Housing is an important health factor among low-income and homeless people in the community, including veterans. New research revealed that clinicians should view veterans’ housing status and their behavioral health factors, including loneliness and substance use disorder.1
Social workers and case managers should keep veterans’ housing and substance use struggles in mind.
Investigators interviewed veterans in project-based housing and found substance use and social isolation were common themes, says Max Winer, LICSW, MPH, primary care social worker at Edith Nourse Rogers Memorial Veterans Hospital in Bedford, MA.
“One of the really nice things about the study was with qualitative work, you get a rich sense of what’s actually going on,” Winer says. “We had the actual perspective and words from participants.”
For example, many veterans talked about their struggle with substance use disorders. “One of the focuses of the study was socialization and social engagement,” Winer says. “Project-based housing is a congregate type of living; it’s more communal living.”
The apartments are independent, with their own bedrooms, kitchens, and bathrooms. But people share communal spaces, and Veterans Affairs (VA) staff are on site, along with social workers. “There’s more support built into project-based housing,” Winer says.
Substance Use Is a Struggle
Even with support, the veterans struggled with substance use issues. “They felt unsafe or frustrated because they were trying to maintain their own sobriety, but with certain triggers, it was difficult,” Winer explains. “Triggers could be someone knocking at their door or someone using substances around them.”
Social isolation also caused frustration. To avoid substance use triggers, residents sometimes missed out on social activities and interactions.
“It’s challenging for someone to engage socially if there is substance use going on and they’re trying to maintain their sobriety,” Winer says.
Maintaining sobriety was easier for veterans who had access to detox services, post-detox programs, and aftercare. “The proximity of [project-based housing] to a hospital was a positive association for veterans being able to get support for their substance use,” Winer says.
Transportation was a major issue for those who lived farther from hospitals and medical support. “Transportation was really tough for most of the veterans we interviewed,” Winer says. “Resources were limited, and that was a major barrier for those folks.”
Isolation Is an Issue
Isolation was tied to both behavioral health and physical health issues. “In my mind, they are all tied together,” Winer says. “Substance use relates to physical health, and the mental health of a person can impact their interest and ability to engage socially.”
Because of their past and present struggles with substance use, many of the veterans found it difficult to feel like they belonged to a community that would be positive for their health. “It felt like socialization was centered around either their using substances or trying not to use substances,” he adds.
But the interviews suggested veterans wanted to be social and maintain friendships and support networks. “Most people want support and people they can call friends,” Winer says. “Many of those veterans did not have strong friendships or a lot of family, but it was clear they were interested in being social.”
Researchers also found project-based communities offer programs and activities that can help tenants, but their engagement could be low. “That was something we talked a lot about on the research team,” Winer says. “It has to do with anxiety of veterans in social settings.”
Anxiety can run high among people who have been homeless. Almost all of them were chronically homeless before entering this program. “Suddenly, they’re housed and there are a lot of people in that situation,” he says. “It can be very scary for folks who’ve been homeless for a long time.”
The veterans often would not take advantage of those opportunities, even if they were interested. “Homelessness is a traumatic experience,” Winer says.
Trauma Can Create Barriers
People who have survived traumatic experiences find it difficult to engage in social activities and build friendships. “It’s about thinking of the context of each individual person’s experience, tragedy, and how they’re housed,” Winer explains. “When working with veterans, do so however they’re comfortable and think about what can help them relearn.”
From a case management perspective, working with a population that has experienced homelessness and substance use disorders requires a multifaceted approach to helping them with their needs, whether for medical care, social-behavioral care, or to overcome social determinants of health obstacles.
“A lot of it is meeting [people] where they are,” Winer says. “There has to be some buy-in and some empowerment from the client to seek progress.”
Case managers should listen to what their patients/clients want from their recovery. Their attitude should be nonjudgmental and open to helping the person meet his or her own goals for the next step. “Relying on multidisciplinary professionals is important, too,” Winer notes.
People may need mental health specialists, substance use professionals, and others on their team. “This is so the case manager is not carrying everything, and there are a lot of different voices and support for the client,” Winer explains.
- Winer M, Dunlap S, St Pierre C, et al. Housing and social connection: Older formerly homeless veterans living in subsidized housing and receiving supportive services. Clin Gerontol 2021;1-10.