma on both an individual and collective level for advancing spatial interventions for healing in spaces of care.

Housing instability increases for stimulant-involved overdose deaths after linking surveillance data to electronic health records in Kentucky

BACKGROUND

According to the U.S. Centers for Disease Control and Prevention, approximately 10.2 % of fatal overdoses in 2022 were among people experiencing homelessness or housing instability. In the United States, the majority of all drug overdoses now involve stimulants.

METHODS

We linked stimulant-involved fatal overdose records occurring between 2017 and 2021 from Kentucky's Drug Overdose Fatality Surveillance System to the electronic health records (EHR) of the state's largest safety-net hospital network. We used State Unintentional Drug Overdose Reporting System (SUDORS) definitions of homelessness or housing instability to establish baseline estimates before linking decedents to medical records. After linkage, we augmented SUDORS data with structured administrative billing codes, semi-structured address data, and unstructured clinical notes identifying homelessness from the EHR.

RESULTS

There were 313 individuals with stimulant-involved fatal overdoses linked to at least one medical encounter in the EHR (2017-2021). Thirty-three individuals (10.5 %) were identified as having unstable housing according to SUDORS. After linkage, 130 individuals (41.5 %) had evidence of housing instability. For this period, these 313 individuals represent 8.0 % of stimulant-involved overdoses in KY or 38.5 % of stimulant-involved overdoses from residents of the primary and secondary catchment area of our healthcare network.

CONCLUSIONS

The single-site increase in observed housing instability in stimulant-involved fatal overdoses suggests that increased data linkage between state medicolegal death investigation system and EHRs would significantly improve the public health surveillance of overdoses.

Developing a Comprehensive Inventory to Define Harm Reduction Housing

Background

The City of Boston has faced unprecedented challenges with substance use amidst changes to the illicit drug supply and increased visibility of homelessness. Among its responses, Boston developed six low threshold harm reduction housing (HRH) sites geared towards supporting the housing needs of people who use drugs (PWUD) and addressing health and safety concerns around geographically concentrated tent encampments. HRH sites are transitional supportive housing that adhere to a "housing first" approach where abstinence is not required and harm reduction services and supports are co-located. Despite the importance of HRH, the specific characteristics and operations of these sites are not well understood. This study sought to address this gap by cataloging the common features of Boston's HRH sites to generate a comprehensive inventory tool for evaluating implementation of harm reduction strategies at transitional housing locations.

Methods

We collected data between June and September 2023 and included semi-structured qualitative interviews with HRH staff (n = 19), ethnographic observations and photos at six HRH sites. Candidate inventory components were derived through triangulation of the data. Two expert medical staff unaffiliated with data collection reviewed a draft inventory measuring awareness and utility of HRH inventory components. We then pilot tested the inventory with 3 HRH residents across two sites for readability and reliability. Inventory performance was further tested in a survey of 106 residents.

Results

HRH staff identified best practices, resources, and policies in HRH sites that were further contextualized with ethnographic field notes. Common to all were overdose prevention protocols, behavioral policies, security measures, and harm reduction supplies distribution. The initial 44-item inventory of services, policies and site best practices was further refined with expert and participant feedback and application, then finalized to generate a 32-item inventory. Residents identified and valued harm reduction services; medical supports were highly valued but less utilized.

Conclusion

The HRH inventory comprehensively assesses harm reduction provision and residents' awareness and perceived helpfulness of HRH operational components. Characterizing the critical components of HRH through this tool will aid in standardizing the concept and practice of HRH for PWUD and may assist other cities in planning and implementing HRH.

Health status and self-perception of health among homeless people in Spain: a mixed-methods study

Introduction

Homelessness is a phenomenon of social exclusion and poverty that has increased alarmingly during recent years. Homeless people (HP) experience violations of several basic human rights or needs that impact their well-being. Therefore, the aim of this research was to assess the health status and self-perceived health of HP and examining the impact of homelessness on their health.

Methods

We used an explanatory sequential mixed-methods approach that integrated a quantitative cross-sectional study within critical social and ethno-sociological qualitative frameworks. Data were collected in Palma, Spain, from December 1, 2020, to January 1, 2023. A total of 198 HP were recruited from the streets and public areas. Basic human needs (Virginia Henderson model), medical diagnoses, substance abuse (DAST-10), diet quality (IASE), depression (PHQ-9), and social support (SSQ-6) were assessed. Then, 17 semi-structured interviews were conducted and were analyzed using thematic content and discourse analysis. Quantitative and qualitative data were integrated and jointly analyzed.

Results

The 79.3% of the participants were men, mean age of 47.8 ± 12.2 years. The 76.4% were Spanish. The participants reported severe difficulties in accessing the labor market, and that this greatly affected their self-esteem and mental health. The 48.9% of the participants suffered from one or more chronic diseases, and 50.3% were diagnosed with a mental health disorder. The participants generally did not consider health problems as a central concern. The health needs that most affected the participants were related to food, safety, and social support. HP frequently felt unsafe, fearfully, and anxious.

Conclusion

Homelessness, unemployment, and social exclusion have significant negative impacts on the health and wellbeing of HP. Precarious work conditions and deficiencies in the welfare system contribute significantly to homelessness. These results highlight the need for systemic solutions that extend beyond short-term housing initiatives.

Service restrictions from emergency shelters among people experiencing homelessness: Uncovering pathways into unsheltered homelessness and institutional circuitry

Service restrictions refer to temporary or permanent bans of individuals from a program or an organization's services, and are widely used in emergency shelter systems. Limited research exists on how service restrictions unfold and their impacts on people experiencing homelessness. This qualitative study used in-depth interviews with timeline mapping to examine the antecedents and consequences of service restrictions from emergency shelters among people experiencing homelessness in two cities in Ontario, Canada. A total of 49 people experiencing homelessness who had been restricted from an emergency shelter program in the past year were recruited and included in the study analysis. A pragmatic and integrative approach was used for data analysis that involved the development of meta-matrices to identify prominent and divergent perspectives and experiences with regard to service restriction antecedents and consequences. Study findings underscored that service restrictions were often the result of violence and aggression, primarily between service users. There were regional differences in other service restriction reasons, including substance use and possession. Service restrictions affected the shelter status of almost all participants, with many subsequently experiencing unsheltered homelessness, and cycling through institutional health, social, and criminal justice services (i.e., institutional circuitry). Other health and social consequences included substance use relapses and hospitalizations; cold-related injuries due to post-restriction unsheltered homelessness; suicidality; food insecurity; diminished contact with support network and connections; and intense feelings of anger, fear, and hopelessness. Overall, the study findings advance our understanding of the role of homeless services in pathways into unsheltered homelessness and institutional circuitry, which raise critical questions about how to mitigate the harms associated with service restrictions, while concurrently facilitating safety and upholding the rights of people experiencing homelessness and emergency shelter staff.