TIP 55

A TreATmenT ImprovemenT proTocol

Behavioral Health 

Services for People 

Who Are Homeless
A Treatment Improvement Protocol

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment

1 Choke Cherry Road 

Rockville, MD 20857

Behavioral Health 

Services for People 

Who Are Homeless 

TIP 55 
 

 

 

 

 

Behavioral Health Services for People Who Are Homeless 

Acknowledgments 

This publication was produced under contract number 270-09-0307 by the Knowledge Application Program (KAP), a Joint Venture of The CDM Group, Inc., and JBS International, Inc., for

the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department

of Health and Human Services (HHS). Christina Currier served as the Contracting Officer’s 

Representative. 

Disclaimer 

The opinions expressed herein are the views of the consensus panel members and do not necessarily reflect the official position of SAMHSA or HHS. No official support of or endorsement by 

SAMHSA or HHS for these opinions or for the instruments or resources described is intended

or should be inferred. The guidelines presented should not be considered substitutes for individualized client care and treatment decisions. 

Public Domain Notice 

All materials appearing in this volume except those taken directly from copyrighted sources are 

in the public domain and may be reproduced or copied without permission from SAMHSA or

the authors. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS. 

Electronic Access and Copies of Publication 

This publication may be ordered for free from SAMHSA’s Publications Ordering Web page at

http://store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) 

(English and Español). The document can be downloaded from the KAP Web site at

http://kap.samhsa.gov. 

Recommended Citation 

Substance Abuse and Mental Health Services Administration. Behavioral Health Services for People Who Are Homeless. Treatment Improvement Protocol (TIP) Series 55. HHS Publication No. 

(SMA) 13-4734. Rockville, MD: Substance Abuse and Mental Health Services Administration,

2013. 

Originating Office 

Quality Improvement and Workforce Development Branch, Division of Services Improvement,

Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857. 

HHS Publication No. (SMA) 13-4734

First Printed 2013 

ii 
 

 

 

 

 

 

 

 

Contents 

Consensus Panel............................................................ v
 

What Is a TIP?............................................................ vii
 

Foreword ................................................................ . ix
 

How This TIP Is Organized................................................... xi
 

PART 1: A PRACTICAL GUIDE FOR THE PROVISION OF BEHAVIORAL
 

HEALTH SERVICES ...................................................... 1
 

Part 1, Chapter 1............................................................... 3
 

Introduction ............................................................... 3
 

Homelessness in America .................................................... 11
 

Homelessness and Behavioral Health Services.................................... 17
 

Stages of Change, Recovery, and Rehabilitation................................... 25
 

Clinical Interventions and Strategies for Serving People Who Are Homeless ........... 32
 

Special Issues in Service Delivery.............................................. 44
 

Community Housing Services for People Who Are Homeless....................... 46
 

You Can Do It ............................................................ 54
 

Part 1, Chapter 2.............................................................. 55
 

Introduction .............................................................. 55
 

Vignette 1—Juan .......................................................... 57
 

Vignette 2—Francis ........................................................ 72
 

Vignette 3—Roxanne ....................................................... 83
 

Vignette 4—Troy ......................................................... 100
 

Vignette 5—René ......................................................... 113
 

Vignette 6—Mikki ........................................................ 129
 

Vignette 7—Sammy ....................................................... 139
 

PART 2: AN IMPLEMENTATION GUIDE FOR BEHAVIORAL HEALTH 


PROGRAM ADMINISTRATORS ......................................... 149
 

Part 2, Chapter 1............................................................. 151
 

Introduction ............................................................. 151
 

Developing Services for Clients Who Are Homeless ............................. 152
 

The Housing First Approach ................................................ 153
 

iii 
Behavioral Health Services for People Who Are Homeless 

 

 

 

 

. .................................................... . .

Exhibit 1-3: Stages of Change .............................................. . .

10
 

25
 

...

 

Exhibit 1-2: Agencies That Provide Substance Abuse Prevention and Mental Health
 

Promotion Services

Exhibit 1-4: Behavioral Health Service Provider Roles and Best Practices 

According to Stage of Recovery 

Challenges in Adapting Programs To Address the Needs of People Who Are Homeless .... 155
 

Modifying Behavioral Health Services To Meet the Needs of Clients Who Are Homeless . . 157
 

Interacting With Community Resources To Build a Continuum of Care.............. 162
 

Collaborative Partnerships .................................................. 162
 

Internet Resources ........................................................ 166
 

Integrating Behavioral Health Services With a Community System of Homelessness 

Services............................................................... 166
 

Building Linkages Among Services ........................................... 173
 

Funding Community Homelessness Services.................................... 175
 

Part 2, Chapter 2............................................................. 179
 

Introduction ............................................................. 179
 

Organizational Approaches to Programming for Homelessness Services .............. 179
 

Sample Policies and Procedures .............................................. 183
 

Sample Forms ............................................................ 190
 

Appendices


Appendix A—Bibliography ................................................. 199
 

Appendix B—Advisory Meeting Panel ........................................ 213
 

Appendix C—Stakeholders Meeting Participants................................ 215
 

Appendix D—Field Reviewers............................................... 219
 

Appendix E—Acknowledgments............................................. 221
 

Index .................................................................. 223
 

Exhibits
 

Exhibit 1-1: Types of Prevention as Described by the Institute of Medicine ............. 8
 

......................................... 27


Exhibit 1-5: Substance Use and Mental Disorder Recovery Processes ................. 28
 

Exhibit 1-6: Promising and Evidence-Based Practices by Rehabilitation Stage .......... 40
 

Exhibit 1-7: Housing Designations and Readiness to Change Substance Use ........... 52
 

Exhibit 2-1: Range of Estimated Service Costs per Day by Setting .................. 153
 

Exhibit 2-2: Key Components for Bottom-Up Modification ....................... 158
 

Exhibit 2-3: Integrated System of Homelessness Services ......................... 163
 

Exhibit 2-4: How To Develop Partnerships .................................... 165
 

Exhibit 2-5: How To Document Partnerships .................................. 165
 

iv 
 

Consensus Panel
 

Consensus Panels Chair 

Hunter L. McQuistion, M.D. 

Director, Division of Outpatient &

Community Psychiatry

Department of Psychiatry and Behavioral 

Health 

The St. Luke’s and Roosevelt Hospitals

Associate Clinical Professor of Psychiatry

Columbia University College of Physicians &

Surgeons

New York, NY 

Part 1 Consensus Panelists 

Jennifer Frey, Ph.D.

KAP Expert Content Director

The CDM Group, Inc.

Bethesda, MD 

Eugene Medina

Aurora, CO 

Jesse B. Milby, Jr., Ph.D.

University of Alabama at Birmingham

Department of Psychology

Birmingham, AL 

Douglas J. Warn, LCSW-R

Brooklyn, NY 

Tommy Wyatt 

Beliflower, CA 

Part 2 Consensus Panelists 

Jennifer Frey, Ph.D.

KAP Expert Content Director

The CDM Group, Inc.

Bethesda, MD 

Debbie Fisk, LCSW

Director 

Outreach and Engagement Project

New Haven, CT 

Kelvin M. Silver, M.Ed., LCPC, LCADC, 

CRC, NCC

Baltimore, MD 

v 

 

 

 

 

What Is a TIP? 

Treatment Improvement Protocols (TIPs) are developed by the Substance Abuse and Mental 

Health Services Administration (SAMHSA) within the U.S. Department of Health and Human

Services (HHS). Each TIP involves the development of topic-specific best-practice guidelines 

for the prevention and treatment of substance use and mental disorders. TIPs draw on the experience and knowledge of clinical, research, and administrative experts in various forms of treatment and prevention. TIPs are distributed to facilities and individuals across the country.

Published TIPs can be accessed via the Internet at http://kap.samhsa.gov. 

Although each consensus-based TIP strives to include an evidence base for the practices it recommends, SAMHSA recognizes that behavioral health is continually evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey 

“front-line” information quickly but responsibly. If research supports a particular approach, citations are provided. 

vii 

 

 

Foreword
 

The Treatment Improvement Protocol (TIP) series fulfills the Substance Abuse and Mental 

Health Services Administration’s (SAMHSA’s) mission to improve prevention and treatment of

substance use and mental disorders by providing best practices guidance to clinicians, program

administrators, and payers. TIPs are the result of careful consideration of all relevant clinical and

health services research findings, demonstration experience, and implementation requirements. A 

panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates debates and discusses their particular area of expertise until they reach a consensus on best

practices. This panel’s work is then reviewed and critiqued by field reviewers. 

The talent, dedication, and hard work that TIP panelists and reviewers bring to this highly participatory process have helped bridge the gap between the promise of research and the needs of

practicing clinicians and administrators to serve, in the most scientifically sound and effective

ways, people in need of behavioral health services. We are grateful to all who have joined with us 

to contribute to advances in the behavioral health field. 

Pamela S. Hyde, J.D.

Administrator 

Substance Abuse and Mental Health Services Administration 

H. Westley Clark, M.D., J.D., M.P.H., CAS, Paolo del Vecchio, M.S.W.

FASAM Director 

Director Center for Mental Health Services 

Center for Substance Abuse Treatment Substance Abuse and Mental Health Services 

Substance Abuse and Mental Health Services Administration 

Administration 

ix 

 

 

 

How This TIP Is Organized 

This Treatment Improvement Protocol (TIP) is divided into three parts:

•	 Part 1: A Practical Guide for the Provision of Behavioral Health Services 

•	 Part 2: An Implementation Guide for Behavioral Health Program Administrators 

•	 Part 3: A Review of the Literature 

Part 1 is for behavioral health service providers and consists of two chapters. Chapter 1 illustrates 

typical problems and issues that arise in behavioral health counseling with people who have experienced or currently are experiencing homelessness. It covers:

•	 Approaches that address the counselor’s setting, role, and responsibilities. 

•	 Screening/assessment, client-centered treatment planning, treatment processes, and continuing care. 

Part 1, Chapter 2, presents seven vignettes; each describes the setting in which the counselor is 

providing services, step-by-step instructions for specific counseling techniques, and master clinician comments. A decision tree is also included in the Francis vignette to help counselors manage 

key points of therapy. The techniques can be applied to and adapted for other settings. Vignettes 

are based on role-played interactions staged by consensus panelists. 

Part 2 is for program administrators and consists of two chapters addressing the following topics 

about servicing people who are homeless:

•	 Collaboration with other service providers to provide comprehensive services 

•	 Service modifications to meet the individual needs of clients 

•	 Providing training and staffing programs that serve people who are homeless 

•	 Providing outreach and engagement, intensive care, and ongoing rehabilitation services 

•	 Resources for implementation of best practices, including sample policies and procedures 

Part 3 is a literature review on the topic of homelessness and behavioral health services and is intended for use by clinical supervisors, interested providers, and administrators. Part 3 has three

sections: an analysis of the literature, links to select abstracts of the references most central to the 

topic, and a general bibliography of the available literature. To facilitate ongoing updates (performed periodically for up to 3 years from first publication), the literature review is only available 

online at the Knowledge Application Program Web site (http://kap.samhsa.gov). 

xi 
 

Behavioral Health Services for People Who Are Homeless 

Terminology 

Substance abuse: Throughout the TIP, the term “substance abuse” has been used to refer to both

substance abuse and substance dependence (as defined by the Diagnostic and Statistical Manual of 

Mental Disorders, 4th Edition, Text Revision [DSM-IV-TR] [American Psychiatric Association,

2000]). This term was chosen partly because substance abuse treatment professionals commonly 

use the term “substance abuse” to describe any excessive use of addictive substances. In this TIP,

the term refers to the use of alcohol as well as other substances of abuse. Readers should attend to 

the context in which the term occurs in order to determine what possible range of meanings it

covers; in most cases, however, the term will refer to all varieties of substance use disorders described by DSM-IV-TR. 

Behavioral health: Throughout the TIP, the term “behavioral health” is used. Behavioral health 

refers to a state of mental/emotional being and/or choices and actions that affect wellness. Behavioral health problems include substance abuse or misuse, alcohol and drug addiction, serious 

psychological distress, suicide, and mental and substance use disorders. This includes a range of

problems from unhealthy stress to diagnosable and treatable diseases like serious mental illness 

and substance use disorders, which are often chronic in nature but from which people can and do

recover. The term is also used in this TIP to describe the service systems encompassing the promotion of emotional health, the prevention of mental and substance use disorders, substance use 

and related problems, treatments and services for mental and substance use disorders, and recovery support. Because behavioral health conditions, taken together, are the leading causes of disability burden in North America, efforts to improve their prevention and treatment will benefit

society as a whole. Efforts to reduce the impact of mental and substance use disorders on communities in the United States, such as those described in this TIP, will help achieve nationwide

improvements in health. 

Recovery: A process of change through which individuals improve their health and wellness, live 

a self-directed life, and strive to reach their full potential. Major dimensions that support a life in

recovery, as defined by the Substance Abuse and Mental Health Services Administration, 

include: 

•	 Health: overcoming or managing one’s disease(s) as well as living in a physically and emotionally healthy way. 

•	 Home: a stable and safe place to live. 

•	 Purpose: meaningful daily activities, such as a job, school, volunteerism, family caretaking, or

creative endeavors, and the independence, income, and resources to participate in society. 

•	 Community: relationships and social networks that provide support, friendship, love, and 

hope. 

xii 
Part 1: A Practical Guide for
 

the Provision of Behavioral
 

Health Services
 

1 

 

 

 

 IN THIS CHAPTER 

• Introduction 

• Homelessness in America 

• Homelessness and 

Behavioral Health 

Services 

• Stages of Change, 

Recovery, and 

Rehabilitation 

• Clinical Interventions and 

Strategies for Serving 

People Who Are 

Homeless 

• Special Issues in Service 

Delivery 

• Community Housing 

Services for People Who 

Are Homeless 

• You Can Do It 

Part 1, Chapter 1 

Part 1, Chapter 1
 

Introduction 

This TIP Is for You, the Behavioral Health Service 

Provider 

This Treatment Improvement Protocol (TIP) is for you, the behavioral health service provider or program administrator who wants

to work more effectively with people who are homeless or at risk of

homelessness and who need, or are currently in, substance abuse or

mental health treatment. The TIP addresses treatment and prevention issues. Some aspects of the TIP will be of primary interest to

counselors across settings, whereas others will be of primary interest to prevention professionals or providers in primary care settings. 

However, the approach advocated by the TIP is integrated and is 

aimed at providing services to the whole person to improve quality 

of life in all relevant domains. 

The information in this TIP can be useful to you if you wish to:

•	 Be a more effective clinician for people facing potential or actual homelessness. 

•	 Recognize and address homelessness as a special dynamic that

affects your clients. 

•	 Help prevent potential crises that result from becoming homeless. 

•	 Provide preventive services for individuals and families who are 

homeless, especially as they relate to emergent substance abuse 

or mental disorders. 

•	 Be more aware of the effects of psychological trauma and cooccurring disorders (CODs) among people who are homeless. 

•	 Provide integrated, more effective services to people who are 

homeless. 

•	 Understand and know how to utilize resources for homelessness (e.g., permanent supportive housing [PSH]) in your

community. 

3 
 

Behavioral Health Services for People Who Are Homeless 

•	 Understand the significance of cultural 

competence in your work with people who

are homeless and experience substance use 

and mental disorders. 

•	 Influence the understanding of others in

your community regarding the interrelationship of homelessness, substance abuse,

and mental illness. 

Behavioral health service providers work today 

in a variety of settings: publicly funded treatment programs, primary care organizations,

hospitals, criminal justice settings, private

practice, the military, schools, the community,

and programs specifically for people who are 

homeless. You will find the information in this 

TIP useful regardless of the setting in which

you work. Although some content may be 

more relevant to your work than other content,

it is important to have an overall view of how

homelessness, substance abuse, and mental 

illness interact to hinder recovery and rehabilitation; how to form a conceptual model to address homelessness in your work; and how to 

access services available in your community. 

This chapter introduces you to homelessness 

in America. It illustrates how homelessness 

affects people, why it often occurs in conjunction with other social and health problems,

and why it cannot be addressed in isolation. It

also provides a brief overview of how communities address homelessness and discusses different types of homelessness and how each

interacts with substance use and mental disorders. 

In addition, the chapter discusses your role(s)

as a provider in working with this population.

Some of the topics addressed include:

•	 The special competencies you will need in

your work with people who are homeless. 

•	 Knowledge, skills, and attitudes in working with specialized community resources 

that can support treatment and prevention 

for people who are homeless. 

•	 How to build responses for homelessness 

or the threat of homelessness into individualized service or treatment plans. 

•	 How to adapt services to the changing

needs of people who are homeless as their

life situations change. 

•	 How to help individuals without permanent housing integrate with other people 

in behavioral health service settings. 

•	 The types of preventive services people 

who are homeless may need. 

•	 Provider self-care when working with the

problems of homelessness. 

The chapter closes with a discussion of how 

communities can address homelessness and 

acquaints you with services that may be available in your community for people who are 

experiencing or who may be at risk for the 

overwhelming problem of homelessness.

Many resources already exist, and it is important for you as a behavioral health service

provider to understand and actively interact

with existing organizations to provide integrated, continuous, and nonduplicative service 

to clients who are homeless. 

Structure of the TIP 

This TIP has three parts:

•	 Part 1: A Practical Guide for the Provision of 

Behavioral Health Services 

•	 Part 2: An Implementation Guide for Behavioral Health Program Administrators 

•	 Part 3: A Review of the Literature 

Part 1 is for behavioral health service providers

and consists of two chapters. In addition to

background information, Chapter 1 illustrates 

common issues that arise in working with

people who have experienced, are currently 

experiencing, or may be at risk for homelessness. It covers: 

•	 Background issues, such as the nature and

extent of homelessness among clients in

treatment, descriptions of models, and 

4 
 

 

 

Part 1, Chapter 1 

principles of care that anchor the practical

information the TIP presents. 

•	 The service provider’s roles, competencies, 

and self-care. 

•	 Outreach, assessment, treatment planning,

the treatment process, and continuing 

care. 

•	 Preventive services for people who are 

homeless. 

Part 1, Chapter 2, presents a series of vignettes 

that serve as teaching tools. Treatment vignettes describe the setting in which a worker

provides services, step-by-step instructions for

specific clinical techniques, and master clinician comments. Vignettes that incorporate 

prevention interventions describe situations in

which a behavioral health service provider assesses prevention needs and either provides 

services or refers to a community agency.

Some vignettes provide decision trees to help

behavioral health service providers manage key

points of service delivery. Most of the vignettes are based on role-plays conducted by

the TIP consensus panelists. 

Part 2 is for program administrators and consists of two chapters. Chapter 1 deals with

providing programming tailored to the needs 

of people who are homeless, including:

•	 Tailoring services to the needs of the population. 

•	 Providing training and staffing to serve

people who are homeless. 

•	 Providing outreach and engagement, intensive care, and ongoing rehabilitation

services. 

Part 2, Chapter 2, contains sample policies and

procedures that support effective services and

collaboration with other service providers to

offer comprehensive services for people who

are homeless, along with sample forms and

lists of steps for program modification. 

Part 3 has three sections: a review of the literature on the prevention and treatment of

substance abuse and/or mental illness among

individuals who are homeless, links to select

abstracts of the references most central to the 

topic, and a general bibliography of available

literature. To facilitate ongoing updates (performed periodically for up to 3 years from first

publication), the literature review is only available online at the Knowledge Application

Program Web site (http://kap.samhsa.gov). 

Topics Addressed in This TIP 

This TIP covers a broad range of skills and

resources useful in work with people experiencing homelessness or at significant risk for

homelessness. For instance, the TIP addresses 

different types of homelessness: transitional,

episodic, and chronic. It provides information 

on different resources and services for people 

who lack adequate housing, including emergency, temporary, transitional supportive, and

permanent supportive housing resources. It

describes a variety of strategies that are instrumental in services to people who are 

homeless, including outreach, initial screening

and evaluation, early intervention and stabilization, coordination with other resources in

the community, treatment planning, case management, client retention in treatment and rehabilitation, and relapse prevention and

recovery management. It also sensitizes clinicians to the special effects of psychological 

trauma, both as a precursor and a contributing

factor to homelessness and as a secondary outcome of homelessness. The TIP considers the 

effects of co-occurring disorders as a causative

factor of homelessness and the special needs of

clients who are homeless and have cooccurring substance use and mental disorders. 

The TIP considers stages of homelessness rehabilitation, including outreach and engagement, transition to intensive care, intensive

care, transition to ongoing rehabilitation, and 

5 
 

 

 

 

Behavioral Health Services for People Who Are Homeless 

rehabilitation. It covers a variety of evidencebased practices for both prevention and treatment. Part 2 of the TIP considers major funding resources, including the Substance Abuse 

and Mental Health Services Administration 

(SAMHSA), the U.S. Department of Housing

and Urban Development (HUD), the U.S.

Department of Veterans Affairs (VA), and

other governmental resources; staffing; and

other information of benefit to administrators. 

The TIP is comprehensive in scope and provides the detail that counselors, preventionists,

and other professional staff need to provide 

services in a variety of contexts to clients with

a variety of needs. The TIP describes intervention methods that can be used in a variety of

stages of homelessness rehabilitation and

methods for pursuing recovery from mental 

illness and substance abuse among people and

families who are homeless. It addresses the 

importance of the integration of behavioral

health services with other social services and 

health care. The TIP recognizes the complexity of providing services to clients who are in

stressful life situations and may resist or misinterpret the efforts of service providers. Perhaps most importantly, the TIP emphasizes 

the need for behavioral health systems to address the needs of the whole person, including

not only mental health issues and substance 

use, but housing, safety, physical health, financial, vocational, family, interpersonal, and other 

life contexts. 

Additionally, this TIP considers content from 

SAMHSA’s Strategic Initiatives (SIs), which 

are delineated in the document entitled Leading Change: A Plan for SAMHSA’s Roles and 

Actions 2011-2014 (SAMHSA, 2011b). The

specific SIs addressed include:

•	 Prevention of substance abuse and mental 

illness (SI #1) by creating safe places for

people to live accompanied by mental 

health and substance abuse screening and

supportive treatment. 

•	 Reducing the potential for and effects of

violence and trauma (SI #2) by providing

safe environments and by recognizing

trauma symptoms and providing traumainformed services. 

•	 The provision of homelessness services to

military families (SI #3) and veterans, 

which includes recognizing their special 

needs and the importance of coordinating

their care with the VA. 

•	 Utilizing recovery supports (SI #4) provided by people in recovery from mental 

illness and substance abuse in the community to support individuals and families 

who are homeless. 

•	 Creating public awareness and support (SI 

#8) for people who are homeless and have

mental illness and/or substance use disorders. 

Did You Know? 

•	 There is no typical profile for persons experiencing homelessness. A person who is 

homeless may be, for example: 

–	 Someone who has lost his or her job or

experienced mortgage foreclosure and

has been evicted along with family 

members. 

–	 A loner who sleeps in the park in a

sleeping bag. 

–	 An individual leaving jail or prison

who has an untreated drug problem 

and no place to live. 

–	 A runaway teen who trades sex for

food and drugs. 

–	 A person in early recovery without

enough money to pay the rent. 

–	 A person with serious mental illness 

(SMI) who needs long-term permanent supportive housing. 

6 
 

 

Part 1, Chapter 1 

–	 A person kicked out of the family 

home due to problems accompanying

substance abuse. 

•	 More than 1 in 10 persons seeking substance abuse or mental health treatment in 

the public health system in the United

States is homeless (SAMHSA, Office of 

Applied Studies [OAS], 2006). 

•	 Keeping things together while being

homeless takes considerable skill and resourcefulness. People who are homeless 

often have well-developed street skills, resourcefulness, and knowledge of the service system—important strengths that can

be built upon in treatment. 

•	 People who are homeless, particularly 

those with co-occurring mental and substance use disorders, present particular

challenges in treatment. All issues must be 

concurrently addressed for treatment to be 

effective. 

•	 People with substance use or mental disorders who are homeless are more likely to

have immediate life-threatening health 

conditions and to live in life-threatening

situations. The first steps toward healing

may be access to medical care and a safe 

and healthy place to live. 

•	 Trauma is another major co-occurring

problem for people who are homeless and

have a substance use disorder. One study 

found that about one fifth of men and one 

third of women who are chronically homeless and have substance use disorders also 

have posttraumatic stress disorder (PTSD;

Jainchill, Hawke, & Yagelka, 2000). 

•	 Safe housing is a point of entry into treatment for many individuals. When safe 

housing is combined with services, the client has the opportunity to build strengths

to move from the precontemplation stage 

through the contemplation stage to an active stage of change concerning recovery 

from mental illness and substance abuse. 

•	 Many individuals in early recovery are only 

a paycheck away from homelessness. 

•	 People leaving prison or jail with no place 

to live who have an untreated substance 

use or mental disorder may lack familial,

occupational, and social resources and

supports. 

•	 People who have experienced multiple episodes of homelessness or who have been 

chronically homeless may be especially 

demoralized and depressed. In addition, in

prior contacts with service systems, these 

individuals may have experienced alienation that will require behavioral health service providers to exercise a full battery of

professional engagement and customer

service skills. 

Why Address Homelessness in 

Substance Abuse and Mental 

Health Programs? 

Serving people who are homeless in behavioral 

health agencies is challenging. So, why do it?

•	 It is crucial. Housing instability is common among people diagnosed with substance use or mental disorders. This 

instability may take the form of: 

–	 Risk of eviction and/or estrangement

from families. 

–	 Risk of homelessness after a stay in jail,

prison, or residential treatment. 

–	 An inability to maintain adequate

housing over a period of time. 

•	 Housing stability is key for long-term recovery from substance use and mental disorders; providing housing with treatment 

and other services reduces relapse (Kertesz,

Horton, Friedmann, Saitz, & Samet, 

2003) and improves outcomes (Milby et

al., 2008; Sosin, Bruni, & Reidy, 1995). 

•	 It is good for your organization. Addressing

the root causes of crises caused by homelessness results in better client retention, 

7 
 

 

 

 

Behavioral Health Services for People Who Are Homeless 

efficient organizational functioning, and

greater program service diversity. 

•	 Participation in your community’s continuum of care for homeless assistance services fosters professional relationships,

funding opportunities, innovative programming, and access to a broader range

of services for the people you are serving. 

•	 It is good for your community. As communities develop plans to end homelessness, increased funding and resources 

become available to implement programs 

and coordinate services. Programs are able

to target and respond to specific community needs more efficiently and effectively,

and some of the problems intensified by

homelessness—such as aggressive panhandling—are reduced. 

Preventive Services for People 

Who Are Homeless 

People who are homeless are at elevated risk 

for substance abuse, mental disorders, and various other physical ailments and social problems (e.g., unemployment, poverty, victimization). Preventive services can reduce these 

risks before problems occur or when early 

signs of the problem are evident. As shown in

Exhibit 1-1, the Institute of Medicine (IOM;

2009) divides substance abuse and mental 

health services into four broad categories:

promotion, prevention, treatment, and

maintenance. Prevention services are further 

divided into: 

•	 Universal prevention services, which target

entire populations (i.e., a community,

State, or country). 

•	 Selective prevention services, which target

subsets of the population considered to be 

at risk. 

•	 Indicated prevention services, which are

delivered to individuals and target people 

who are exhibiting early signs of problem 

behaviors. 

By definition, universal prevention efforts are 

not specifically targeted to persons who are 

homeless because they are part of a larger

community, State, or national population. 

Exhibit 1-1: Types of Prevention as Described by the Institute of Medicine 

Source: IOM, 2009. Adapted with permission. 

8 
 

 

 

 

Part 1, Chapter 1 

However, people who are homeless may be the 

beneficiaries of these prevention efforts (e.g.,

workplace programs, recreation programs,

enforcement efforts to reduce crime, schoolbased prevention programs for children enrolled in school). Because of their high-risk 

status, these efforts may be especially important to persons who are homeless or at risk

of becoming homeless. 

This TIP focuses primarily on selective and

indicated prevention, referring to them collectively as “clinical preventive services,” as they 

are often provided in clinical settings (primary

care, hospitals, counseling centers, etc.). Clinical preventive services include life skills development, stress and anger management,

anticipatory guidance, parenting programs,

and screening and early intervention. These 

programs may be designed to directly prevent

substance abuse and/or promote mental health

and may strengthen individuals and families

and enrich quality of life to build resiliency. 

The categories in Exhibit 1-1 are tools for

considering prevention initiatives; they aren’t 

hard and fast. In practice, they often blend,

and a given initiative may fit into more than

one category. 

Housing as prevention 

Providing housing to people who are homeless 

can help prevent the exacerbation of substance 

use and mental disorders or the transition 

from normal functioning to the first phases of

problem development. A number of considerations support this assertion. 

Homelessness itself is a risk factor for mental 

and substance use disorders, given the many 

life challenges and disruptions that people 

who are homeless face: for example, stress, loss 

of social connectivity, increased threats, harm

through victimization and exposure, and deterioration of health status. Indeed, these risk 

factors for adults and youth are one reason this 

TIP emphasizes the importance of preventive 

services for people who are homeless. 

Effects may be especially acute in children, for 

whom homelessness may mean a loss of family 

stability, disruptions in school attendance or 

performance, and being ostracized by peers.

Brokering prevention services in the community can help mitigate the impact of these circumstances (see the “Case Management”

section later in this chapter as well as Vignettes 4 and 6 in Part 1, Chapter 2). 

Are you a prevention worker in the 

behavioral health field? 

When many professionals think of prevention 

service providers, mental health and substance 

abuse workers come to mind. In truth, a broad

array of professionals in the community contributes to the treatment and prevention of

mental illness and substance abuse. The community agencies and organizations listed in

Exhibit 1-2 have a part to play in the prevention of these problems. If your agency or organization is on this list, you are a prevention

worker. 

Not only does your community benefit when

professionals from a wide range of sectors participate in prevention; you may also find your 

job to be easier as well. People with substance 

use or mental disorders often present significant treatment challenges in the community 

agencies and organizations with which they

have contact. When substance abuse and mental health issues are prevented or identified

early, quality of life improves for everyone. 

It is beyond the scope of this TIP to provide

an introduction to prevention theory and practice. Instead, it focuses on preventive services 

for persons who are homeless. 

9 
 

 

Exhibit 1-2: Agencies That Provide Substance Abuse Prevention and Mental 

Health Promotion Services 

State Governments 

Public health authority 

Substance abuse authority 

Mental health authority 

Governor’s Highway Traffic Safety Office 

Alcohol beverage control 

State aging and disability authority 

State police 

Corrections 

County/Local Governments 

Public health authority 

Substance abuse authority 

Mental health authority 

Tribal governments 

Courts/probation 

Local police 

Recreation departments 

Area agencies on aging 

Educational Institutions 

K–12 schools 

Colleges, universities 

Research centers 

Healthcare Facilities 

Primary care 

Specialty care (e.g., mental health/substance abuse, 

emergency/trauma, obstetrics and gynecology, 

home health, dentistry) 

Nongovernmental Organizations 

Community coalitions 

Boys/Girls Clubs, Young Men’s/Women’s Christian 

Association (YMCA/YWCA), Scouts 

Fraternal organizations 

Faith-based organizations 

Hospitality industry 

Housing and homelessness service organizations 

Media Outlets 

Print 

Electronic 

Billboards, bus placards, etc. 

Behavioral Health Services for People Who Are Homeless 

sources as you assess and work with abstinence readiness in your clients. 

•	 Solving homelessness is more than just

having a safe place to live. Homelessness 

typically presents along with multiple,

complex other problems: substance abuse,

mental health issues, medical problems,

legal/criminal justice issues, social challenges, and so forth. You must be able to

prioritize these factors when creating a 

person-centered treatment or prevention

plan and know how to access appropriate 

supervision concerning these complexities. 

•	 People who experience homelessness can 

be particularly demoralized, needing active 

and often persistent engagement; be flexible in engaging them, especially in earlier

stages of work. 

•	 Income stability through access to Federal 

or local income benefits is a critical ingredient in helping a person who is homeless 

Recommendations of the 

Consensus Panel 

You are a behavioral health professional working with people who are homeless or at risk 

for homelessness, but most likely, your background does not include detailed training in

addressing this aspect of their lives. This TIP

is designed to fill that gap and increase your

understanding of how homelessness affects a 

person’s ability to engage in treatment or

benefit from prevention. In particular, the consensus panel recommends the following:

•	 Housing access is the bulwark of recovery 

for a person who is homeless and has a

substance use disorder and/or a mental illness. Various housing models can be effective in addressing homelessness and

substance abuse or mental illness. You 

must be active in identifying housing re10 
 

 

 

 

 

 

 

 

 

Part 1, Chapter 1 

reintegrate into the social mainstream.

Clinicians and prevention workers must

know how to help the people they serve 

gain access to these benefits. 

•	 Work and/or education are basic goals for 

the majority of people who are homeless.

These are sources of significant selfesteem, counteracting demoralization and

providing daily structure and a long-term 

foundation to prevent subsequent homelessness. You will want to be familiar with 

community resources for vocational and

educational training and placement. 

•	 Many people who are homeless have no

social supports, but some do—especially 

those with brief intermittent periods of

homelessness. Family or close friends can

offer support; be alert to these resources 

when helping people repair their social 

networks. For someone with a history of

chronic homelessness, you may need to reconceptualize how to help rebuild his or

her social supports. 

•	 People who experience homelessness encounter a range of problems. You can apply the skills gained from serving this 

population to your work with anyone experiencing biopsychosocial challenges.

Conversely, the techniques you have already mastered can be applied in your

work with people who are homeless, depending on the stage of change they are in. 

Homelessness in America 

How Is Homelessness Defined? 

There is no single definition of homelessness;

however, most Federal homelessness programs 

use the definition of a homeless individual 

provided by the McKinney-Vento Act (P.L.

100-77): 

An individual who lacks a fixed, regular, and

adequate nighttime residence; and a person

who has a nighttime residence that is (a) a supervised publicly or privately operated shelter 

designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for the

mentally ill); (b) an institution that provides a

temporary residence for individuals intended

to be institutionalized; or (c) a public or private

place not designed for, nor ordinarily used as, a

regular sleeping accommodation for human 

beings. (42 U.S.C. § 11302) 

In other words, a person experiencing homelessness has no fixed place to live and often

dwells in public spaces, shelters, or drop-in 

centers or may double up in others’ homes in a

temporary or makeshift way. The more recent

Homeless Emergency Assistance and Rapid

Transition to Housing (HEARTH) Act of

2009 (P.L. 111-22), which amends the 

McKinney-Vento Act (see Part 2, Chapter 1,

for further detail), expands the definition (Sec

103, 42 U.S.C. § 11302) of a person or family

who is homeless to include anyone who:

•	 Resided in a shelter or place not intended

as a home and is now leaving an institution where he or she temporarily resided. 

•	 Is losing his or her housing in 14 days or

fewer; cannot obtain housing through his

or her support networks or other resources. 

•	 Has, at some point, lacked independent

permanent housing for a long period of

time; has moved frequently; and is likely to

continue doing so as a result of physical 

disability, mental disorder, addiction, or 

other barrier. 

•	 Has experienced domestic violence, sexual 

assault, and/or other dangerous or lifethreatening conditions in a housing situation that he or she is leaving. 

•	 Is an unaccompanied youth who is homeless. 

HUD (2001) defines a person who is chronically homeless as “an unaccompanied homeless 

individual with a disabling condition who has

either been continuously homeless for a year

or more OR has had at least four [4] episodes 

11 
 

Behavioral Health Services for People Who Are Homeless 

of homelessness in the past three [3] years” (p. 

6). Unaccompanied individuals who are homeless are men and women not accompanied by

children or a partner. Disabling conditions include mental disorders, substance use disorders, and medical conditions. 

How Many People Are Homeless? 

It is difficult to count the number of people 

who are homeless accurately because they 

move frequently. This means they can be 

counted more than once or missed. HUD has 

estimated, based on point-in-time counts, that 

643,067 persons were homeless at a single 

point in time in January 2009, of whom

237,934 were on the streets, in abandoned

buildings, or in other places not meant for

human habitation (HUD, 2010). Sixty-three

percent of people who were homeless were 

single individuals and the rest were members 

of families experiencing homelessness. Another estimate using these data arrived at a slightly higher number: 656,129, a 3 percent

increase over the previous year. The number of

families facing homelessness increased by 4

percent over the same period, although the 

figures are much higher in some States (Sermons & Witte, 2011). The full extent of the 

effects of the 2008 recession on homelessness 

may not be measured for some time. 

On a single night in 2009, an estimated

75,609 veterans were homeless; 57 percent

were staying in an emergency shelter or transitional housing program, and the remaining 43

percent were unsheltered—that is, living on

the street, in an abandoned building, or in another place not meant to serve as a human

dwelling. Of veterans in shelters, approximately 96 percent were individuals and slightly less 

than 4 percent were part of a family that was

homeless (HUD & VA, 2010). For more information, see the online literature review in

Part 3 of this TIP. 

Who Is Homeless? 

People who are homeless come from all strata

of society, although the poor are most certainly 

overrepresented. The high percentage of people of color in the homeless population is related to their chances of being poor, not to 

their race/ethnicity (Burt, 2001). The National

Survey of Homeless Assistance Providers and

Clients (Burt et al., 1999) reported that:

•	 About 40 percent of clients who are 

homeless are African American, about 40

percent are White, about 11 percent are 

Hispanic, and about 8 percent are Native

American. 

•	 About 61 percent of clients are men by 

themselves, 15 percent are women by 

themselves, 15 percent live with their own

children under age 15, and 9 percent live 

with another adult. 

•	 Clients who are homeless are concentrated 

in central cities (71 percent), with fewer in

urban fringe areas and suburban areas (21

percent) and rural areas (9 percent). 

What Factors Contribute to 

Homelessness? 

Both the environment and individual factors 

contribute to homelessness. 

Environmental factors 

Poverty predisposes people to homelessness 

through a range of environmental factors; 5 to

10 percent of people who are poor experience

homelessness in a given year (Burt, 2001).

Since the 1970s, vulnerability to homelessness 

has increased among the poor as access to affordable housing, social safety nets (e.g., housing/income subsidies, affordable health care, 

hospitalization), and adequate income have

decreased. In addition: 

•	 Housing costs price many people with

below-poverty incomes (e.g., very lowincome families and single adults) out of

the market (Burt, 2001). More than 14 

12 
 

 

 

 

Part 1, Chapter 1 

million families have “worst-case housing

needs,” defined as spending more than

50 percent of monthly income on rent

(Lipman, 2002). 

•	 The removal of institutional supports (e.g.,

deinstitutionalization) has resulted in fewer housing options for people diagnosed

with SMI (Burt, 2001). It is critical that

housing issues be addressed in disposition

planning when individuals are discharged

from inpatient or outpatient mental health 

or substance abuse treatment settings. Clients leaving intensive treatment settings 

who do not have adequate housing to support their recovery have a significantly 

higher risk of relapse. 

•	 Decreased job options for people with 

high school educations and increasing disparity between minimum wage and cost of

living have made it increasingly difficult to

earn enough money to afford housing

(Burt, 2001). 

Environmental factors affecting vulnerability 

to homelessness relate directly to community

resources. Community solutions for preventing homelessness and ending chronic homelessness include affordable housing, access to

permanent supportive housing for clients with 

mental illness and substance use disorders, improved schools, training, prison transition programs, job opportunities, and support services 

(Burt, 2001). 

Individual factors 

In addition to substance use and mental disorders, a range of complex, interrelated individual risk factors are related to homelessness, 

including trauma-related symptoms, cognitive 

impairment, medical conditions, lack of support from family, limited education and job

skills, and incarceration (for more detail, see 

the literature review in Part 3 of this TIP, 

which is available online at the KAP Web site 

(http://kap.samhsa.gov). A significant percentage of individuals who are homeless will 

likely experience at least one of these issues.

For example:

•	 Mares and Rosenheck (2004) found that

veterans who are homeless report that

three aspects of their service contributed to

their homelessness: substance abuse beginning in the military (75 percent), inadequate preparation for civilian

employment (68 percent), and loss of

structure (68 percent). 

•	 People who have or have had mood disorders, schizophrenia, antisocial personality 

disorder, or any substance use disorder are

at least two times more likely to have been

homeless than those without these diagnoses (Greenberg & Rosenheck, 2010a,b). 

•	 Of people who are homeless and in substance abuse treatment, 68 percent of men

and 76 to 100 percent of women report

trauma-related events (Christensen et al.,

2005; Jainchill et al., 2000), similar to rates

reported by general samples of people who

are homeless. 

•	 As many as 80 percent of people who are 

homeless exhibit cognitive impairment,

which can affect their social and adaptive

functioning and their ability to learn new

information and new skills (Spence, 

Stevens, & Parks, 2004). 

•	 People who are homeless have high rates 

of HIV/AIDS, hepatitis C, cardiovascular 

conditions, dental problems, asthma, diabetes, and other medical problems 

(Klinkenberg et al., 2003; Magura,

Nwakeze, Rosenblum, & Joseph, 2000;

Schanzer, Dominguez, Shrout, & Caton, 

2007).

•	 Lack of familial support increases the risk 

of episodic and chronic homelessness and

manifests as disconnection from family, 

childhood placement in foster care or other institutions (27 percent), and childhood 

physical and/or sexual abuse by family 

members (25 percent; Burt et al., 1999). 

13 
 

 

 

 

Mikki 

Mikki is transitionally homeless. Her boyfriend (who is also the father of her youngest child) has left 

her. He promised financial support for Mikki and the two children, ages 7 and 3, but only provided 

money for a few months. Mikki was evicted from her apartment 3 weeks ago and has been living with 

her children in the family car, which won’t start. When the children come down with bad colds, she 

takes them to the community health center. 

Mikki has become progressively more depressed as a result of her breakup and the stress of homelessness. She has begun drinking at night to sleep. The case manager in the community health center 

helped her arrange temporary emergency housing until more stable transitional or permanent supportive housing can be arranged. He also referred her for a psychiatric evaluation and worked with 

the school system to provide supportive and preventive services to the children. One of his primary 

goals has been to intervene before a pattern of long-term homelessness is established. The case 

manager is also cognizant that Mikki’s co-occurring depression and substance abuse must be addressed as part of a larger treatment plan that includes adequate housing, employment, financial 

support, child care, and services for mental health and substance abuse treatment. 

Part 1, Chapter 2, describes how the caseworker helps Mikki obtain these services. 

Behavioral Health Services for People Who Are Homeless 

•	 Thirty-eight percent of people who were 

homeless and received services in 1996 

lacked a high school diploma or equivalent

(Burt et al., 1999). 

•	 Incarceration is common among people 

who have experienced homelessness (54

percent of those who received services in

1996; Burt et al., 1999). Many individuals

leaving prison have no place to live and

seek housing through community resources for homelessness. 

Are There Different Types of 

Homelessness? 

Surveys conducted with people who are 

homeless indicate that there is a continuum of 

homelessness (Burt, Aron, Lee, & Valente,

2001). This section offers brief explanations of 

the types of homelessness, the prevalence of

each, and illustrative vignettes. 

Transitional homelessness 

A first or second episode of homelessness,

ranging from a few weeks or months to less 

than a year, is considered transitional homelessness. About half of the homeless population falls into this category, including many 

families who are homeless. Families are likely 

to qualify for public assistance programs, so

they are less likely to be homeless or to be 

homeless for long periods. People leaving prison or jail may be transitionally homeless. 

Episodic homelessness 

Episodic homelessness means entering and

leaving homelessness (e.g., shelters) repeatedly.

Between episodes of homelessness, a person

might be tenuously housed (in his or her own

housing or living with friends/relatives) and at

high risk for becoming homeless again. About

one fourth of people who are homeless have

gone in and out of homelessness numerous 

times (Burt et al., 2001). 

Chronic homelessness 

About a quarter of people who are homeless 

have been continuously so for at least 5 years 

(Burt et al., 2001). Engaging people who are

chronically homeless in housing and other

services requires willingness to provide housing and services that are attractive to clients. 

How Do Communities Respond to 

Homelessness? 

Homelessness is a broad social problem, and 

14 
 

 

Francis 

Francis is chronically homeless. He has lived in a subway tunnel for some time and is known to the 

staff of the local homeless program. It’s been more than 5 years since he had a home. His medical 

records indicate that he has an intelligence quotient (IQ) of about 70, possible cognitive impairment 

from an old injury, and diabetes. With cold weather predicted, the outreach and engagement team 

want to see how he is functioning, if he has immediate needs, and whether he will accept shelter. 

Techniques for engaging Francis into appropriate services are illustrated in Part 1, Chapter 2. The 

importance of cultural competence in working with Francis is shown in the vignette. 

Roxanne 

Roxanne is episodically homeless. She has a history of illicitly using and selling extended-release 

oxycodone and other opioid drugs. She has been diagnosed with antisocial personality disorder. She 

lived with friends until they tired of her drug use and erratic behavior. Roxanne now lives in single 

room occupancy (SRO) housing. Roxanne’s drug use and erratic behavior make it hard for her to hold 

a job. She occasionally engages in prostitution and sells pain pills for income. She’s been told not to 

bring customers to the SRO but sometimes brings them anyway. Failing to follow the rules puts her 

at risk of ending up back on the street. Roxanne’s behavior and risk of eviction predispose her to victimization. Although currently housed, Roxanne has a long history of episodic homelessness beginning in childhood. As an adult without family, she is ineligible for most safety-net programs, so she is 

at risk for continued episodic homelessness. 

Part 1, Chapter 2, shows how her counselor helps ready her for services to reduce risk of homelessness, address pervasive trauma symptoms that interfere with life functioning, and maintain commitment to mental health and substance abuse treatment and recovery. 

Part 1, Chapter 1 

communities have established a range of

strategies to manage homelessness. On one 

hand, faced with demands from business owners and other citizens, some public officials 

have turned to criminal justice solutions to

respond to street homelessness. Legal 

measures include prohibition of sleeping,

camping, begging or panhandling, and storing

personal possessions in public areas. Other

trends restrict serving food to the poor and

homeless in public places. Such measures can

impede provision of services and create additional barriers to recovery (such as criminal 

records), which can delay access to housing

and decrease eligibility for employment. 

On the other hand, a growing number of

States and communities are adopting progressive initiatives, including the development of

drug, mental health, and homelessness courts, 

which divert people who are homeless from 

incarceration; mobile crisis teams working in

tandem with police trained to respond to

people who are homeless; programs to bridge 

reentry into the community for people exiting

the criminal justice system; and specialized

community services, such as crisis intervention

beds, sobering stations, and homelessness assistance centers. As of August 2007, more than

300 communities had formal plans to end

chronic homelessness (see the U.S. Interagency

Council on Homelessness [USICH] Web site 

at http://www.usich.gov) and were offering a 

wide range of treatment and housing services 

to meet this goal. 

A particularly progressive initiative is the provision of permanent and transitional supportive housing, which offers stable, safe, affordable, 

long-term housing for individuals and families

who would otherwise be homeless. Permanent 

supportive housing provides long-term hous15 
Behavioral Health Services for People Who Are Homeless 

ing and supportive services to people with

physical disabilities, mental illness, or other

long-term impairments (such as developmental disabilities) that limit the individual’s ability to maintain housing without assistance.

Transitional supportive housing provides stable housing along with social and health services but is more often used with individuals 

and families in crisis or transition. 

PSH helps eligible people find a permanent

home and obtain needed mental health and 

substance abuse treatment services. An important component of PSH is that housing is

not contingent on whether an individual obtains mental health, substance abuse, or other 

services, but rather, allows the individual to

decide when and how to seek out services. 

PSH supports individuals in choosing their

own living arrangements and helps them access services based on the support they need at

any given time. 

An example of a candidate for transitional

housing is an individual leaving addiction

treatment who has no place to live, needs a

sober environment to support recovery, and

can be expected to regain employment in the 

near future. Transitional housing is normally 

limited to 2 years. Some of the social and

health services frequently offered in supportive 

housing include mental health and substance 

abuse treatment, employment services, job

training, life skills training, interpersonal skills 

development, medical case management, and

coping skills training. Transitional and permanent supportive housing can range from a

rooming house with individuals having their

own rooms to clusters of small apartments in a

single location to scattered-site programs in

which rent subsidies are provided for individuals and families to have a home in the greater

community. 

A major support for persons in need is

SAMHSA’s Projects for Assistance in 

Transition from Homelessness (PATH)

program. Administered by the Center for

Mental Health Services (CMHS), PATH is

part of a formula grant to States and provides

minimal housing assistance for individuals.

PATH funds help individuals with SMI and 

co-occurring mental and substance use disorders access needed services. PATH provides

technical support and funding for outreach,

screening and diagnostic treatments, community mental health services, alcohol and drug

treatment, staff training, case management,

health referrals, job training, and educational 

and housing services. 

There are approximately 600 local PATH organizations that work to engage behavioral

health service agencies and housing programs.

Nearly all States use money from PATH formula grants to contact and engage people who

are disconnected from mainstream resources. 

This includes collaboration with the Social 

Security Administration to support access to

Social Security Income benefits among homeless populations with mental illness, as well as 

collaborative planning efforts with local continua of care to coordinate homelessness services and to end homelessness. According to

the PATH Web site 

(http://pathprogram.samhsa.gov/), PATH

providers work with service delivery systems 

and use effective practices by:

•	 Partnering with Housing First and permanent supportive housing programs. 

•	 Providing flexible consumer-directed and 

recovery-oriented services. 

•	 Improving access to Social Security and 

other benefits. 

•	 Employing consumers or supporting 

consumer-run programs. 

•	 Partnering with medical providers, including Health Care for the Homeless and

community health centers, to integrate 

mental health and medical services. 

•	 Improving access to employment. 

16 
 

 

 

 

 

 

Part 1, Chapter 1 

•	 Using technology, such as handheld electronic devices, electronic records, and 

Homeless Management Information 

Systems (SAMHSA, n.d.; USICH, 2011). 

Vignette 7—Sammy in Part 1, Chapter 2, of

this TIP—illustrates how PATH can be of 

assistance for clients with SMI who are homeless. For more information about PATH, related resources, and a list of PATH grantees, visit

the PATH Web site 

(http://pathprogram.samhsa.gov). 

Homelessness and 

Behavioral Health Services 

Behavioral health problems are common

among people who are homeless, and the risk 

of chronic homelessness increases when substance use or mental problems are present.

Substantial progress toward recovery and selfsufficiency may require significant engagement

efforts and repeated attempts at treatment and

housing rehabilitation. In addition, relapse

during substance abuse treatment may create 

barriers to a variety of services, including transitional and permanent supportive housing

(Kertesz et al., 2007). Furthermore, clients 

who relapse and exhibit symptoms of their

mental disorder (e.g., a person with bipolar

illness who relapses into a manic episode) may 

find their opportunities for housing restricted.

People who are homeless or at risk for homelessness and have a substance use or mental 

disorder are often cut off from social supports 

and need services ranging from safe and stable

housing, food, and financial assistance to medical care, mental health treatment, child care,

education, skills development and other preventive services, employment, screening and

early intervention, and recovery support. It is 

important that you, as a behavioral health service provider, participate in a system of care

that responds specifically to your clients’ wideranging needs. Comprehensive recovery efforts 

must include not only housing, but also supportive mental health, substance abuse, medical, occupational, and social services. 

The Special Rewards of Working 

With People Who Are Homeless 

As a behavioral health service provider, working with individuals who are homeless may 

mean entering a world you have previously 

seen only from a distance. It is common to 

have concerns and anxieties when first beginning to work with people who are homeless.

In providing services for this population, you 

will likely face some complex and challenging

problems. At the same time, however, your

work with people who are homeless can be 

quite rewarding; their gains can be dramatic as

they move through their personal recovery 

processes. 

For many, working with clients who experience homelessness provides the opportunity to

look inside a world that may be very different

from their own and to learn life histories that 

depart substantially from those of most people 

they know. Living on the streets requires substantial skill, strength, and resourcefulness.

People who are homeless have lessons to teach

about being survivors in difficult and often

hostile environments. 

Perhaps surprisingly, some people who are 

homeless are de facto experts on the service 

systems in their communities. These individuals have valuable firsthand information about 

where to go (and not go) to seek food, shelter,

medical services, and other resources. You can

gather valuable information about community 

resources from these people. 

In working with this population, you have the

opportunity to make a real difference for some 

of your community’s most vulnerable and disenfranchised citizens: 

•	 With your help, a person’s immediate risk of 

harm can be substantially reduced. Assisting 

17 
 

Behavioral Health Services for People Who Are Homeless 

your clients in obtaining even temporary 

housing will substantially reduce their risk 

of victimization, morbidity or mortality

from exposure, and exacerbation of mental 

illness. For clients with existing health

problems, temporary housing can mean

the opportunity to obtain needed medical 

care. 

•	 You can help people realize elusive lifelong

goals. For many persons who are homeless,

life in stable housing may feel like a distant or unattainable dream. But this transition can be made, and you can be one of

the change agents that makes it happen.

See Vignette 1 in Chapter 2 (Juan). 

•	 You can help people transform their lives. The 

difference between being homeless and being housed affects almost all aspects of a 

person’s life, including increasing the likelihood of advancing personal recovery

from mental illness and substance abuse,

as is the case with René in Vignette 5 in

the next chapter, and reducing the risk of

future substance abuse and mental disorders, especially for children who are homeless (see Troy and Mikki in Vignettes 4

and 6, Part 1, Chapter 2, of this TIP). 

•	 You will come to understand, firsthand, one of

our Nation’s pressing social problems. The 

Francises, Roxannes, and Mikkis of your

community are not able to work for

change, at least not until they are further 

along in recovery. Working with them and

actively helping them navigate and benefit

from a layered service system is rewarding

work. Moreover, through your experiences 

and your understanding of their world, you

can help improve the behavioral health 

system that reduces homelessness and the 

hardships faced by people who are homeless. 

Counselor Competencies for 

Working With People Who Are 

Homeless 

The knowledge, skills, and attitudes for working effectively with people who are homeless 

in all phases of rehabilitation are presented in

this section (see also the Center for Substance 

Abuse Treatment’s [CSAT’s] Technical Assistance Publication 21, Addiction Counseling

Competencies: The Knowledge, Skills, and Attitudes of Professional Practice [CSAT, 2006a] for

more information on counselor competencies).

Some specific knowledge, skills, and attitudes 

helpful for your work with clients with a substance use disorder and/or mental illness and

facing or experiencing homelessness are listed

below. All of the discussion below presumes 

that you, as a behavioral health service provider, possess sufficient knowledge and skills and

appropriate attitudes for working with people 

with mental illness and/or substance use disorders. Some competencies will be more relevant to either treatment or prevention workers.

However, anyone who provides behavioral 

health services needs at least a basic level of 

competence in each area discussed in this section to ensure the delivery of integrated care 

and services to the whole person. 

Knowledge 

To provide effective services to people who are 

homeless or at risk of becoming so, behavioral 

health workers should possess knowledge of:

•	 Homelessness: its impact on people and

families, how it acts as a barrier to services 

for other problems, such as substance 

abuse and mental illness, and how, without intervention, it can become selfperpetuating. 

•	 How substance abuse, mental illness, and

homelessness interact to limit clients’ opportunities for growth and change. 

18 
 

 

 

Part 1, Chapter 1 

•	 Medical comorbidity in homeless populations and how to help people address 

physical wellness. 

•	 The pervasiveness of physical and sexual 

trauma within homeless populations and

the effects of trauma in limiting opportunities for recovery from mental illness and

substance abuse. 

•	 The effects of experiences of incarceration

among clients who are homeless. 

•	 Local homelessness assistance services and 

available community resources and how to

help clients with a mental illness or a substance use disorder access them. 

•	 The process of recovery from substance 

abuse, mental illness, and homelessness, 

including appropriate interventions at different stages in recovery. 

•	 The interaction of co-occurring substance

use and mental disorders and homelessness. 

•	 Prevention and treatment methods that 

have been shown to be effective or promising with people with substance abuse 

and/or mental illness who are homeless. 

•	 The fact that having a substance use disorder or mental illness can itself affect the 

process of relationship development and

trust in others. 

•	 Types of housing services that might be 

useful and how to access these services. 

Skills 

Using the following skills will allow behavioral 

health service providers to work more successfully with clients who are experiencing homelessness or the threat of it: 

•	 Use techniques for creating trusting, collaborative relationships with members of a 

population that experiences high rates of

social disaffiliation; for identifying client

strengths; and for helping clients empower

themselves to initiate and sustain stable 

housing and recovery. 

•	 Demonstrate specific outreach skills for

people who are homeless, particularly 

those who are chronically homeless and

have a substance use and/or mental disorder. 

•	 Conduct an initial screening and needs 

assessment for clients who present with a

substance use and/or mental disorder and

are homeless or are facing homelessness. 

•	 Recognize the effects of psychological 

trauma on trust, willingness to persevere

and accept help from others, and a variety 

of other personal and interpersonal dynamics that are important in treatment 

and recovery. 

•	 Support clients’ early changes (e.g., entering treatment, recognizing/addressing

mental and substance use disorders, finding temporary housing, obtaining needed

medical care, getting financial support). 

•	 Develop person-centered treatment and/or 

prevention plans that consider the whole 

person and his/her individual needs, including early intervention for emerging

mental and substance abuse problems,

mental illness and substance abuse treatment and rehabilitation, and programming

to build resiliency and enhance quality of

life by developing social and occupational 

skills. 

•	 Use case management skills in helping

people make contact with and continue 

accessing needed community resources, including prevention programs. 

•	 Retain clients in treatment and prevention

programs by maintaining rapport, motivation, and hope and by helping them work 

through the obstacles they face in recovery. 

•	 Develop realistic, individualized relapse 

prevention and recovery management

plans that include specific “how-to” steps 

to follow if the client experiences a recurrence of behavioral health symptoms,

homelessness, or other life problems. 

19 
 

Behavioral Health Services for People Who Are Homeless 

•	 Collaborate with other service providers,

family members, and social supports to: 

–	 Help people who are homeless access 

services. 

–	 Better understand needs and strengths. 

–	 Ensure appropriate care and smooth

transitions. 

Attitudes 

Behavioral health workers engaged in providing services to clients who are dealing with

homelessness can benefit from certain attitudes. For example: 

•	 Accept and understand powerful emotional responses to client behavior and address 

these responses in supervision. 

•	 As a precondition to a positive working

relationship, meet clients where they are 

rather than where they should be. 

•	 Appreciate that people must assume responsibility for their own recovery trajectories, although they sometimes make 

choices that do not appear to be in their

own best interests. 

•	 Trust that change begins with small steps 

that are self-reinforcing and aggregate to

larger changes. 

•	 Understand that all change is incremental 

and that many clients who are experiencing homelessness are on a long recovery 

pathway. 

•	 Recognize that consistency and reliability 

can counteract the disaffiliation and mistrust experienced by many persons who are 

homeless and have substance use or mental 

disorders. 

•	 Appreciate that work with people who are 

homeless and in need of treatment requires collaboration and cooperation

among a range of service professionals and

peer supports. 

Self-Assessment of Attitudes 

Toward People Who Are 

Homeless 

Attitudes toward homelessness, substance 

abuse, and mental illness vary widely. Many of

these beliefs originate in childhood and influence your perception of these problems. These 

perceptions, whether beneficial or limiting,

tend to be reinforced as you encounter people 

dealing with substance use or mental disorders 

and homelessness. It is important for you to be 

particularly aware of your attitudes and beliefs 

regarding these topics. Likewise, it is important to remember that not everyone holds 

your particular views or attitudes. 

Behavioral health service providers work with

people who are homeless and have a substance 

abuse or mental health diagnosis in many different settings: street outreach, mobile crisis

teams, drop-in centers, shelters, assertive 

community treatment (ACT) teams (see p. 

143), permanent supportive housing programs,

criminal justice environments, healthcare facilities, and other community behavioral health

prevention and treatment programs. This work 

presents many challenges along with opportunities for professional growth. One of the important challenges is to monitor and be aware 

of your personal attitudes and beliefs about

your clients. This section presents:

•	 Opportunities to consider your reactions

to and assumptions about people who are 

homeless. 

•	 Myths people often believe about people 

experiencing homelessness. 

•	 Methods for managing responses when

working with this population. 

Reactions and assumptions about 

people who are homeless 

Three people with mental or substance use disorders who are homeless were described earlier 

in this chapter. Your reactions, assumptions, 

20 
 

 

Part 1, Chapter 1 

and beliefs influence how you might interact

with each one. After reading their descriptions, some of the reactions you might experience as you imagine a conversation with

Mikki, Roxanne, or Francis include:

•	 Empathy (I have an emotional understanding of what it’s like to be in his or her 

shoes). 

•	 Sympathy (I feel sorry for him or her). 

•	 Fault finding (Why doesn’t he or she... 

like everyone else?). 

•	 Curiosity (I wonder what his or her story 

is?). 

•	 Aversion (I don’t want to meet him or 

her). 

•	 Fear (This person may hurt me in some 

way). 

Your personal experiences and history play an

important role in how you perceive and work 

with people who are homeless and have substance use or mental disorders. Ask yourself

the following:

•	 What is my personal and family experience with substance abuse, trauma, mental 

illness, and homelessness? 

•	 What personal experiences do I have with

these problems, and how do those personal experiences—for better or worse—affect

my work? 

•	 What is my emotional reaction to people 

who have a mental or substance use disorder and are homeless? 

•	 How comfortable do I feel providing services to people with these problems, and

what are the areas of discomfort that I experience? 

•	 What did I learn about homelessness, substance use, and mental illness growing up? 

•	 What beliefs and attitudes do I hold today 

that might challenge or limit my work 

with persons who are homeless and have a 

substance use or mental disorder? 

Myths and realities about people 

who are homeless 

When providers have insufficient information

about social and health problems, myths may 

arise about the nature of the problems, the 

kinds of people who are likely to be affected

by them, and how the problems are best addressed. Homelessness, and the relationship

between homelessness and behavioral health 

problems, are not exceptions. Care providers 

are not exempt from the myths that universally abound. Your awareness and management of

attitudes and beliefs that may interfere with

your work will result in personal growth and

better relationships with clients. Following are 

some common myths about people who are 

homeless. 

Myth #1. People choose to be homeless. 

Reality: Most people who are homeless want

what most people want: to support themselves,

have jobs, have attractive and safe housing, be 

healthy, and help their children do well in

school. 

Myth #2. Housing is a reward for abstinence 

and medication compliance, and society 

shouldn’t house people who have active substance use or mental disorders. 

Reality: Housing may be the first step to becoming abstinent and/or entering treatment to

address a variety of problems. From a public

health perspective, adequate housing reduces 

victimization, hypothermia or hyperthermia,

infectious diseases, and other risks to the population as a whole. 

Myth #3. People who are homeless are unemployed. 

Reality: Many people who are homeless are 

employed full or part time. According to data 

from the National Survey of Homeless Assistance Providers and Clients (Burt et al., 1999),

44 percent of people who were homeless and 

21 
 

 

 

The Impact of Homelessness on Children and Families 

Homelessness results in a loss of community, routines, possessions, privacy, and security. Children, 

mothers, and families who live in shelters must make significant adjustments to shelter living and are 

faced with other problems, such as feeling ashamed of being homeless and accepting help, the anger and confusion of being relocated, and having to adjust to a new school and other new routines. 

The stress related to these risks adds to the stress resulting from homelessness itself and can impede recovery due to ongoing traumatic reminders and challenges: 

• The experience of homelessness puts families at greater risk of additional traumatic experiences, 

such as assault, witnessing violence, or abrupt separation. 

• Children, parents, and families are stressed not only by the nature of shelter living and the need 

to reestablish a home, but also by interpersonal difficulties, mental and physical problems, and 

child-related difficulties such as illness. 

• The stresses associated with homelessness can worsen other trauma-related difficulties and interfere with recovery due to ongoing traumatic reminders and challenges. 

Children are especially affected by homelessness: 

• Children who are homeless are sick twice as often as other children and suffer twice as many ear 

infections, four times the rate of asthma, and five times more diarrhea and stomach problems. 

• Children who are homeless go hungry twice as often as children who have homes. 

• More than one fifth of preschoolers who are homeless have emotional problems serious enough 

to require professional care; less than a third receive any treatment. 

• Children who are homeless are twice as likely to repeat a grade as those with homes. 

• Children who are homeless have twice the rate of learning disabilities and three times the rate of 

emotional and behavioral problems compared with children who are not homeless. 

• Half of school-age children who are homeless experience anxiety, depression, or withdrawal 

compared with 18 percent of children who are not homeless. 

• A third of children over age 8 who are homeless have a major mental disorder. 

These are not only challenges in themselves, but also may act as “secondary adversities,” putting a 

child at greater risk for trauma reactions and making recovery difficult. For more information and a 

list of resources about providing care and improving access to services for children and families who 

have been traumatized and/or are homeless, visit the National Child Traumatic Stress Network Web 

site (http://www.NCTSNet.org). 

Source: Bassuk & Friedman, 2005. 

Behavioral Health Services for People Who Are Homeless 

received services did some work for pay in the 

month before being surveyed. A single-day

count of people who were homeless in an urban area of Washington State found that 20

percent were employed at least part time 

(Putnam, Shamseldin, Rumpf, Wertheimer, &

Rio, 2007). 

Myth #4. There are few homeless families. 

Reality: To describe the full impact of homelessness, episodes of homelessness, and the effects on children of tenuous living situations 

(such as the “doubling up” of one family in the 

home of another family), the National Center

on Family Homelessness (NCFH) used refined methods for estimating the number of

children exposed to these burdensome and

stressful difficulties. NCFH determined that 

in 2010, 1.6 million children in America were 

exposed over the course of the year and 

200,000 on any given night (NCFH, 2010). 

Myth #5. People who are homeless aren’t 

smart enough to make it. 

Reality: Keeping things together while homeless takes ingenuity and experience. People 

22 
 

 

 

Part 1, Chapter 1 

who are homeless often have well-developed

street skills, resourcefulness, and knowledge of

the service system. 

Myth #6. Those with substance use or mental 

disorders need to “bottom out,” so homelessness is okay and provides a motivator to make 

behavioral changes. 

Reality: People who have substance use and

mental disorders are more responsive to interventions before they become homeless or

when placed in housing. 

Myth #7. Everyone stands an equal risk of

homelessness. 

Reality: Although any of us could find ourselves homeless in our lifetime, some people 

are at higher risk than others. If we can identify people at special risk of homelessness, we 

may be able to intervene earlier and prevent

the devastating effects experienced by people 

who are homeless and have accompanying

mental and/or substance use disorders. 

Myth #8. All clients with substance use and 

mental disorders who are homeless require 

extensive, long-term care. 

Reality: The process of recovery from substance abuse and mental illness is an ongoing

and sometimes lifelong process, yet healing

often begins with short-term, strategic interventions. Screening, brief intervention, and

referral to treatment (SBIRT; see the section

on p. 35 for more information) is a proven

method for early intervention with substance 

use and mental disorders, and it can significantly reduce the impact and progression of

illness. 

Self-Care for the Behavioral 

Health Service Worker 

The intensity of the work with people who are 

homeless and have mental and/or substance 

use disorders can lead to burnout, ethical dilemmas, and a sense of being overwhelmed by 

your work. Your personal history is unique;

however, commonalities of experience in

working with people who are homeless allow 

some generalizations about the need for selfcare. Some of the actions you can take are consistent across a variety of roles, personalities,

and circumstances. 

Common responses to working with 

people who are homeless 

Working with people who are homeless may 

entail addressing emergency situations, complex case management demands, severe and

persistent symptoms, and refusal of services.

The pace of the work may be a stressor, as 

some people who are homeless are reluctant to

engage in services and require a lot of time 

and patience to develop trusting relationships.

You may experience stress or unrealistic expectations when working with this population.

Other common reactions include: 

•	 Considerable anxiety regarding clients in

dangerous situations (e.g., refusing shelter

on frigid nights). 

•	 A strong desire to repeatedly try to persuade someone to go to treatment because 

you are concerned about his or her pace in 

recovery. 

•	 Frustration and strong urges to use involuntary measures (e.g., police transport to

the hospital) despite no clear risk of imminent danger to self/others when a severely 

impaired person is slow to engage. 

•	 Conflict over family members’ reactions,

given their experience (e.g., burnt bridges,

extreme feelings of guilt) with an individual’s past behavior. 

•	 Feeling overwhelmed or frightened by 

your client’s irritability, anger, and frustration. An example of deescalating a person

in the midst of an intense emotional reaction is given in Vignette 3 (Roxanne, Part

1, Chapter 2). 

23 
 

 

Behavioral Health Services for People Who Are Homeless 

•	 Thinking about violating ethical boundaries or agency policies to meet the immediate needs of a person who is homeless 

(e.g., give them personal funds). Feelings 

of helplessness or a sense of guilt about a 

person’s situation may add to the temptation to violate boundaries and policies. 

•	 A struggle to understand and appreciate 

the survival skills of a person who is homeless, particularly when his or her choices

and behaviors (e.g., distrust, agitation)

create barriers to receiving services. 

•	 Guilt about going home at night while a

client is sleeping on the street. 

•	 Anger or frustration about missed appointments, which indicate resistance to

engaging with services. 

•	 Reluctance to continue providing services 

to someone whose priorities conflict with

your ideas about their needs (priority to

find drugs rather than adequate housing,

resistance to obtaining medical care for an

immediate problem). 

•	 Frustration and feelings of ineffectiveness 

when your efforts to help seem to be unappreciated. 

•	 A sense of disconnection from clients who 

seem demanding, needy, miserable, or

overwhelmed. 

Your own experiences also play a role in your

responses to people who are homeless, and

these experiences may interfere with your

work, particularly if:

•	 A member of your family has a substance 

use or mental disorder and/or has experienced homelessness. 

•	 You have trouble differentiating your own

recovery process from that of your client. 

•	 You have ever been homeless or faced with 

the prospect of being homeless. 

•	 You see yourself as someone who has 

overcome the odds and pulled yourself up

“by the bootstraps.” 

•	 It is difficult for you to work with people 

who are overtly angry, excessively passive,

or insistent about doing things their way. 

•	 The experience of working with people 

who are homeless is new to you. 

Whether or not you have had these types of

personal experiences, you may struggle with

your reactions when working with this population, especially when dealing with stressful situations. 

Managing responses to working 

with people who are homeless 

Managing your responses to feelings and

stressors is easier if you develop and maintain

sources of personal support (CSAT, 2006a):

•	 Learn to recognize when you need help

(both technical and personal); ask for it. 

•	 Work in teams and establish networks;

discuss feelings and issues with teammates 

to lower stress and maintain objectivity. 

•	 Be open and sensitive to differences of attitude or opinion among your colleagues 

regarding individuals who are homeless 

and the problems they face. 

•	 When you find yourself being angry, critical, or dismissive toward the feelings or

needs of a person who is homeless, consider whether this is a sign of an attitude conflict, job burnout, or some other dynamic

related to your work. 

•	 Work closely with your supervisor and be 

open about any difficulties (for more information about the benefits and process 

of clinical supervision, refer to TIP 52,

Clinical Supervision and Professional 

Development of the Substance Abuse

Counselor [CSAT, 2009b]). 

Managing feelings and stressors is easier if you 

maintain healthy boundaries between your

work and personal life:

•	 Resist the urge to bring work home. 

24 
 

 

 

 

 

 

•	 Don’t spend your free time at work or

with your clients. 

•	 Resist the urge to be a friend or feel responsible for rescuing the people you serve 

from homelessness. 

•	 Recognize that your role is to help people 

help themselves and enable them to address their life problems, not to take responsibility for their problems. 

Stages of Change, 

Recovery, and 

Rehabilitation 

This section presents several frameworks for

helping people who are homeless by describing three important aspects of a trajectory out 

of homelessness: 

•	 Stages of change (Prochaska, DiClemente,

& Norcross, 1992). This transtheoretical 

model describes the process of behavioral 

change, beginning with precontemplation

and continuing through maintenance. It is

often used to reflect the process of change

for people with substance use disorders. 

•	 Critical stages of recovery (Townsend,

Boyd, Griffin, & Hicks, 2000). The critical stages of recovery model, often applied

to describe the change process with serious 

mental illness, emphasizes social and interpersonal connectedness and the relationship of the individual with systems 

that provide care. The model describes 

movement through four levels, from dependence through interdependence. 

•	 Stages of homelessness rehabilitation

(McQuistion & Gillig, 2006). This model 

describes the logical progression of rehabilitation—a process of moving from engagement though intensive care and into

ongoing rehabilitation. It describes the 

consequences of homelessness in a holistic

manner, recognizing that homelessness is 

not only the lack of adequate housing but 

Part 1, Chapter 1 

also the psychological, emotional, occupational, interpersonal, health, and other effects on an individual’s or family’s ability 

to function. 

Stages of Change 

Stages of change, which comprise the key organizing construct of the transtheoretical

model of change, inform effective interventions to promote behavior change. Although 

they have traditionally been associated with

substance misuse, they may also be applied to 

a person’s experience in coming to grips with

serious mental illness. The stages of change are 

equally applicable to prevention or treatment

interventions, although in prevention, behavior

change may involve risk or protective factors 

(e.g., parenting skills, physical inactivity) rather than problem behavior per se. 

Most people cycle through the stages more 

than once, and movement through the stages 

can fluctuate back and forth (Exhibit 1-3). 

The stages are:

•	 Precontemplation—Clients view behavior

(e.g., substance use, psychological symptoms, healthcare choices) as unproblematic

and do not intend to change. Your focus 

Exhibit 1-3: Stages of Change 

Source: Prochaska & DiClemente, 1986. 

Adapted with permission. 

25 
Behavioral Health Services for People Who Are Homeless 

on changing behavior at this stage may alienate clients. Instead, appropriate interventions help clients engage in services 

and become ready to consider change. 

•	 Contemplation—Clients think about 

whether to change behavior, become aware

of problems their behavior causes, and experience ambivalence about their behavior. 

•	 Preparation—Clients decide to make a 

change and have perhaps already begun to

change problematic behavior. 

•	 Action—Clients make a clear commitment to change; they engage in activities

as alternatives to problem behaviors, avoid

high-risk situations, and develop relationships that reward their changed behavior. 

•	 Maintenance—Clients have sustained new 

behaviors for at least 6 months. They sustain and further incorporate changes

achieved in the action stage and are actively working on supporting their recovery. 

Two other stages of the transtheoretical model 

are sometimes identified: relapse and termination. Relapse is a return to problem behaviors.

Most relapses to substance use occur within 3

months of behavior change; risk of relapse 

then begins to decline (Connors, Donovan, &

DiClemente, 2001). Termination occurs when

new behaviors are thoroughly stabilized and

there is a compelling belief that a return to the 

problem behavior is highly unlikely (see TIP

35, Enhancing Motivation for Change in Substance Abuse Treatment [CSAT, 1999b] for an 

indepth discussion of stages of change). 

Regardless of the model for understanding

change, it is important to remember that people are often in different stages of change for

different issues. For example, a person may be 

willing to accept housing or medical care 

(preparation stage of the transtheoretical 

model) while not yet thinking about substance 

abuse or mental health treatment or broadening coping skills or community involvement 

(precontemplation stage).The provider’s challenge is to understand and respect the service 

recipient’s stage of readiness and provide interventions and services that facilitate forward 

movement. Skilled providers recognize that

readiness to change some behaviors might

provide an opportunity to explore ambivalence 

and enhance readiness to change others; for

example, persons may be willing to seek housing but not immediately address substance use 

behavior. When they do recognize that housing issues are intertwined with substance use,

they may be more willing to explore the pros 

and cons of their use. 

As people move toward the action stages in

any model, they become ready for more intense services, which often require more active 

collaboration with clients and may be offered

in more structured housing and treatment or

prevention programs where individual responsibility for completion of tasks and behavior

change yields successful outcomes. 

Critical Stages of Recovery 

Whereas the stages of change model addresses 

psychological readiness for behavioral change,

the stages of recovery model addresses developmental goals that are more closely related to

mental health recovery, the degree and nature 

of social connectedness, and the relationship

between an individual and the service delivery 

system. As clients engage in their recovery 

process, they begin in a state marked by high

dependence on the human services system and

other community supports but are paradoxically unaware of that dependence. As they 

gain greater mastery over their recovery, they 

may remain dependent on support from others, yet become aware of that dependence. Following this is a stage of awareness and relative 

independence from these structures, and finally,

a stage characterized by a sense of interdependence, in which they are aware of challenges and

can use natural support systems, both formal 

26 
 

 

 

 

 

 

 

 

 

Part 1, Chapter 1 

and informal, realizing that they are also actively contributing to the social environment.

(Townsend et al., 2000.) 

The stages of recovery model recognizes the 

right of people to live in the community and

to choose their lifestyle. It is premised on a

number of additional guiding principles. Perhaps most important is that a client directs 

and manages his or her recovery process. A

corollary of that is that behavioral health service providers need to be wary of their tendency to encourage clients to be dependent on the 

treatment system (Townsend et al., 2000). As

part of a community system of care, the behavioral health service provider has an important role in each of these stages to promote 

recovery (Exhibit 1-4). 

Processes in recovery from 

substance use and mental disorders 

In recovery, people actively manage substance 

use and/or mental disorders and seek to transcend these experiences as they build or reclaim 

meaningful lives in the community (Davidson 

Exhibit 1-4: Behavioral Health Service Provider Roles and Best Practices 

According to Stage of Recovery 

Stage Service Provider’s Role Best Practices To Facilitate Recovery 

Dependent/Unaware • Demonstrate hope 

• Encourage self-acceptance 

• Educate about behavioral health 

problems and the benefits of a 

recovery plan 

• Engage family and other social 

supports 

• Build relationship by listening, 

valuing, and accepting client as a 

worthwhile person 

• Collaborate with client in managing 

behavioral health problems 

• Build rapport with family/others 

• Link to services and benefits 

Dependent/Aware • Promote readiness to make 

choices about life roles/goals 

• Educate family about available 

choices 

• Offer support in designing a 

recovery plan 

• Involve client with groups that address his or her specific needs 

• Educate about behavioral health 

problems and relevant coping skills 

• Help with choosing goals 

Independent/Aware • Help develop life roles/goals 

• Encourage individual coping 

strategies to deal with symptoms 

and distressing experiences 

• Support medication management and use of recovery plan 

• Encourage appropriate support 

from families and others 

• Assist with connection to community resources 

• Work on recovery plan, recovery 

support, coping skills, and crisis 

plan 

Interdependent/ 

Aware 

• Work with client and support 

system to support life goals 

• Help with community resources 

• Review recovery plan regularly 

• Support interdependence in 

community 

• Support continuing recovery 

• Advocate use of community 

resources 

• Encourage involvement in community activities 

Source: Townsend et al., 2000. 

27 
 

 

 

 

Behavioral Health Services for People Who Are Homeless 

& White, 2007). The term “recovery” may 

have somewhat different meanings in substance abuse treatment settings than it does in

mental health settings. For instance, many clients in substance abuse recovery may say they 

are never fully recovered from their illness and

are “only one drink away from a drunk,”

whereas individuals with a single major depressive episode in their history may consider

themselves recovered, even “cured” of their illness. In either case, it is important to know

how each individual client understands these 

terms and how they apply to the recovery process for the specific individual. 

Considering the broader framework of recovery—integrating the recovery process from 

substance use disorders with that of mental 

disorders—Davidson et al. (2008) obtained

information from people in recovery about

their experiences. For most of the respondents,

recovery meant taking an active role, profoundly changing the way they lived their

lives, opening up to new learning, and becoming more flexible. The processes the authors 

describe are presented in Exhibit 1-5. The authors recognize that recovery is not linear, but

they believe that processes represented together on a single line in the exhibit occur more or 

less simultaneously. This progression also suggests that some recovery strategies may be 

more useful at some points in the process than

others. For example, early in recovery, a behavioral health service provider might want to

focus on strengthening mutual support systems and fostering a belief in recovery. 

These processes are also valid for clients entering homelessness services from the criminal 

justice system. Developed in partnership with 

people in recovery, these processes reflect challenges people face in recovery and solutions

for them. Your role and that of the program 

administrator is to help articulate and then

support clients’ efforts in recovery by helping

them identify acceptable strategies and resources to confront these challenges. 

Prevention activities can play a central role in

recovery, especially those that relate to skills 

Exhibit 1-5: Substance Use and Mental Disorder Recovery Processes 

Source: Davidson et al., 2008. 

Initiating recovery and assuming control Creating and maintaining mutual 

relationships 

Renewing hope, confidence, and commitment 

Understanding, accepting, and redefining self 

Becoming an empowered citizen 

Assuming control Overcoming stigma and promoting positive 

views of recovery 

Incorporating illness and maintaining recovery 

(including managing symptoms & triggers) 

Community involvement and finding a niche 

28 
 

 

Part 1, Chapter 1 

development and wellness self-management.

In addition, prevention programs can adopt

and benefit from a recovery orientation when

working with individuals who are homeless. 

The process, dynamics, and important interventions related to recovery are addressed in

detail in the planned TIPs, Building Health,

Wellness, and Quality of Life for Sustained Recovery (SAMHSA, planned b) and Recovery in 

Behavioral Health Services (SAMHSA,

planned e). Refer to these TIPs for more information on supporting long-term recovery. 

Stages of Homelessness 

Rehabilitation 

Stages of homelessness rehabilitation refer to

the different types of care a client with behavioral health problems, and his or her family,

may receive while moving toward housing stability. Your work may involve clients at any of

these stages. For individuals who are homeless,

attaining housing and financial stability are

inextricably tied to other aspects of social support and to rehabilitation from disabling behavioral health conditions. Depending on the

services an individual who is homeless needs,

stagewise interventions may emphasize outreach and case management, screening and

evaluation, crisis intervention, clinical preventive services, preparation for treatment, treatment planning, relapse prevention or recovery 

promotion, or ongoing counseling. 

Your existing skills in providing treatment and

prevention services in behavioral health settings will be invaluable and can often translate 

directly into working with people with mental 

and/or substance use disorders who are homeless. Nevertheless, you may need to develop

some specific skills for work in this area. It will 

be necessary to coordinate your services with

those provided by staff in other homelessness 

programs and health and social service organizations. Your services and the services provided by other health and social service organizations are often delivered across stages, with

service transition points being particularly 

high-risk periods for dropout. The stages of

homelessness rehabilitation are: 

• Outreach and engagement. 

• Transition to intensive care. 

• Intensive care. 

• Transition to ongoing rehabilitation. 

• Ongoing rehabilitation. 

The amount of time a person spends in any of

the stages of homelessness rehabilitation depends on barriers to providing and accepting

services—such as availability of appropriate

housing options, severity and chronicity of

substance use disorders and symptoms of

mental illness, and availability and acceptability of social supports for changing problematic

behaviors. Progress through the stages of rehabilitation is not steady. Clients may drop

out, relapse in their substance use, and need

outreach and reengagement several times before achieving ongoing homelessness rehabilitation. For this reason, this TIP assumes that 

motivation for changing problematic behaviors will fluctuate, that behavioral health

symptoms may recur, and that a client may 

return to homelessness during any phase of

rehabilitation. 

Outreach and engagement 

Engagement is the first stage of work with

people who are homeless (McQuistion, Felix,

& Samuels, 2008). Its goal is to facilitate the

individual’s movement through the early stages of behavior change (Prochaska et al., 1992).

Approaches during this phase include active 

outreach to prospective clients and engagement services—including capturing prospective clients’ interest in a variety of

homelessness services, as well as substance 

abuse, medical, mental health, and social services; gaining the prospective client’s trust; and

increasing motivation for change. For families 

29 
 

Behavioral Health Services for People Who Are Homeless 

who are homeless, the prospect of preventive 

services for children may be especially attractive. During this process, you should identify 

and attempt to meet basic needs for shelter

and safety, and you should attend to immediate health concerns. 

For some persons who are homeless or at risk 

for becoming so—those coming from criminal

justice settings or those being discharged from 

treatment programs—outreach may not be a

particularly difficult issue, but engagement in

social, health, and continuing prevention and

recovery services may present more of a problem. Persons with transitional homelessness 

may not perceive the need for additional services beyond lodging, seeing their stay in a

shelter or other homeless housing program 

unrealistically as a temporary transition to getting a place of their own. Additionally, clients 

recently in treatment for mental and substance 

use disorders may not recognize the effect of

their impending homelessness on substance 

abuse and mental health recovery and across 

all other aspects of their lives. 

As a behavioral health worker, you can play an

important role in outreach by acknowledging

homelessness as a significant element in when

and how people can access treatment, by recognizing the needs of people who are homeless for preventive and basic services, and by 

developing productive, trusting, and supportive 

relationships with people who are homeless 

and come to you for services. 

Transition to intensive care 

People enter the intensive care phase of homelessness rehabilitation when they agree to accept health and/or financial benefits; medical,

substance abuse, and/or mental illness treatment and prevention services; and, frequently,

housing. This transitional phase is a high-risk 

period during which a large percentage of individuals drop out of services. The transitional 

phase requires intensive support (e.g., intensive case management, critical time intervention) and your acceptance that some people 

may have increased ambivalence and may not

attend program sessions or keep appointments 

or commitments. Essential elements in this 

phase include locating clients or program participants when they fail to make contact, making phone calls, and providing immediate

tangible benefits (e.g., food, safe shelter, bus 

fare). 

Accordingly, you may have to adapt traditional

assumptions about and approaches to service 

provision when a client is in the transitional

phase of homelessness rehabilitation (e.g., assuming clients will make and keep appointments; assuming program participants will 

attend sessions; assuming individuals have

transportation to service settings; having

standard time lengths for counseling, psychoeducational, or anticipatory guidance sessions). You may need to exercise greater

persistence and advocacy with these individuals. On the other hand, the skills you regularly 

use, such as maintaining a trusting and supportive relationship, working with resistance,

or adapting to specific needs or concerns can

be a significant benefit in working with individuals in this stage who are homeless. 

Intensive care 

As its name denotes, the primary focus of intensive care is a comprehensive but carefully 

synchronized orchestration of homelessness 

rehabilitation, including treatment for mental 

and substance use disorders, access to benefits,

active attention to medical problems, housing

access, and preventive services, such as assessment of and training in necessary skills (e.g.,

money management, parenting, employment, 

and other life skills). Cattan and Tilford

(2006) suggest that for younger people who

are homeless, including young adults, mental 

health promotion activities that help create a

sense of community and empowerment may 

30 
 

 

 

be particularly important.Thus, prevention

activities at this stage may include encouraging participation in positive community activities (e.g., sports and the arts) and community 

service. 

Intensive care is implemented in a manner

that emphasizes clients’ participation in defining and managing their own goals. People in

intensive care may drop out or return to

homelessness and need to be reengaged several 

times. In some cases, people verbalize this 

choice; in others, it is evidenced by angry outbursts, disappearance from services, rule violations, or other behaviors. Appropriate

responses include respecting personal choices,

attempting to reengage, welcoming the person

back, and revising treatment and prevention

plans when he or she returns. Some people in

this phase will accept higher intensity transitional housing models combined with behavioral health services as well as social and 

medical services. Others will only accept options that provide housing and voluntary participation in supportive services. 

It is important in the intensive care phase of

homelessness rehabilitation to ensure that 

people maintain the gains they have made 

through previous substance abuse and mental 

health services. Maintaining momentum for

recovery and relapse prevention, continued use 

of new skills, and involvement in community 

activities can be essential at this point. Staying

in touch with mental health, substance abuse,

and other resources in the community is critical, even given transportation problems, employment considerations, multiple pressing

needs, and financial constraints. 

This phase requires behavioral health services 

that are integrated with other ongoing housing, healthcare, legal, and social services. Close 

collaboration among all providers is a priority.

The case management skills that treatment 

Part 1, Chapter 1 

professionals use are highly applicable to serving these clients. 

Transition from intensive care to 

ongoing rehabilitation 

Before individuals move into the ongoing

homelessness rehabilitation phase (when they 

are preparing for optimal social reintegration), 

it is important to ensure that they have a comprehensive and evolving plan for sustaining

the process of recovery, including acquisition

of stable housing, gains made in social and

other skills, and involvement in community 

activities. Successful plans also include a realistic long-term plan for relapse and homelessness prevention, development of strong

connections to social supports (e.g., family,

faith, and recovery communities), stable income and health benefits (e.g., job skills and

employment, health insurance, Federal disability benefits, local government cash supports,

veterans benefits, food stamps), and meaningful daily activities that complement their recovery plans. 

Making the transition from intensive care to

the open-ended stage of ongoing rehabilitation takes time. Increased risk of dropout from 

services (including behavioral health services) 

because of increased ambivalence is common 

and can be addressed by providing increased

case management services, staff attention, incentives to remain engaged (e.g., paid vocational services contingent on abstinence and

positive work behaviors, transportation), and

increased relapse prevention efforts. 

Some people may attain such improved functioning, coping skills, social support, and financial resources that they can maintain

independent, affordable housing with followup services to ensure their gains in recovery 

and other areas of functioning. Others may 

benefit from 1 to 2 years or more of a supportive recovery and housing environment (e.g., 

31 
 

 

 

Behavioral Health Services for People Who Are Homeless 

Oxford Houses) to develop better coping skills 

for maintaining recovery and improving social

functioning. Still others need weekly contact

with a case manager from a multidisciplinary,

community-based team to address any threats 

to housing stability and recovery as they arise.

Transportation issues that limit participation

in ongoing rehabilitation activities must also

be addressed prior to exiting this phase. 

Behavioral health counseling and anticipatory

collaborative problem-solving for clients in

transition to ongoing rehabilitation are particularly important. Helping clients stabilize in

recovery, engage and maintain attendance in 

self-help programs, develop a realistic individualized relapse prevention/recovery promotion

program, and begin to develop a healthy lifestyle are also important at this point. 

Ongoing rehabilitation 

Ongoing rehabilitation is an open-ended 

phase in which people gradually establish an

identity as no longer homeless (McQuistion et

al., 2008). This stage includes an active and

continuing supportive counseling relationship

and continued participation in prevention

programs as appropriate (e.g., regular followup meetings to address any problems related

to housing stability and recovery). In this 

stage, clients have a contact person in case of a

crisis or relapse. 

You can play a significant role as the program

participant begins to depend less on services 

and service providers for assistance. Your consistent, ongoing collaborative relationship with

clients may be especially beneficial as their

self-concept, expectations for the future, selfesteem, and ability to manage life’s problems 

evolve. Your support for the person’s continued 

attendance at 12-Step and other wellness selfmanagement programs and involvement in

new community activities is also helpful. You 

can be a role model for appropriate absinent

behavior and help people share with others 

what they have learned in their transition from 

homelessness to an interdependent relationship with their environments. 

Clinical Interventions and 

Strategies for Serving People 

Who Are Homeless 

Behavioral health service providers working

with people who experience homelessness 

need special skills. Specific knowledge about

homelessness and its effect on recovery and

change is important, as is careful assessment

and modification of attitudes that affect your

work with this population. Understanding the 

cultural context of clients and having the skills 

to adapt to a variety of cultures of people who

are homeless is very important. The skills you 

normally use in providing behavioral health

services are applicable but may also need to be 

modified or honed to address the specific

needs of people experiencing or facing homelessness. 

It is beyond the scope of most behavioral 

health programs to meet many of the urgent

needs of people who are homeless. Inevitably,

this means that you—who may be the point of

contact or “first door” for a person who is

homeless or facing homelessness—must have a

working knowledge of resources in the community for these people, not only for housing

services, but also for services that address

physical health care, financial crises, criminal

justice constraints, and dietary needs, among

other concerns. Ideally, a behavioral health

program will maintain reciprocal alliances

with other community resources that allow for

efficient case management of persons with

complex needs. 

Additionally, people who are homeless may 

have special mental health and substance 

abuse treatment needs, including special trauma-informed treatment services, specialized 

32 
 

 

Part 1, Chapter 1 

care for co-occurring disorders, services to ensure medication management, and close medical supervision while undergoing

detoxification. 

If not already integrated into programming,

treatment programs must include prevention

programs in their alliances, because many of

these programs are designed to meet highpriority needs of persons and families who are 

homeless (e.g., skills development, parenting

education, expanding recreational opportunities, community involvement). Larger programs, especially treatment programs, may also

have a designated case management staff 

member who coordinates referrals and ensures 

that clients follow through on referrals and

that services are provided. 

This TIP discusses seven activities common to 

many behavioral health service situations 

along with special adaptations that are useful 

in working with people who are homeless:

•	 Outreach 

•	 Initial screening and evaluation 

•	 Early interventions and stabilization 

•	 Treatment and prevention planning 

•	 Case management 

•	 Client retention and maintenance of continuity of care 

•	 Relapse prevention and recovery management 

Some of these areas may be more applicable to

some settings than others, but unless you work 

in a very specialized setting, all will probably 

be applicable to your current or future work. 

Outreach 

Outreach plays a crucial role in work with 

people who are experiencing homelessness. It

means making contact with individuals on

their terms—where they live—rather than in

an agency setting. It involves developing sufficient trust to help people consider receiving

services and the benefits they might accrue 

from them. It may well mean developing rapport with people who, because of their experiences, have no expectation of a positive 

outcome. 

Outreach is particularly relevant to the engagement stage of homelessness rehabilitation.

It involves deliberately and methodically cultivating a relationship with the person or family 

who is homeless. Effective outreach skills include: 

•	 Expressing appreciation for survival skills 

as strengths and coping mechanisms. 

•	 Understanding substance abuse and/or

psychological symptoms from the client’s 

perspective and understanding how those 

symptoms are interrelated. 

•	 Addressing financial and health benefits as

well as food, healthcare, housing, and other immediate needs. 

•	 Expressing optimism that together you 

can create a plan that meets the person’s 

needs. 

•	 Empowering the client to set goals and

create a plan for recovery and growth. 

You will probably find that outreach efforts 

with people experiencing homelessness are 

more aggressive and proactive than those you

use in traditional mental health and substance 

abuse settings. You may find yourself meeting

your clients literally where they are rather than

waiting for them to come to you. While taking

care to respect people’s autonomy, you may be 

more assertive in engaging people into services. In treatment settings, you may be more 

assertive in establishing the therapeutic relationship. You may find yourself responding

more actively to crises or becoming more involved than you would with most treatment

clients or prevention program participants. In

effect, the skills of outreach are generic, but

how you apply those skills may be different

from your traditional role. 

33 
 

 

 

Behavioral Health Services for People Who Are Homeless 

Initial Screening and Evaluation 

This activity will generally be different for

treatment and prevention professionals. Within prevention settings, a first contact with a 

person who is homeless may differ little from 

your first contact with other program participants. However, you will wish to pay special 

attention to constraints on participation

(transportation, child care, etc.) and assist participants who are homeless in addressing these 

issues. Within your zone of comfort, you may 

also want to inquire as to other services that

your program participant is receiving and suggest community resources where additional

services may be accessed. 

Within treatment settings, a first contact with 

a person who is homeless or facing homelessness will ordinarily involve initial observations 

and, potentially, decisions about care. For instance, although a prospective client may not

be forthcoming with information, it may fall 

to you to evaluate whether the individual is in

immediate danger with consequences to

health or safety as a result of his or her life situation. You might be in the position of having

to determine whether the client needs immediate care as a result of drug use or mental illness or to evaluate his or her ability to make 

decisions about care. Frequently, it will be necessary to determine which other team members or program staff persons might be helpful 

in determining urgent client needs (e.g., primary care provider, housing specialist, other

mental health professional). 

People who are homeless typically engage 

gradually with services as trust is established.

As opposed to techniques in more traditional 

settings (whether focused on treatment or prevention), gathering information may take 

more time and be ongoing; new information 

may surface as the client stays connected. To

understand the client’s level of functioning

and identify appropriate services, screening 

and evaluation should gather information

about: 

•	 Substance use and/or mental disorders,

including: 

–	 Evidence of a substance use disorder,

which can include quantity and frequency of use, compulsive use, craving,

and problems related to drug use. 

–	 The effect of specific symptoms (e.g.,

paranoid thinking, undue grandiosity,

constraints resulting from depression)

on a client’s ability to seek and accept

help with housing and other services. 

–	 Problematic substance use, symptoms 

of mental disorders, and client readiness for changing substance use behaviors and other areas of social 

functioning; specific screening instruments can be used to determine each 

of these. 

–	 Screening for the presence of a disorder (positive screens should be referred

for further assessment and formal diagnosis). 

–	 The possibility of co-occurring mental

and substance use disorders and the 

implications of co-occurring disorders

for immediate and extended treatment 

and recovery. 

•	 Current and past exposure to trauma and

related safety issues. 

•	 Primary care records, history of medical

conditions and hospitalizations, list of previous and current medications, and the

current need for medical and dental care,

including risk of and treatment for 

HIV/AIDS and other communicable diseases. 

•	 Onset and course of homelessness and 

how it relates to the course of other symptoms. 

•	 Current skills and ability to maintain stable housing. 

•	 Current and/or pressing criminal justice 

issues, including outstanding warrants that 

34 
 

 

 

 

Part 1, Chapter 1 

might lead to incarceration; probation and 

parole status; and current behaviors that, if

discovered, might lead to arrest. 

•	 Social functioning in terms of social supports, literacy, education, job skills, employment, and income, as well as: 

–	 The client’s family (as he or she defines it) and other social supports that

the client wants to incorporate into the

plan for recovery. 

–	 Immediate stressors (e.g., shelter living,

housing instability, lack of money, debt,

legal issues). 

•	 Client interest in prevention-related activities, such as life skills development, 

stress and anger management, anticipatory 

guidance for youth, parenting programs,

recreational or volunteer activities, and 

cultural enrichment programs. Having a

directory of such prevention resources in

your community will be a useful adjunct to

other service directories you use in your

work. 

Screening, brief intervention, and 

referral to treatment 

SAMHSA has endorsed the use of SBIRT,

which integrates initial screening with brief

interventions or referral to treatment in some 

settings with people who may have problems 

with substance use—including clients with

substance use disorders and co-occurring

mental disorders. SBIRT is particularly useful

with individuals who are homeless in that it 

requires relatively little time (roughly 5

minutes to screen a patient and 10 minutes to

provide a brief intervention) and can prevent

the need for further, more intensive services 

later on (Bernstein et al., 2009). 

In 2009, the National Institute on Drug

Abuse released an Internet-based, interactive

tool for screening and brief intervention to

address use of illicit substances. Research supports the efficacy of SBIRT in reducing heavy 

use of alcohol and illicit drug use across a

range of settings and clients. One evaluation

of SAMHSA’s SBIRT service program found

that SBIRT interventions had a positive impact on homelessness as well, with significantly fewer patients reporting lack of housing 6

months after the intervention than had reported it at baseline (Madras et al., 2009). 

SAMHSA’s SBIRT model provides for early 

intervention and treatment services on a continuum of substance use. Beyond providing for 

substance abuse treatment, SBIRT also targets 

nondependent substance use problems and

provides effective strategies for early intervention before the need develops for more extensive or specialized treatment. See SAMHSA’s 

planned Technical Assistance Publication,

Systems-Level Implementation of Screening,

Brief Intervention, and Referral to Treatment,

for more information (SAMHSA, planned g). 

Early Interventions and 

Stabilization 

As behavioral health service providers further

develop and maintain trusting relationships, 

they engage in intensive early intervention and

stabilization while addressing urgent environmental needs (such as health or criminal justice issues) and managing acute substance 

abuse and mental health symptoms. In both

treatment and prevention, this activity involves

constructing a treatment and/or prevention 

plan that is person centered, adhering to an 

individual’s goals. Some people who are homeless will need detoxification as part of a stabilization process. Others may need brief

hospitalization to stabilize acute symptoms.

Stabilizing is a process of beginning to restore

physical health and feelings of safety, to relieve 

emotional turmoil, and to get a sense of future 

goals and needs. 

Stabilization is a prerequisite for beginning an

ongoing recovery program. Yet, for some peo35 
 

 

 

How Does SBIRT Work? 

Screening 

No or Low Risk Moderate Risk Moderate to High Risk Severe Risk, 

Dependence 

No Further Intervention Brief Treatment 

(on site or via referral) 

Referral to Specialty 

Treatment Brief Intervention 

Screening (S) is a process of identifying clients with possible substance abuse problems and determining the appropriate course of future action for these individuals. The screening process does not 

identify exactly what kind of problem the person might have or how serious it might be; it simply 

determines whether a problem exists and, if so, whether further assessment is needed. 

Brief intervention (BI) is appropriate for clients identified through screening to be at moderate risk 

for substance use problems. BI can be provided through a single session or multiple sessions of motivational interventions. These interventions focus on increasing a client’s insight into and awareness 

about substance use and behavioral change. 

Brief treatment (BT), also called brief intensive intervention, is a specialty outpatient treatment modality—a systematic, focused process that relies on assessment, client engagement, and implementation of change strategies. The treatment consists of assessment and a limited number (typically 6 

to 20) of evidence-based, highly focused, and structured clinical sessions (e.g., solution-focused 

therapy, cognitive–behavioral therapy). Clients may receive BT on site but more commonly are referred to an outside program or another component of a medical system. 

Clients identified as needing BT or more intensive treatment are referred to specialty substance 

abuse treatment (referral to treatment [RT]), the primary goals of which are to identify an appropriate treatment program and to facilitate the individual’s engagement. RT requires a proactive, collaborative effort between SBIRT providers and those providing specialty treatment to ensure that, 

once referred, the client accesses and engages in the appropriate level of care. 

Source: SAMHSA, planned g. 

 

Behavioral Health Services for People Who Are Homeless 

ple—particularly those who have been living

in ambiguity, chaos, or from crisis to crisis—

stabilization can be uncomfortable. Some 

might describe their experience as “waiting for

the other shoe to drop.” Others may have a

well-developed ability to “look good” despite

physical, emotional, interpersonal, and 

environmental instability. It is important for

you to assess carefully the rate and extent to

which a person has actually begun to stabilize; 

you must resist the temptation to push ahead

before stabilization is established. This accentuates how the activities of stabilization may

often challenge engagement, in that careful 

and active worker–client collaboration is required. 

36 
 

Part 1, Chapter 1 

Treatment and Prevention 

Planning 

Treatment and prevention planning needs to

be person-centered, addressing the client’s 

goals and using agreed-upon strategies. Planning should include decisions about:

•	 Which services the person needs and

wants. 

•	 Where the services will be provided. 

•	 Who will share responsibility with the individual for monitoring progress. 

•	 How services will be coordinated and reimbursed. 

Developing treatment and prevention plans 

for clients with complex needs is, at best, difficult. Services have to be prioritized and plans 

made based on outcomes that have not yet 

been achieved. Both treatment and prevention

are likely to involve multiple programs, each

with its own goals and priorities, rules, and

restrictions, and with different levels of involvement with the client or program participant. For instance, some services require a

one-time visit (such as obtaining identification

or screening for substance-related and mental 

health issues), whereas others—such as management of chronic health conditions—may 

be ongoing. Given this degree of complexity,

treatment plans should include:

•	 Specific biopsychosocial goals relevant to

the individual and his or her living situation. 

•	 Projected timeframes for accomplishing

these goals. 

•	 Appropriate treatment and prevention approaches. 

•	 Housing and services the client will need

during service delivery. 

•	 Follow-up activities during ongoing rehabilitation. 

Some services may have priority over others by 

virtue of immediacy of need or other constraints. For many people who are homeless, 

life stabilization and safe housing are requisites for approaching and establishing recovery

from substance abuse or mental illness. For 

others, achieving some treatment goals (such

as abstinence) may diminish the intensity or

importance of other problems. Most important, treatment and prevention planning

needs to consider the whole person and to prioritize clients’ immediate and longer-term 

goals. Planning should consider the environment in which clients live, differentiate between the problems that can be resolved and

those that can only be lessened, and set priorities for services. 

Case Management 

Case management, which is often assertive in

the beginning of care for people in homelessness rehabilitation, is essential in addressing

clients’ manifold needs and preventing clients 

from becoming lost in the maze of community 

services. The job of case management will 

generally fall to a counselor in a treatment

agency, but there is no reason why a properly 

trained preventionist cannot serve as a case 

manager. Although most behavioral health 

counselors are well trained in case management processes and techniques, clients who are

homeless have unique needs and may require 

assistance with such tasks as arranging transportation, obtaining appropriate clothing for

interviews, ensuring follow-through on referrals, understanding the instructions provided

by other agencies, and assembling appropriate 

information and credentials needed by other

community programs. Particularly in work 

with people who are homeless, case management services need to begin when the client

enters the service system so that needs are anticipated, clients are not overwhelmed with

numerous referrals at once, and you and your

clients have time to prepare for upcoming referrals. 

37 
 

 

 

 

 

Behavioral Health Services for People Who Are Homeless 

Preventive services using case 

management methods 

Although traditionally associated with health,

mental health, or substance abuse treatment

services, case management extends to preventive services as well. Indeed, the same concerns 

that motivate case management in treatment

services (e.g., matching services to needs, locating appropriate providers, supporting participation in and compliance with 

collaborative treatment planning, assisting

with logistics such as transportation and child 

care, monitoring attendance and progress) apply as much to preventive services. 

The same person may serve as a treatment and

prevention case manager, or the prevention

case management function may be fulfilled by 

a prevention professional collaborating with

the treatment case manager. In either case, the 

goal is to integrate treatment and prevention

services to meet the unique needs and personal 

goals of the service recipient. 

This TIP emphasizes that people who are 

homeless or at risk of homelessness can benefit from a variety of preventive services, especially clinical preventive services (i.e., selective 

and indicated prevention; see Exhibit 1-1).

The TIP has discussed a variety of preventive 

services, including screening and brief or early 

intervention for emerging substance use or

mental disorders, skill building (e.g., parenting

skills, coping skills, anger management),

strengthening families, relaxation training, exercise, recreation programs, and community 

involvement. These are illustrated in Vignettes 

4 (Troy) and 6 (Mikki) in Part 1, Chapter 2.

Such services may be offered by local governments, schools and community colleges, freestanding prevention agencies, social service 

agencies, primary care providers, organizations

that serve aging individuals, community clinics, Boys & Girls Clubs, YMCAs, YWCAs, 

fraternal organizations, congregations, community coalitions, and so on. Not all communities offer all these services. Prevention case 

managers should develop a comprehensive 

prevention directory for use in matching client

needs to available services. 

The principles and procedures presented in

this chapter apply to prevention-related case 

management as much as to treatment-related

case management. The only difference is that

the prevention case manager will likely need to

access a wider variety of community agencies 

to meet preventive service needs. 

Retaining Clients in Treatment 

and Maintaining Continuity of 

Care 

For clients who have been living with chronic

crises of housing, health care, drug use, criminal justice constraints, financial needs, and

perhaps other issues, providing comprehensive,

integrated care can seem an impossible task.

As a result, it becomes important to keep

treatment and prevention goals realistic and

achievable, relatively short term (although you 

and the client may have long-term goals in

mind), and measurable. Specific strategies to

improve retention may be desirable, such as 

rewards for achieving and maintaining drug

abstinence or consistent participation in

treatment or prevention activities. 

Defining a process for the setting of goals can 

be beneficial. You should collaborate with clients to set goals in accordance with their priorities. Targeted goal management will allow you

to work with clients to assess current and 

evolving needs for financial benefits and health

insurance; substance abuse, psychological, and

medical treatment and prevention services;

housing resources; access to transportation;

employment and education; social supports;

assistance with legal problems; and recreational

activities. 

38 
 

 

 

Part 1, Chapter 1 

As people identify their most important, pressing goals, collaboratively identify one activity

related to each goal area that:

•	 Is specific (e.g., number of weekly negative 

urine samples screened, groups attended,

parenting sessions completed, volunteer

opportunities identified, or job applications completed). 

•	 Can be completed successfully in a given

timeframe. 

•	 Can be verified objectively via receipts,

agency reports, worksheets, or the like. 

•	 Is tailored to the client’s individual level of 

psychosocial functioning and personal and

social resources to increase the likelihood 

of successful completion. 

Small successes and progress toward personally meaningful goals while maintaining accountability and autonomy build client selfesteem and confidence. Your relationship with

the people you serve is strengthened through

collaborative decisionmaking about activities

to be accomplished and reinforcing the individual’s completion of activities. In traditional

treatment programs, reinforcement for completing activities includes social recognition

and sponsor status in mutual support groups,

take-home privileges, early dosing windows in

methadone maintenance programs, and

vouchers for self-care items and food. In prevention programs, reinforcement may take the 

form of social recognition, opportunities for

training, or attendance at conferences. 

Relapse Prevention and Recovery 

Management 

Clients with mental illnesses, substance use 

disorders, cognitive impairment, and/or family 

histories of substance use and mental disorders 

are at higher risk for relapse and subsequent

loss of housing (see the planned TIP, Recovery 

in Behavioral Health Services [SAMHSA,

planned e]). As individuals move into the clinical stage of ongoing rehabilitation, a variety of 

evidence-based and best practices interventions are available to support personal recovery, including relapse prevention and wellness 

self-management. 

Wellness self-management, also termed illness 

self-management, is a manualized, evidencebased, time-limited group technique that helps 

teach skills of maintaining and enhancing

health and wellness (Mueser et al., 2006). Interventions are typically delivered through a

series of classroomlike group sessions that

capitalize on cognitive–behavioral techniques,

each focusing on a wellness topic, such as 

medication compliance, diet, or stress management. Simultaneously, mental health and

substance use issues undergo continuing

treatment, along with housing supports. Supportive housing that accepts and addresses relapse or recurrence of psychiatric symptoms 

aids this. Coping skills training, employment 

and educational assistance, and the encouragement of establishing social connectedness 

through participating in other community institutions (e.g., faith-based organizations, senior centers, community volunteer groups, 

recreational groups), as well as recovering family ties, help maintain the personal recovery 

process (Marlatt & Donovan, 2005). 

Evidence-Based Practices in 

Homelessness Rehabilitation 

Exhibit 1-6 presents promising and evidencebased practices that support people who are 

homeless while they move through the stages

of rehabilitation and establish stable housing

and long-term recovery. You may already use 

these practices in the behavioral health treatment settings in which you work. 

Several evidence-based practices have been

evaluated specifically with homeless populations, including ACT, critical time intervention

(CTI), motivational interviewing (MI), contingency management, cognitive–behavioral 

39 
 

Behavioral Health Services for People Who Are Homeless 

Exhibit 1-6: Promising and Evidence-Based Practices by Rehabilitation Stage 

Treatment Approach Engagement Transition 

Intensive 

Care Transition 

Ongoing 

Rehabilitation 

Incentives (food, transportation, 

benefits) X X X X 

Primary medical care X X X X X 

Motivational interviewing X X X X X 

Clinical 

preventive services 

Indicated (e.g., screening, 

brief intervention) X X X X 

Selective (e.g., skills development, anger management, anticipatory 

guidance, parenting programs) 

X X X X 

Universal prevention programs (e.g., workplace 

programs, recreation programs, volunteerism) 

X X X X X 

Integrated treatment for CODs X X X X X 

Peer support X X X X X 

Family and social support X X X X X 

Intensive case management X X X X 

Critical time intervention X X 

Contingency management X X X 

Assertive community treatment X X X 

Illness self-management X X 

Medication X X X X 

Cognitive–behavioral interventions X X X 

Relapse prevention X X X 

Supportive housing X X X X X 

Supportive employment (e.g., the 

International Center for Clubhouse 

Development model) 

X X 

interventions, supportive housing, and supportive employment. ACT is a widely used

treatment method adapted from services for 

people with chronic mental illness for work

with people who are homelessness. Numerous 

studies (e.g., King et al., 2009; Nelson, Aubry,

& Lafrance, 2007) have shown that the intensive services provided by ACT teams increase treatment adherence, reduce days of

hospitalization, and increase housing stability.

Teams composed of mental health professionals provide a wide variety of services, including

case management, mental health services, crisis intervention, treatment, education, and

employment support. ACT services are available around the clock to respond to the client’s 

immediate needs. ACT has been widely implemented in a number of countries, including

the United States. For more information on 

ACT, visit the ACT Association Web site 

(http://www.actassociation.org). 

CTI is a time-limited adaptation of intensive

case management to bring problem-solving

resources, community advocacy, and motivational enhancement to clients who are homeless. It is particularly useful in work with

clients who are in transition, such as those entering homeless shelters from prison, and in

the development of continuity of care for 

40 
 

 

 

 

 

Part 1, Chapter 1 

people with CODs who are leaving shelters 

for other community housing resources 

(Draine & Herman, 2007; Herman, Conover,

Felix, Nakagawa, & Mills, 2007; Jones et al.,

2003). New York Presbyterian Hospital and

Columbia University (2011) developed The 

Critical Time Intervention Training Manual, 

which describes the phases of the 9-month 

program of care in CTI as follows:

•	 Phase One—Transition to Community. A

treatment plan is made; clients are linked

to appropriate community resources. 

•	 Phase Two—Try Out. Linkages in the 

system are tested; the treatment plan is 

formalized, adjusted, and implemented. 

•	 Phase Three—Transfer of Care. Longterm community linkages are monitored

and long-term goals are established; work 

toward them is begun. 

Contingency management uses tangible rewards for housing, work training, and work

opportunities and can provide direct monetary 

reinforcement (e.g., gift cards) for accomplishing clearly defined weekly rehabilitation goals.

These procedures have been studied intensively in a community setting in Birmingham, AL, 

in a series of four randomized, controlled trials 

that showed significant improvement in sustained abstinence, housing stability, and stable

employment (Milby et al., 1996, 2000, 2005,

2008). 

Cognitive–behavioral interventions have 

shown clear treatment advantages and sustained superior outcomes for abstinence from 

6 to 12 months and from 12 to 18 months after follow-up compared with contingency 

management alone in a delayed treatment effect. Additional cognitive–behavioral interventions were added to and compared with

contingency management alone (Milby et al.,

2008). 

MI is a client engagement, motivational enhancement, and counseling process that has 

been widely used in mental health and substance abuse treatment settings and has been

adapted for the needs of clients in homelessness rehabilitation. It is particularly efficacious 

in work with clients who are homeless, abuse 

substances, and are entering sober housing

(Fisk, Sells, & Rowe, 2007). Many standard

MI techniques and protocols for enhancing

commitment to treatment and reducing resistance are applicable to clients experiencing

homelessness. For more information on MI 

protocols, see TIP 35 (CSAT, 1999b). 

Supportive housing can improve sustained abstinence, stable housing, and employment

(Milby, Schumacher, Wallace, Freedman, &

Vuchinich, 2005), and it can greatly improve

housing stability for clients with serious mental illness who are homeless (Tsemberis, Gulcur, & Nakae, 2004). 

Supportive employment assists clients in accessing, obtaining, and maintaining employment as a primary method to prevent or end

homelessness. Recognizing work as a priority 

in preventing or ending homelessness, Shaheen and Rio (2007) note that early treatment 

and rehabilitation efforts often focus more on 

housing and supportive services and highlight

the value of assisting clients in obtaining employment and/or education early in rehabilitation. They suggest that employment helps 

clients who are experiencing homelessness develop trust, motivation, and hope. Supportive 

employment not only helps people find jobs; it

also helps them achieve continued employment by teaching them skills such as problemsolving, managing interpersonal conflicts, developing appropriate work-related behaviors,

and managing money wisely. 

Your knowledge and skills in working with

clients who have mental and substance use 

disorders may be particularly important in

helping them maintain abstinence, regulate 

symptoms, maintain motivation, and 

41 
 

 

 

 

 

 

 

Behavioral Health Services for People Who Are Homeless 

strengthen the interpersonal skills that are 

necessary to maintain employment and pursue 

education. Many individuals who have not

been employed for months or years—clients 

who are just leaving prison or are chronically 

mentally ill—may first need a supervised work 

environment to develop or improve these 

skills. The VA hospital system has used a variation of supportive employment called individual placement and support (IPS). IPS

focuses on rapid placement in jobs of the clients’ choosing, competitive employment, ongoing and time-unlimited support, integrated

vocational assistance and clinical care, and

openness to all who want to work, regardless 

of clinical status or work experience (Rosenheck & Mares, 2007). 

There are dozens of universal, selective, and

indicated evidence-based prevention programs 

applicable to populations of people who are 

homeless, but few have been specifically tested

with these populations. SAMHSA’s National

Registry of Evidence-Based Programs and

Practices (NREPP) lists two evidence-based

prevention programs for youth that address

substance abuse and mental health outcomes. 

The Curriculum-Based Support Group

(CBSG) Program (Arocena, 2006) is a support group intervention designed to increase 

resiliency and reduce risk factors among children and youth ages 4 through 15 who are

identified by school counselors and faculty as 

being at elevated risk for early substance use 

and future delinquency and violence (e.g., they 

are living in adverse family situations, displaying observable gaps in coping and social skills,

or displaying early indicators of antisocial attitudes and behaviors). Based on cognitive–

behavioral and competence-enhancement

models of prevention, the CBSG Program 

teaches essential life skills and offers emotional support to help children and youth cope 

with difficult family situations; resist peer 

pressure; set and achieve goals; refuse alcohol,

tobacco, and drugs; and reduce antisocial attitudes and rebellious behavior. 

Lions Quest Skills for Adolescence is a multicomponent, comprehensive life skills education program designed for schoolwide and

classroom implementation in grades 6 through

8 (ages 10–14). The goals of the Lions Quest

program are to help young people develop

positive commitments to their families,

schools, peers, and communities and to encourage healthy, drug-free lives. (See 

SAMHSA’s NREPP for further information 

at http://nrepp.samhsa.gov.) 

Say it Straight (Englander-Golden et al.,

1996) is a communication training program

that helps students and adults develop empowering communication skills and behaviors 

and increase self-awareness, self-efficacy, and

personal and social responsibility. In turn, the 

program reduces risky or destructive behaviors

(e.g., substance use, eating disorders, bullying,

violence, precocious sexual behavior, behaviors

that can result in HIV infection). 

One area of mental health promotion/mental 

illness prevention that has been addressed in

some literature is suicide prevention. People 

who are homeless have high rates of suicidal 

ideation and suicide attempts. Childhood

homelessness, being homeless for 6 months or

more, and substance use disorders in adults 

ages 55 and older are all associated with greater rates of suicidality (Prigerson, Desai, Mares, 

& Rosenheck, 2003). More information on 

suicide prevention for clients in substance 

abuse treatment can be found in TIP 50,

Addressing Suicidal Thoughts and Behaviors in

Substance Abuse Treatment (CSAT, 2009a). 

Additionally, a variety of evidence-based practices noted in NREPP, although not tested

specifically with populations of people who are 

homeless, have significant implications for 

42 
 

The Clubhouse Model of Transitional Employment 

NREPP lists the International Center for Clubhouse Development’s (ICCD’s) clubhouse model as an 

evidence-based program. A clubhouse is a day program, often run at a community center, that supports people recovering from mental illness by helping them rejoin the job force and fostering 

stronger friendships, family relationships, and educational aspirations. Clubhouses are built on: 

• A work-ordered day. The daily activity of a clubhouse is organized around a structured system 

known as the work-ordered day. The work-ordered day includes an 8-hour period that parallels 

typical business hours. During this period, members and staff work together to perform important tasks in their communities. There are no clinical therapies or treatment-oriented programs in the clubhouse; members volunteer to participate as they feel ready and according to 

their individual interests. 

• Employment programs. Clubhouses provide members with opportunities to return to paid employment in integrated work settings. These opportunities include transitional employment—a 

highly structured means for gaining work in local business and industry. Members receive parttime placements (15–20 hours per week) along with onsite and offsite support from clubhouse 

staff and members. Placements generally last 6 to 9 months, after which members can seek another transitional placement or move on to independent employment. Transitional employment 

allows mentally ill individuals to gain the skills and confidence necessary for employment while 

they hold a real-world job. 

• Evening, weekend, and holiday activities. Clubhouses provide both structured and unstructured 

social/recreational programming outside the work-ordered day. 

• Community support. People with mental illness often require a variety of social and medical services. Through the work-ordered day, members receive help accessing the best quality services 

in their community, acquiring and keeping affordable and dignified housing, receiving psychiatric and medical services, getting government disability benefits, and so forth. 

• Outreach. Clubhouse staff maintain contact with all active members. If a member is hospitalized 

or does not attend the clubhouse, a telephone call or visit serves to remind that member that he 

or she is missed, welcomed, and needed at the clubhouse. 

• Education. Clubhouses offer educational opportunities for members to complete or start certificate and degree programs at academic and adult education institutions. Members and staff also 

provide educational opportunities within the clubhouse, particularly in areas related to literacy. 

• Housing. A clubhouse helps members access safe, decent, dignified housing. If there is none 

available, the clubhouse seeks funding and creates its own housing program. 

• Decisionmaking and governance. Members and staff meet in open forums to discuss policy issues and future planning. An independent board oversees management, fundraising, public relations, and the development of employment opportunities for members. 

The ICCD Web site (http://iccd.org/) offers a directory of clubhouses and more information on this 

transitional employment model. TIP 38, Integrating Substance Abuse Treatment and Vocational Services, covers employment services and can help you select employment support models suitable for 

clients who are homeless and have behavioral health issues (CSAT, 2000a). SAMHSA’s Supported 

Employment Evidence-Based Practices (EBP) KIT (SAMHSA, 2009) provides practice principles for 

supported employment, an approach to vocational rehabilitation for people with serious mental illness. 

It promotes the belief that everyone with SMI is capable of working competitively in the community. 

The KIT is available for free at SAMHSA’s Publications Ordering Web page (http://store.samhsa.gov). 

Source: International Center for Clubhouse Development, 2009. Adapted with permission. See also 

Schonebaum, Boyd, & Dudek, 2006; Macias, Rodican, Hargreaves, Jones, Barreira, & Wang, 2006. 

Part 1, Chapter 1
 

43 
 

 

 

 

 

 

Behavioral Health Services for People Who Are Homeless 

work with this population. Three examples of

tested programs for trauma treatment include 

Seeking Safety, Trauma Recovery and Empowerment Model (TREM), and a modification of TREM, The Boston Consortium

Model: Trauma-Informed Substance Abuse 

Treatment for Women. All of these programs

use cognitive–behavioral and psychoeducational methods to teach problem-solving, coping skills, and affect regulation strategies to

individuals who have experienced significant

trauma. A program that is particularly relevant

to people who are homeless and have cooccurring substance use and mental disorders 

is Modified Therapeutic Community for Persons With Co-Occurring Disorders, a longterm residential program with the structure 

and processes of a traditional therapeutic

community but with adaptations for individuals with co-occurring disorders. The program

can be flexibly applied in both correctional 

and community settings and includes components on mental health and substance abuse 

treatment. For more information on these and 

other evidence-based programs, refer to the

NREPP Web site (http://nrepp.samhsa.gov/). 

Special Issues in Service 

Delivery 

People with substance use and/or mental disorders who are homeless have a variety of specific needs and considerations in treatment 

and prevention programs.These needs tend to

fall into three major categories:

•	 Specific client needs 

•	 Family services to reduce the risk of intergenerational problems 

•	 Cultural competence 

Specific Client Needs 

needs are not met. It is also much more difficult for individuals with substance use and 

mental disorders to manage their symptoms 

when these basic needs are not met. Some of 

the most pressing issues of people who are 

homeless include: 

•	 Addressing acute and chronic medical

conditions (e.g., diabetes, HIV infection,

heart and respiratory conditions, and the

like, as well as drug detoxification and 

medical stabilization of mental illnesses). 

•	 Having untreated or inadequately treated

disabilities, such as hearing and/or vision

impairment, lack of balance, or mobility 

impairments. 

•	 Recognizing cognitive problems, such as 

memory deficits, poor attention, and concentration. 

•	 Making the transition from jail or prison

to the “free world,” which includes adapting survival skills that were functional in

prison but are counterproductive outside 

the criminal justice system. 

•	 Making the transition from inpatient hospitalization, where people are free from responsibility for their care, to having to

assume full accountability for their care 

and their behavior. 

•	 Dealing with a history of trauma when

sudden or unexpected events may trigger

flashbacks or other responses that are perceived as inappropriate and when symptoms of psychological trauma mimic,

exaggerate, or obscure the symptoms of

other mental and substance use disorders. 

Family Services To Reduce the 

Risk of Intergenerational 

Problems 

Integration of prevention and treatment services for families who are homeless is critical. 

It is unrealistic to expect that people who are Family programs involving parents and their

experiencing homelessness will be able to children have been a mainstay of universal,

maintain housing if their social and health selective, and indicated prevention programs 

44 
 

 

Part 1, Chapter 1 

for at least 3 decades. Examples include parent

participation (e.g., homework assignments) in

school-based programs (universal), home-visit

programs for high-risk families (selective), and

intensive parent–child interventions when one 

or both parents are undergoing substance 

abuse treatment (indicated). All of these programs—particularly those categorized as indicated—are appropriate for families who are 

homeless in which the parents receive substance abuse or mental illness treatment. 

NREPP (http://nrepp.samhsa.gov) lists over

50 family programs that may be relevant to

working with families who are homeless. A

few examples include:

•	 The Strengthening Families Program:

This is a family skills training program designed to increase resilience and reduce 

risk factors for behavioral, emotional, academic, and social problems in children 3–

16 years old. 

•	 The Strengthening Families Program for

Parents and Youth 10–14: This family 

skills training intervention is designed to

enhance school success and reduce youth

substance use and aggression among 10­

to 14-year-olds. 

•	 The Clinician-Based Cognitive Psychoeducational Intervention: Intended for 

families with parents who have a significant mood disorder, this intervention is

designed to provide information about

mood disorders to parents, equip them 

with skills they need to communicate this 

information to their children, and open a 

dialog in families about the effects of parental depression. 

•	 DARE To Be You: This multilevel prevention program is intended for high-risk 

families with children 2–5 years old. Program objectives focus on children’s developmental attainments and aspects of

parenting that contribute to youth resilience to later substance abuse, including 

parental self-efficacy, effective child rearing, social support, and problem-solving

skills. 

•	 Familias Unidas: A family-based intervention for Hispanic families with children

ages 12 to 17. The program is designed to

prevent conduct disorders; use of illicit

drugs, alcohol, and cigarettes; and risky 

sexual behaviors by improving family functioning. 

Cultural Competence 

Race, ethnicity, and culture influence how 

people express problems, seek help, and accept

services. Your cultural background and that of

your clients can influence how you present

services and how acceptable they are to clients. 

Staff members should reflect the diversity of

the population, work in teams that incorporate 

diversity, and engage in team discussions about

the influence of cultural factors on engagement and retention, risk and protective factors,

and resiliency (Rowe, Hoge, & Fisk, 1996). It

may be important to include service providers 

on your team who have experienced homelessness themselves and understand that 

homelessness itself can be part of a subculture 

with its own expectations, behaviors, and patterns of communication; understanding this

culture is essential to effective work with individuals and families who are homeless. 

Culturally competent service providers understand that people sometimes reject services 

because of cultural norms and/or past negative 

experiences with the service system. For example, your organization may find that many

clients who are at risk of homelessness live 

with family members who will not come to

your organization for services. A culturally responsive service strategy may involve a service 

provider of the same cultural background

providing services where the client lives. You 

can act as a consultant, offering psychoeducation and skills development to address 

45 
 

 

 

Behavioral Health Services for People Who Are Homeless 

individuals’ issues in a manner that is acceptable to them (Connery & Brekke, 1999). 

Culturally competent counselors are also

mindful of the client’s linguistic requirements 

and the availability of interpreters. You should

be flexible in designing a treatment plan to

meet client needs, and, when appropriate, you

should draw upon the institutions and resources of your client’s cultural community.

Treatment providers need to plan for the provision of linguistically appropriate services beginning with actively recruiting bicultural and 

bilingual clinical staff, establishing translation

services and contracts, and developing treatment materials prior to client contact. Even

though you cannot anticipate the language 

needs of all potential clients, you can develop a 

list of available resources and program procedures that can be followed when language 

needs fall outside the treatment program’s typical client demographics. 

Women often have unique experiences and

challenges different from the male majorities 

usually found in substance abuse treatment.

They often find or take few opportunities to

talk in male-dominated groups about physical 

or sexual abuse perpetrated by the men in

their lives, perceived barriers to restoring child

custody, and other women’s issues. Absence of 

opportunities to discuss gender-related problems usually precludes the development of a

comprehensive rehabilitation plan to address 

them (CSAT, 2009d). 

People who are lesbian, gay, bisexual, or

transgendered may face different barriers to

services. People who are transgendered may 

need special consideration of options and advocacy prior to placement in shelters, treatment centers, prevention programs, and

housing. 

For more information on culturally competent

behavioral health treatment, see the planned 

TIPs, Improving Cultural Competence

(SAMHSA, planned c) and Behavioral Health 

Services for American Indians and Alaska Natives (SAMHSA, planned a), as well as A Provider’s Introduction to Substance Abuse 

Treatment for Lesbian, Gay, Bisexual, and

Transgender Individuals (CSAT, 2001). 

Community Housing 

Services for People Who 

Are Homeless 

Unless you work in a setting specifically designed to serve people who are homeless, you 

are probably not acquainted with the variety of

homelessness services available in your community. Services can vary widely from one 

community to another based on community 

needs and program goals. You may also not be 

aware of abstinence or other specific requirements among different program and housing

options. Housing services also exist for special 

populations that might be important in your

work, such as veterans or people who live in

rural areas. Additionally, the services clients 

need will vary by the type of homelessness 

they are experiencing. 

In general, housing services can be divided 

into four main categories. 

Emergency shelters provide brief-stay, overnight accommodation to people who have no 

safe place to stay for a short period of time.

Often, people cannot enter the shelter until 

the late afternoon and must leave by a specific 

time the next morning. Most allow for storage 

of personal possessions during the day while 

the individual has to be out of the shelter;

some require that all possessions be taken by 

the occupant when they leave each day. Most

shelters offer assistance with food and other 

emergency needs, but given their short-term 

focus, do not provide ongoing services for residents. 

46 
 

Part 1, Chapter 1 

Temporary housing can be provided in a variety of settings, including shelter settings (such

as a shelter specifically for persons affected by 

domestic violence), multiple-occupancy dwellings, hotels and single-room occupancy (SRO)

settings, small clustered apartments, or apartments in the community.Temporary housing

is often a resource for families and individuals 

in crisis who need immediate housing help

and assistance with social service, health, mental health, substance use, financial, legal/criminal justice, and other needs.

Temporary housing services typically provide

outreach and engagement, case management,

referral, and follow-up services to mitigate or

resolve crises. Temporary housing services are 

generally limited to 2 or 3 months’ duration. 

After stabilization, individuals and families

may move to either transitional or permanent

supportive housing. 

Transitional housing is useful for individuals 

who have no permanent place to live and are 

making a transition from a location where

they have been temporarily housed (temporary 

housing, a substance abuse or mental health 

treatment facility, a criminal justice setting, 

etc.) to housing that supports their transition

to a more permanent setting. Transitional 

housing is normally provided for periods of a

few months to 2 or 3 years and is accompanied

by a variety of resources (social services, health

care, employment assistance, mental health

and substance abuse treatment, case management, and other services).The use of transitional housing supports for people who have 

been in substance abuse and/or mental health

treatment to smooth reentry into the community is discussed in Part 1, Chapter 2, of this

TIP (see the vignette about Sammy). Transitional housing and accompanying supportive

services are funded by a variety of resources. 

Permanent supportive housing combines a 

long-term commitment to affordable housing 

with supportive services to allow individuals 

and families to live more productive and stable 

lives; it is a primary thrust of SAMHSA’s 

(along with other Federal agencies’) efforts to

address the needs of people with disabilities.

Typically, permanent supportive housing provides homes for individuals and families who 

otherwise would be living with the constant

threat of homelessness and would lack the 

supportive social and health services (such as 

primary health care, mental health treatment, 

employment, and economic and other resources) necessary to adequately cope in the 

community. There are no requirements that

individuals in permanent supportive housing

obtain mental health or substance abuse 

treatment, and there are no requirements 

about abstinence from alcohol and/or drugs as 

a condition for participation in the program.

Supportive housing can, however, be coupled

with such social services as job training, life 

skills training, and alcohol, drug abuse, and

mental health treatment. 

Case management is a key element in helping

individuals and families in permanent supportive housing obtain the care they need.

Permanent supportive housing can be an

apartment or SRO in a building that houses

individuals who were formerly homeless, special-needs housing in the same building with

generally affordable housing, a rent-subsidized

apartment in the open housing market, designated units within privately owned buildings, 

or individual single-family homes. 

Examples of populations served by permanent

supportive housing are adolescents, the elderly,

persons with serious mental illness, people 

who are developmentally disabled, and people 

moving out of transitional or temporary housing who still lack the resources to live in the

community without housing assistance. Permanent supportive housing has been shown to

be economically viable by creating safe and 

47 
 

 

 

Behavioral Health Services for People Who Are Homeless 

stable environments in which individuals and 

families can regain employment, reduce social 

service and healthcare costs, and reduce costs

related to dependence on more expensive 

housing options. As with transitional housing,

permanent supportive housing is supported by 

HUD, SAMHSA, other Federal resources,

State and community resources, and direct

payment from those receiving services. 

SAMHSA’s Homelessness Resource Center 

(http://homeless.samhsa.gov/) offers resources 

on community housing services for individuals 

and families who are homeless or threatened 

with homelessness. Their efforts include the 

Permanent Supportive Housing Evidence-Based

Practices (EBP) KIT (SAMHSA, 2010), a series of eight booklets on developing permanent supportive housing programs using

evidence-based practices. 

What the Behavioral Health 

Service Provider Should Know 

Your community may offer a variety of housing options to behavioral health clients who

are homeless or are at high risk for homelessness. Some of these options are for emergencies only or are short term, whereas others are 

ongoing. Some have special restrictions, such

as serving only persons with a major mental 

illness or requiring participation in programs

to build employment, money management,

and daily living skills. Some programs that

primarily serve clients with substance use disorders have rules about drug use either in the 

residence or while a client is in the program.

However, the permanent supportive housing

approach, a major focus of Federal housing

assistance today, does not mandate mental 

health, substance abuse, or other care or social

services as a condition of participation. 

One of your jobs is to become familiar with

the resources in your community. You will 

want to build linkages with these organizations and with their staff members to learn 

what range of services they provide. This will

allow you to recommend particular clients to

these organizations in accordance with their

specific needs. What are the requirements for

accessing their services? What types of reimbursement do they accept? You may be aware 

of gaps in the services available in your community. Collaborative efforts can, in some 

cases, help obtain funding, staff, and facilities

to fill these gaps. Part 2 of this TIP discusses 

“bottom-up planning,” in which treatment

staff identify a service need and programs

evolve in response to it. Bottom-up planning

should always involve program administration,

direct service personnel, clients, and other

community resources. 

Knowing how to assess your clients’ needs is 

also part of your job. Do they need substance 

abuse and/or mental health services? Are they 

ready to accept such services? From what types

of medical services and financial help would

they benefit? Are they self-sufficient? Do family members need prevention services? Do

they require special services to address physical 

or other disabilities? Are their housing needs 

chronic and long term or transitional and

short term? 

Along with these questions, you will want to

consider the issue of how best to present a 

program’s goals and rules to clients so as to

encourage them to take advantage of community resources. They may need to accept restrictions on their behavior in exchange for

shelter. Some negotiation may be necessary to

help the client see the advantages of receiving

services while consenting to a program’s 

boundaries. 

48 
 

 

Part 1, Chapter 1 

Housing Services for Individuals 

With Substance Use and/or 

Mental Disorders 

Housing services for people with a substance 

use disorder and/or a mental illness can be divided into two broad categories: (1) housing

specifically provided for clients in early and

ongoing recovery from substance use and

mental disorders, and (2) housing that offers a

safe place to live, a variety of options for

homelessness rehabilitation, and other social,

health, and behavioral health services. Sometimes, these programs will offer behavioral 

health treatment and prevention services primarily directed toward the precontemplation

and contemplation phases of treatment. 

Some communities may offer homelessness 

and behavioral health treatment services that 

overlap with these two housing options. Additionally, other shelter or housing options in

your community may simply offer temporary 

housing with no additional social, physical

health, or behavioral health services. Because 

most communities have few, if any, prevention 

services specifically designed for persons who

are homeless, training for prevention workers 

in the special needs of homeless populations 

may broaden the range of preventive interventions available to these populations. 

Clearly, there is no “one size fits all” accommodation for the diverse population of people 

with substance use disorders and/or mental 

illness who are also faced with homelessness. 

For example, people who are in crisis and

transitionally homeless need different services 

from those who are chronically homeless. Programs for persons with mental or substance 

use disorders may need to work in close coordination with homelessness programs, especially in early recovery. 

Housing services focused on 

supporting recovery from substance 

abuse and mental illness 

In your work, you will encounter individuals 

who either are homeless when they enter your

program or become homeless during program 

participation. Some people who are homeless 

enter programs, especially treatment programs,

because they perceive that they have no other

place to go. Others—including persons coming from the criminal justice system—may

have had stable housing (jail or prison) but

have not considered where to live after being

released. Some lose their jobs before or during

program participation and are left with no

housing options. Others may have family 

members who refuse to allow them to return 

until they have achieved substantial sobriety,

significant stabilization of their psychological

symptoms, or significant improvement in interpersonal skills. In any case, homelessness or

the threat of it represents a substantial crisis 

that destabilizes people and challenges their

ability to maintain recovery and other gains. 

Homelessness also represents a significant case 

management problem for mental health and

substance abuse treatment staff members who 

are concerned with finding housing resources.

Some considerations that have to be addressed 

include limited resources for housing people in

early recovery from substance abuse and/or 

mental illness in the community, the time required to find and evaluate potential resources,

the collaboration efforts involved in working

with other community agencies, and the limited funding available for housing services appropriate for people in early recovery. In

addition to addressing these considerations,

you will need to ensure that individuals who

are homeless can continue to participate in

services and continuing care. You will need to

work with them to manage transportation,

mental health, healthcare, financial, criminal 

49 
 

 

 

Behavioral Health Services for People Who Are Homeless 

justice, and employment issues that are complicated by homelessness.The reality is that an

individual who is homeless is in crisis and has 

housing needs that must be addressed in a

very limited period of time. 

Some frontline resources often used to help

individuals who are homeless make the transition to more stable recovery are residential recovery and other housing options that have a

primary focus on recovery from substance 

abuse and mental illness. Generally, these resources fall into four categories: halfway houses, 3⁄4-way houses, sober living residences for

clients with substance use disorders, and supportive housing for clients transitioning out of

intensive mental health treatment or treatment 

for co-occurring disorders. With perhaps a

few exceptions for clients from the criminal 

justice system, all clients in these residences 

enter and remain voluntarily. 

Halfway houses with a primary focus on substance abuse or mental illness recovery generally offer more intensive treatment than other

recovery housing options, have the most structured programs, and are the most likely to be 

professionally staffed. They also generally are 

the most time-limited service (usually 30–60 

days). Persons are likely to enter a halfway 

house on completion of intensive treatment. In

a halfway house, residents are expected to participate in regularly scheduled (usually daily)

individual and group treatment, and regular

attendance at 12-Step or other self-help and

recovery programs is either mandated or actively encouraged. Program rules often limit

the amount of time residents can spend away 

from the house and the contacts they can have

in the community. Programs also specify meal 

and sleeping times, provide medication management, and usually have an active focus on

relapse prevention and recovery maintenance.

Case management services, provided by counselors or specialized case management staff, 

are often available. Frequently, supportive services, such as employment assistance, health

care, and financial assistance, are available to

residents either “in house” or through referral. 

Generally, 3⁄4-way houses have fewer staff persons with professional credentials and may 

only be staffed by a house manager and assistants. Residents have more autonomy in managing their time and community contacts, and

(unless employment is not a consideration for

the client) they are usually employed, expected

to be seeking employment, or in a job training

and support program. Significantly less treatment by professionals is offered in 3⁄4-way 

houses than in halfway house programs. Residents are expected to maintain abstinence, 

monitor psychological symptoms, and manage

their medication with the support of staff; are

often expected to participate in continuing

care and 12-Step recovery programs; and may 

be encouraged (after some time in the house)

to seek other residential options. Clients may 

have the option of staying in a 3⁄4-way house 

for a longer period than in a halfway house. 

In recent years, a variety of sober living housing options have emerged for people in recovery from substance use disorders and fill a

critical need for housing for people in recovery 

who do not need more intensive residential 

services. The best known sober living facilities 

today are Oxford Houses

(http://www.oxfordhouse.org). The Oxford

House movement has residential facilities 

throughout the United States that are drug

free, self-supporting, and democratically governed by the residents and a board of directors. 

They normally have 8 to 15 residents. Complete abstinence from alcohol and illegal or

illicit drugs is a requisite for residence. Residents can live in the house as long as they desire. There is no professional staff and there

are no requirements about attending treatment. Participation in 12-Step programs is 

50 
 

 

 

 

 

 

 

 

 

Part 1, Chapter 1 

strongly encouraged. Other sober living houses

that are not affiliated with Oxford Houses 

may also be available in your community. 

Community transitional supportive housing

can be an intermediate step between leaving

an inpatient facility for substance abuse and/or

mental health treatment and living independently in the community. Supportive housing programs for people leaving intensive 

treatment ordinarily provide an affordable 

place to live; close links to treatment; support

in medication maintenance; services to develop and enhance skills in household, job, and

financial management; and day-to-day support from professional and paraprofessional 

staff. Supportive housing reduces isolation,

reduces relapse rates, offers early intervention

so that living problems do not escalate, and

provides safe housing for people at a very vulnerable point in their lives. 

Housing services focused primarily 

on safe housing and social services 

Substance use-related designations 

for shelter and housing 

Housing and shelter programs are sometimes 

defined by policies related to substance use on

and off the premises. Different types of housing are appropriate for clients in different

stages of change for substance use behavior

and who are, in turn, ready for varying levels 

of service intensity. In housing, “wet,”“damp,”

and “dry” refer to these levels of service intensity and a concomitant demand for abstinence. 

Exhibit 1-7 describes each program type. Although programs are defined by allowed substance use, their services are not restricted to

people with substance use disorders. 

Sometimes, people are placed in housing

when they are in the precontemplation stage 

of change regarding their substance use or 

mental health issues. They may show little or

no motivation or behavior suggesting that they 

would even consider addressing their problems. Even so, you may still have several options for working with clients who are in the 

precontemplation stage, including:

•	 Providing information about recovery and

resources that are available, if and when

they do sense a need to do something

about their use. 

•	 Building stronger relationships focused on

their ability to contact a service provider if

they decide to get help for substance use. 

•	 Supporting their efforts to consider or act

on changing substance use behavior—for 

instance, by supporting efforts toward abstinence, even for brief periods. 

•	 Helping individuals develop or improve 

coping skills for managing life without 

substances. 

•	 Locating housing in congregate living settings with staff members on site who can

provide safety and support. 

Concerns, such as drug trafficking on the 

premises, may be a particular risk factor for 

some persons attempting to maintain abstinence. Onsite staff persons have a greater opportunity to build relationships by sharing

activities and conversation. They can also assess an individual’s functioning and engage 

them in appropriate services. 

Services for veterans who are 

homeless 

In addition to services available in the community and local treatment system, veterans 

who are homeless may be eligible for VA services. Eligibility varies for each of these services. In general, eligibility is least restrictive 

for entry to VA homelessness programs. Those 

who have a service-connected disability or VA

pension are most likely to access VA services.

Nearly every VA hospital has a Health Care 

for Homeless Veterans (HCHV) Program

caseworker who can inform you about local 

services and eligibility criteria. VA services for 

51 
 

 

 

 

 

 

 

 

Behavioral Health Services for People Who Are Homeless 

Exhibit 1-7: Housing Designations and Readiness to Change Substance Use 

Housing 

Type 

Relevant Stage 

of Change Description of Housing and Supportive Services 

Wet Suited to precon­ • Permits use of legal substances (i.e., alcohol) on premises. 

Housing templation or contemplation stages 

of change 

• Meets basic needs for safe shelter; increases client readiness 

to accept other services. 

• Staff creates consistent, empathic relationships with clients 

and addresses behaviors related to substance use (e.g., loud, 

destructive parties) to help clients recognize how substance 

use affects their lives, goals, and chances of staying housed. 

• Residents are engaged in treatment and other services as 

they are ready. 

Damp 

Housing 

Suited to contemplation and preparation stages of 

change 

• Abstinence is recommended but not required; intervention 

occurs if safety becomes an issue. 

• Meets basic needs for safe shelter; increases client readiness 

to accept other services. 

• Staff createes consistent, empathic relationships with clients 

and addresses behaviors related to substance use (e.g., loud, 

destructive parties) to help clients recognize how substance 

use affects their lives, goals, and chances of staying housed. 

• Residents are engaged in treatment and other services as 

they are ready. 

Dry or Suited to action or • Strict abstinence policy—substance use results in termination 

Sober maintenance of housing. 

Housing stages of change • Staffed group homes (i.e., transitional or permanent supportive housing programs) or independent group sober living, 

like Oxford Houses. Residents pay rent, utilities, and other 

household expenses. 

Source: Hannigan & Wagner, 2003. 

veterans who are homeless vary geographically 

and include the following:

•	 HCHV: VA outreach workers and case 

managers help establish eligibility for VA

medical services, develop appropriate 

treatment plans, and screen for community 

placement. 

•	 Stand Downs: These give veterans who are 

homeless 1–3 days of safety and security

where they can obtain food, shelter, clothing, and other types of assistance, including

VA-provided health care, benefits certification, and linkages with other programs. 

•	 Drop-In Centers: These programs are a

daytime sanctuary where veterans who are 

homeless can clean up, wash their clothes,

and participate in therapeutic and rehabilitative activities. 

Recovery-oriented and rehabilitative treatment programs for veterans who are homeless 

include: 

•	 Domiciliary Care for Homeless Veterans 

(DCHV): DCHV provides residential 

treatment and rehabilitation to veterans 

who are homeless. 

•	 VA Grant & Per Diem Program: This

program subsidizes residential treatment

and transitional housing. 

•	 VA-based substance abuse treatment programs: These can be found using the 

52 
 

 

 

Part 1, Chapter 1 

SAMHSA Treatment Locator 

(http://findtreatment.samhsa.gov/). 

•	 Supportive Housing: This program provides ongoing case management services to

veterans who are homeless. The emphasis 

is on helping veterans find permanent

housing and providing clinical support to

keep veterans in permanent housing. 

•	 Veterans Affairs Supportive Housing Program with HUD: This program provides

Section 8 voucher program and permanent

housing and treatment for veterans who

are homeless and have mental and substance use disorders through VA outreach,

clinical care, and ongoing case management services. 

Homelessness services in rural areas 

People who are homeless in rural and remote 

areas typically live temporarily in campers,

cars, abandoned buildings, tent encampments,

or with a succession of friends or family in

overcrowded, substandard housing (Dempster

& Gillig, 2006). As a result, people who are 

homeless in rural areas are often less visible 

than those in more urban settings and may not

be counted in census or other surveys. Outreach and engagement are different in rural 

areas than in urban centers, because people 

who are homeless in rural areas are more difficult to identify. In addition, outreach and engagement activities are successful only if you 

can refer individuals to services relevant to rehabilitation from homelessness. 

Job opportunities, transportation, health and

social services, and shelter options tend to be 

more limited in rural areas. Individuals with 

mental illness who are homeless and unable to 

live with family in rural areas may be particularly vulnerable and may migrate to larger

population areas to obtain housing and services. In rural areas where the predominant

employment is agriculture, migrant workers

who are homeless and depend on employersupplied housing can be particularly vulnerable. Often, the housing offered for temporarily 

employed migrant workers is substandard and

inadequate, creating a unique situation of

homelessness or near homelessness. 

To create temporary shelter, some providers 

develop contracts with local property owners 

in which an agency pays a monthly rate for

sleeping rooms used as temporary housing until other arrangements are made. This may be 

more cost-effective when actual numbers of 

clients do not warrant larger shelter programs;

it gives the individual and the agency flexibility 

to better prepare for more adequate housing. In

some locations, faith-based communities can

temporarily house people for brief periods in

members’ homes, church buildings, or in lowcost motels paid for with money set aside to

help those in need. 

SAMHSA’s PATH program provides formula

grants to States, which they can then use for

homelessness services in rural areas. The 

grants can be used for outreach, screening, behavioral health services, case management, and

other supports for housing assistance. A primary problem is that, given the actual number

of individuals and families needing a specific

form of housing among a dispersed, rural population, costs for the construction of congregate housing or shelters can be prohibitive. As 

a result, developing an adequate supply of

rental stock and providing rental subsidies 

may take on particular importance. There is 

often a waiting list in rural areas for housing

that is available through programs serving

people who are homeless. 

Where adequate services do not exist, workers 

in PATH-supported outreach and engagement programs in rural areas often carry 

sleeping bags, camping gear, and food. Some

programs employ former consumers who can

establish good rapport with individuals who

are homeless. The programs work to create 

53 
Behavioral Health Services for People Who Are Homeless 

linkages and good relationships with nearby 

communities and agencies (Robertson & Myers, 2005). The National Alliance to End

Homelessness (2010) emphasizes using naturally occurring support networks in rural areas 

to provide support to people who are homeless. Involvement of local area leaders and 

stakeholders promotes an inclusive, collaborative system. 

You Can Do It 

Working with clients who are homeless or at

risk of homelessness certainly increases the 

complexity of your job. Clients who are facing

homelessness have unique personal and environmental dilemmas that require special care 

and attention. Nevertheless, with some additional knowledge, enhanced skills, and an examination of your own attitudes toward 

homelessness, you can do this work effectively.

The skills required will simply complement

the skills you already have as a treatment or

prevention professional. The additional 

knowledge you need will benefit not only your

work with people who are homeless, but also

your work with any person who has layered

problems. A significant milestone in professional growth is expanding your horizons and

capabilities to work with different types of

people, some of whom have more complex

needs than others. 

In the next chapter, you will meet several people who are homeless and in various stages of

need, and you will examine how your new and

expanded knowledge, skills, and attitudes can

be applied in realistic treatment and prevention service situations. 

54 
 

 IN THIS CHAPTER 

• Introduction 

• Vignette 1 —Juan 

• Vignette 2 —Francis 

• Vignette 3 —Roxanne 

• Vignette 4 —Troy 

• Vignette 5 —René 

• Vignette 6 —Mikki 

• Vignette 7 —Sammy 

Part 1, Chapter 2 

Part 1, Chapter 2
 

Introduction 

In this chapter, you will meet several people with behavioral health

disorders who are homeless or at risk of homelessness. Each person

is introduced in a vignette that demonstrates effective approaches 

to treatment for people who are in different phases of homelessness 

rehabilitation (described in Part 1, Chapter 1) and who have a substance use and/or mental disorder. Prevention techniques and

methods to reduce the incidence or manifestations of mental illness 

or substance abuse are also demonstrated. 

Skills introduced in the seven vignettes include:

•	 Building rapport. 

•	 Identifying client strengths, needs, preferences, and resources 

in housing and other life issues. 

•	 Managing inappropriate behavior, requests, and expectations. 

•	 Providing case management to access and coordinate housing

and other services. 

•	 Developing and monitoring treatment and housing goals. 

•	 Assisting clients in improving coping skills. 

•	 Adapting services for people who have cognitive problems. 

•	 Adopting a trauma-informed approach to working with all clients who are homeless. 

•	 Helping clients stay engaged in recovery despite ongoing mental illness/substance abuse symptoms. 

•	 Recognizing the impact of co-occurring disorders (CODs) on 

recovery from homelessness. 

•	 Helping clients find appropriate housing among the variety of

options that may be available. 

•	 Preparing clients to accept the terms of rental agreements and

other housing constraints. 

Each vignette begins by describing the setting, learning objectives,

strategies and techniques, and counselor skills and attitudes specific 

55 
Behavioral Health Services for People Who Are Homeless 

to that vignette. A description is given of a client’s situation and current symptoms. Counselor–

client dialog is provided to facilitate learning, along with a selection of aids that may include:

•	 Master clinician notes: comments from an experienced clinician about the strategies used,

possible alternative techniques, and insights into what the client or prospective client may be 

thinking. 

•	 How-to notes: step-by-step information on how to implement a specific intervention. 

•	 Decision trees: aids to help you sort options and arrive at the best possible outcome. 

The master clinician represents the combined experience of the contributors to this Treatment 

Improvement Protocol (TIP). Master clinician notes assist behavioral health counselors at all levels: beginners, those with some experience, and master clinicians. 

Before using the described techniques, it is your responsibility to determine whether you have 

sufficient training in the skill set and to ensure that you are practicing within the legal and ethical

bounds of your training, certifications, and licenses. It is always helpful to obtain clinical supervision in developing or enhancing clinical skills. For additional information on clinical supervision,

see TIP 52, Clinical Supervision and the Professional Development of the Substance Abuse Counselor

(Center for Substance Abuse Treatment [CSAT], 2009b). 

For the convenience of the reader, the TIP refers in the vignettes to “counselor” generally rather

than specifically by name. This will make it easier for the reader to track who is speaking at any 

given point in the vignette. As you are reading, try to imagine yourself through the course of the 

vignette in the role of the counselor. The seven vignettes are as follows:

•	 Vignette 1: Juan is in the outreach and engagement (O&E) phase of homelessness rehabilitation. This vignette demonstrates approaches and techniques for responding to his chronic

homelessness. 

•	 Vignette 2: Francis is in the outreach and engagement phase of homelessness rehabilitation.

This vignette demonstrates approaches and techniques for responding to his health and safety concerns. 

•	 Vignette 3: Roxanne is in the intensive care phase of homelessness rehabilitation. This vignette demonstrates approaches and techniques for preventing homelessness and stabilizing a

client who is in the precontemplation stage of substance abuse treatment. 

•	 Vignette 4: Troy is in the intensive care phase of homelessness rehabilitation. This vignette 

demonstrates approaches and techniques for preventing homelessness and engaging the client

in substance abuse treatment. 

•	 Vignette 5: René is in the transition planning/ongoing homelessness rehabilitation phase.

This vignette demonstrates approaches and techniques for substance abuse relapse prevention. 

•	 Vignette 6: Mikki is in the early intervention stage of homelessness prevention. This vignette 

demonstrates approaches and techniques for preventing additional trauma to her family because of temporary homelessness. 

•	 Vignette 7: Sammy is in the permanent supportive stage of homelessness rehabilitation. This 

vignette demonstrates approaches and techniques for supporting access to housing for a client

with serious mental illness (SMI) through programs partially funded by the Substance Abuse 

and Mental Health Services Administration’s (SAMHSA’s) Projects for Assistance in Transition from Homelessness (PATH) program. 

56 
 

 

 

Part 1, Chapter 2 

Vignette 1—Juan 

Overview 

Juan is in the outreach and engagement phase of homelessness rehabilitation. This vignette 

demonstrates approaches and techniques for responding to his chronic homelessness. 

Juan is in his mid-thirties and is chronically homeless. He is dependent on crack cocaine, drinks

alcohol, and occasionally smokes marijuana. He typically sits alone at a soup kitchen table. He 

knows who the outreach team members are and has walked away in the past when approached. 

The outreach team has information about Juan from shelter staff members and other people who

are homeless. He is unemployed but has worked in the past. Juan is hypersensitive to being “put

down” by others. He is easy to anger, and his anger is often out of proportion to the stimulus. If

he feels criticized, he will become sarcastic and will withdraw from interaction with others. He is 

very suspicious of the motives of others, often expecting that people have an agenda to disrespect

him. These limitations have resulted in many losses: jobs, family relationships, apartments, and

social supports. He has a history of being banned from shelters as a result of outbursts and

fighting. The outreach team members believe that if they form a relationship with Juan and offer

him a place to live, they will be able to engage him in treatment. 

Substance use is believed to play a significant role in Juan’s homelessness, so the member of the 

team who provides substance abuse counseling will take the lead in engaging him. The counselor’s goals for the first visit are to: 

•	 Meet Juan and begin to establish a relationship with him. 

•	 Determine whether or not Juan will engage in a conversation about housing and other services. 

Setting 

The behavioral health counselor is a member of a community-based, interagency O&E team and

works for a mental health and substance abuse treatment organization providing O&E services 

in collaboration with counselors, case managers, and outreach workers from other organizations.

A Housing First program is available to clients through this interagency partnership. 

Learning Objectives 

•	 Use rapport-building outreach methods: 

–	 Accurately identify the client’s beliefs and frame of reference. 

–	 Reflect the client’s feelings and message. 

–	 Demonstrate empathy, respect, and genuineness. 

–	 Offer concrete assistance. 

•	 Establish an initial plan based on the client’s needs and preferences, community resources, 

and the intervention plan. 

•	 Determine the client’s stage of change; respond appropriately to changes in client behavior. 

Strategies and Techniques 

•	 Rapport and relationship building with a client who is difficult to reach 

57 
 

 

 

 

 

Behavioral Health Services for People Who Are Homeless 

• Housing First as an approach to provide safe and stable housing 

• Motivational interviewing (MI) 

Counselor Skills and Attitudes 

• Recognize and address ambivalence and resistance. 

• Work as a member of a team to remove barriers to services. 

• Emphasize client autonomy and development of skills. 

• Show respect for both the client’s needs and the organization’s services. 

• Help the client explore resources and determine which ones he would like to use. 

Vignette 

Visit 1 (soup kitchen) 

The counselor walks to a seat near Juan at the soup kitchen, noticing that Juan watches her from 

the corner of his eye and appears tense. He sits alone and appears disinterested in the goings-on 

around him. 

COUNSELOR: How’s it going? 

JUAN: Do you work here? 

COUNSELOR: I work for the local outreach and engagement team. 

JUAN: You’re treating people? 

[He talks to her, but his demeanor is aloof and suspicious, and he maintains his distance.] 

Master Clinician Note: Building relationships with people who are homeless 

proceeds at their pace. You can give people opportunities to accept assistance, but 

it is important that you consistently respect their choices. If someone refuses to talk 

to you, respectfully leave and plan to show up again with something the client 

might accept (e.g., coffee, socks, a chance to talk). Building relationships with soup 

kitchen workers who know the client can help you gather more information and 

facilitate a meeting. 

COUNSELOR: No. I get to go out and spend time with people out here. Do you mind if I sit


down? [Juan nods.] What do you think of the coffee here?
 

JUAN: Not too good. Better than nothin’.
 

COUNSELOR: Better than nothin’, that’s for sure. The food’s okay?
 

JUAN: Yeah. This is a good place to eat, you know, a meal. What’s your name?
 

COUNSELOR: It’s Megan. How about yours?
 

JUAN: I’m Juan.
 

COUNSELOR: It’s nice to meet you. So you’ve been in the area long?
 

58 
 

Housing First Models 

Housing First approaches have been used to engage people who are chronically homeless and have 

severe and chronic mental illnesses. The goals of Housing First are to end homelessness and promote 

client choice, recovery, and community integration. Housing First engages people whom traditional 

supportive housing providers have been unable to engage by offering immediate access to permanent scatter-site independent apartments in buildings rented from private landlords. Clients have 

their own lease or sublease and only risk eviction from their apartments for nonpayment of rent, creating unacceptable disturbances to neighbors, or other violations of a standard lease. To prevent 

evictions, teams work closely with clients and landlords to address potential problems. Refusal to engage in treatment does not precipitate a loss of housing. Relapses to substance abuse or mental 

health crises are addressed by providing intensive treatment or facilitating admission to detoxification or the hospital to address the clinical crisis. Afterward, clients return to their apartments. Support 

services are often offered through multidisciplinary assertive community treatment (ACT) teams, with 

slight modifications. 

Source: Stein & Santos, 1998. 

 

 

Part 1, Chapter 2 

[Juan says that he’s been in town for a while and knows his way around. He’s currently staying at 

a shelter that he doesn’t like. The noise keeps him up at night, his things get stolen, and there are 

too many rules. He says he’d rather camp out, except for the police. The counselor mentions the 

possibility of housing.] 

Master Clinician Note: Nonclinical conversation is an important outreach tool. 

Social conversation is an icebreaker and helps identify a person’s interests and 

needs. While the counselor talks with Juan, she listens for information that will help 

her guide him in creating a recovery plan—that is, information that may indicate 

some of Juan’s strengths and limitations, problems related to substance use and 

homelessness, housing history, goals, values, and so forth. 

COUNSELOR: If you were to have your own place, what would that be like for you?
 

JUAN: Well, that’s what I do if I find a building where I can camp out. I make it my own place.
 

Master Clinician Note: Having clients imagine themselves in a desired situation can 

help you identify what matters to them and the barriers to their goals. Open 

questions and reflection encourage Juan to elaborate. 

COUNSELOR: You set up house.
 

JUAN: Right. Right now I don’t have an income, so there’s no way I can pay the rent or get a
 

place, so I’m just making the best of what I got.
 

COUNSELOR: It’s hard to imagine what it’d be like to move into your own place right now 


because it’s hard to imagine how you’d get it. You don’t have any income, and that’s a problem.
 

JUAN: Right.
 

COUNSELOR: One of the things I do is help people find places to live that they can afford.
 

JUAN: Are you playing a game? You want me to go to treatment or something like that?
 

59 
 

 

 

 

 

 

 

Behavioral Health Services for People Who Are Homeless 

COUNSELOR: No, you don’t have to go to treatment to get into housing. We have a program

called “Housing First” that might really be something you could look into. 

JUAN: Well, I don’t understand. Why would you do that for me? 

COUNSELOR: I think somebody would do that for you if they thought you could do it successfully. 

JUAN: My own place—somebody’s gonna give me my own place? 

COUNSELOR: Doesn’t make a lot of sense to you, does it? 

JUAN: No; what’s the catch? 

COUNSELOR: You and I would have to have a plan for how you would hang onto that place. 

Master Clinician Note: The counselor demonstrates that the client can expect her 

to be honest about what to expect. As he considers making a change, it’s natural 

for him to feel ambivalent about it and back off. This is part of the process of 

engagement, and the counselor doesn’t want to prevent his ambivalence from 

arising. In the following exchange, she’ll reflect both sides of his ambivalence so he 

can see the discrepancy between where he is now and where he wants to be. This is 

a technique from MI. Additional information on MI can be found in TIP 35, 

Enhancing Motivation for Change in Substance Abuse Treatment (CSAT, 1999b). 

JUAN: Make a plan for how somebody wouldn’t take it away from me. 

COUNSELOR: How you’d be able to hang onto it, yeah. So that would mean income. Let me 

ask you this: When you got your last place, how did you do that? 

JUAN: Uh, I got on assistance and they just took the rent out of that, so I never saw the rent 

check. But I got kicked out ’cause I had friends over, and we were partying. It got loud and somebody got into a fight, and then somebody else called the police. The next week I was out. I still 

get my disability assistance from the government. 

COUNSELOR: So, a couple of things happened there. You got on assistance that paid the rent,

you got your place, and then your friends came over and had a party. Things got loud and people 

started fighting, and that caused a problem. 

Master Clinician Note: The counselor gathers housing history information and 

summarizes what Juan says to reinforce her understanding of how he lost his 

housing. Reflecting Juan’s response empathically helps him feel heard and accepted 

and builds a mutual understanding of the issues they will need to address to make 

his plan for housing work. The counselor carefully avoids blaming Juan for losing his 

housing. 

JUAN: Yeah. It’s not like other people weren’t having parties. They were having them every 

weekend, so I had a party, and the next week, I’m out of there. 

COUNSELOR: It didn’t make any sense to you that you were bounced out and other people got

to stay, even though they were having the same kind of parties. 

60 
 

 

 

 

 

Part 1, Chapter 2 

JUAN: Yeah. I don’t want rules for when I can come and go or who I can have visit and stay over.
 

COUNSELOR: You want to be able to come and go as you please.
 

JUAN: Yeah. Just like anybody else paying rent for an apartment.
 

COUNSELOR: What other sorts of things do you think would be reasonable for a landlord to 


ask from you? Paying rent, that’s one.
 

Master Clinician Note: Given Juan’s history of homelessness and tendency to be 

irritable, the issue of reasonable expectations of a landlord is a touchy one. To avoid 

provoking Juan, the counselor is eliciting and reinforcing his understanding of 

reasonable expectations from a landlord. 

JUAN: Pay for your rent.Take care of the place. Don’t smash in the walls. Stuff like that. 

COUNSELOR: Okay. So you wouldn’t tear the place up and you’d pay the rent. The only other

thing from the last story is that it sounds like maybe your guests might get a little loud. 

JUAN: Yeah. I mean, what can you do in that situation? You ask the guys to keep quiet. If you try 


to throw them out, you may get hurt yourself.
 

COUNSELOR: You’re not real sure what to do if they start being that way.
 

JUAN: Right.
 

COUNSELOR: So if we’re going to make a plan, we might need to include some ideas about
 

that for you.
 

JUAN: Like, no parties?
 

COUNSELOR: Well, how to deal with that kind of situation. We could look at your options 


and see what you’d like to do. How does that sound to you?
 

JUAN: You mean you’re offering me a place now?
 

COUNSELOR: I’m offering to work with you to help you see if it’s something you want.
 

Master Clinician Note: If the counselor agrees with Juan’s understanding of her 

offer, then she’s agreeing to help him find a home before they have agreed on how 

they’ll work together to help him keep it. She’s balancing good judgment with 

moving at his pace. From his history, she knows that if he’s housed without being 

confident that he can adhere to the terms of a standard lease, he’ll be at high risk 

for a return to homelessness. 

JUAN: Yeah, I mean, I’d like that.
 

COUNSELOR: Well, there are a couple of things that you and I need to do. The first step is to


begin to fill out an application where I’m going to ask you for—
 

JUAN: [interrupts] Filling out lots of papers?
 

61 
 

 

 

Behavioral Health Services for People Who Are Homeless 

[As they move toward beginning the process, Juan experiences more intense ambivalence. The 

counselor expected this and responds to it with acceptance.] 

COUNSELOR: It’s not pleasant, is it. How do you feel about that? 

JUAN: [irritably] Eh, I don’t need to get into that stuff. If that is where this is going, I don’t want 

to go there. I don’t need that stuff. 

COUNSELOR: Okay. I can appreciate that. 

[Juan’s ambivalence intensifies. He backs his chair away and leaves, ignoring the counselor’s request for him to wait. The next time she sees Juan, she tries to approach him, but he walks away.] 

Visit 2 (shelter) 

A few days after the first visit, the counselor finds out that Juan is at the shelter and stops by in

hopes of bumping into him. Her goals for this meeting are:

• To reengage him. 

• To offer him the opportunity to look at an apartment that has become available. 

• If he wants the apartment, to see whether he can create a plan that will help him keep it. 

Juan is cranky but agrees to talk to the counselor. He says he’s been in the shelter for 4 days, that

a staff member is badgering him into substance abuse treatment, and that he’s getting ready to

leave. Noting the opportunity, she reflects his wish for new accommodations and offers to take 

him to see an apartment. 

COUNSELOR: So, you could use some options like maybe having a place to stay. We have an

apartment that’s become available, and the last time we talked, you sounded like you might be 

interested in something like that if it could be worked out to your satisfaction. I wonder if you’d 

be interested in taking a look. 

JUAN: [suspiciously] Now? 

COUNSELOR: Yes, I have a van here and a coworker from my outreach team. We can take you. 

JUAN: All right, where is it? Not around here? 

COUNSELOR: Well, it’s not immediately around here. It’s a few miles away. 

JUAN: Well, I kinda like this part of town. 

COUNSELOR: So that would be a big change for you, being way over there. Tough decision

whether to go see a place that far out of your usual space. But, it’s near a bus stop. 

JUAN: Sure. Well, I’ll go take a look at it. 

[The counselor and her colleague drive Juan to the apartment. As she shows him the building, he 

mentions a landscaping job he had. He’s proud of his landscaping abilities and describes being 

fired.] 

JUAN: Yeah, I changed the garden around to make it better, and they told me I was doing stuff I 

wasn’t supposed to do. They just didn’t know what they were doing. I said, “I’m outta here.” 

62 
 

 

 

 

 

Part 1, Chapter 2 

COUNSELOR: I see. So as far as you’re concerned, they didn’t appreciate that you were taking 

initiative to try to make things better. 

JUAN: Oh, yeah! Right on. 

[They look around, and the counselor tells Juan he can move in when the paperwork is approved

and they are able to reach an agreement to help him keep this apartment.] 

COUNSELOR: We have to do the paperwork and work out a plan that makes you and everyone 

else feel confident that you would be able to keep this place. 

JUAN: Like whether you’re bringing in bags with bottles in them, or... ? 

COUNSELOR: No, they don’t complain about people bringing in bags with bottles in them.

Remember that party you were talking about where things got heavy and the cops came? That’s 

the sort of thing that would cause concern. You and I are going to have to figure out what the

program guidelines are and what that means for you. 

Master Clinician Note: Juan is in the precontemplation stage of change for 

substance abuse and the contemplation stage of change for housing (see Part 1, 

Chapter 1, of this TIP). The counselor is seeking to enhance the relationship with 

him to support his engagement—first to obtain housing and then to help him move 

toward acting on other issues in his life, particularly his substance abuse. 

[Juan agrees to go back to the shelter to start the paperwork despite his ambivalence. At the 

shelter, the counselor begins to collect information about Juan’s housing history for the application. She mentions the party that led to his most recent eviction.] 

COUNSELOR: We started talking about the parties and how those can disturb other people. 

JUAN: Well, it’s not like other people didn’t have parties. I didn’t complain about that. 

COUNSELOR: So this is one of those areas where it may feel like you’re being treated unfairly. 

Master Clinician Note: Again, the counselor is careful to reframe this issue to be 

about Juan’s experience of what happened and avoid making him feel blamed, 

judged, or disrespected by the counselor. This is especially important given his 

sensitivity to feeling criticized. 

JUAN: [irritably] I can tell you, I’m not gonna stop having my friends over.
 

COUNSELOR: Okay.
 

JUAN: [still irritably] What’s the point of having your own place if you can’t do what you want?
 

I’m not saying they’re gonna come over and bust the place up. I don’t want that, either. But...
 

COUNSELOR: Well, you don’t want people to come over and bust the place up and neither


would any landlord. That makes sense to you. That seems reasonable.
 

JUAN: Yeah, sure, yeah. But these guys weren’t fighting, nothing got broken, and they weren’t any 


louder than the couple next door hollering at each other all the time.
 

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COUNSELOR: Right. So, you feel like the thing that happened last time, the thing that caused

the problem, you didn’t feel it was as big a deal as they made it out to be. 

JUAN: No. No way! 

COUNSELOR: There really wasn’t anything there for them to be concerned about at all. 

Master Clinician Note: The counselor is using a technique known as “overreflecting.” This deliberate emphasis on Juan’s initial opinion concerning the 

episode invites him to think more deeply about the episode and his feelings, 

evoking self-reflection, especially because he is a person who may not 

spontaneously self-reflect. There are risks with this approach—such as provoking 

defensive anger—but if presented with a nonconfrontational and supportive tone, 

even the most sensitive people will not respond negatively. 

JUAN: No. They just didn’t treat me right—with respect. 

COUNSELOR: That was the problem; it felt like they were kind of singling you out. 

JUAN: Yeah. And then that guy upstairs was always playing that #*%! speaker—I could feel the 

#*%!ing thing in my ceiling. Nobody else complained about that! They didn’t kick him out. 

COUNSELOR: Uh-huh. So part of what made you so angry the last time was that it seemed

like everybody else was doing this stuff and not getting into trouble for it. You were the only one. 

JUAN: Right! 

COUNSELOR: It’s hard for you to see what was different about your situation that got you 

kicked out. 

JUAN: There wasn’t anything different about this! They just need the excuse of their #*%!ing 

rules! I think it’s better sometimes just to camp out. Nobody tells you what to do. 

COUNSELOR: One of the things that’s easier about camping out is that you don’t have to deal 

with other people’s ideas about the things you’re doing. 

JUAN: Right. If things get bad there, you just move off to another place, and that’s cool. 

COUNSELOR: That’s right. You just keep moving around when it starts to get bad. So that’s 

some of the good stuff about camping out; you don’t have to put up with other people’s complaints. If we’re going to make this apartment work for you, we need to figure out how to help

you manage those situations. I can’t guarantee that the housing manager won’t have some opinions about any parties you might throw. 

Master Clinician Note: The counselor identifies a potential challenge for Juan in 

maintaining stable housing. The counselor avoids an adversarial stance by also 

commenting on the client’s coping mechanisms in an accepting manner. Thus, the 

counselor attempts to begin to frame the issue of housing stability as an objective 

“problem” that would need to be “solved” by Juan with the counselor’s support. 

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Part 1, Chapter 2 

JUAN: Those guys, they weren’t fighting, they were arguing with me. Maybe they got a little bit 

loud, but they didn’t bust up the place. 

COUNSELOR: That’s another thing that might happen, right? You might have some friends 

over and they might just be hanging out, and somebody else might complain. That’d be tough for 

you to deal with. 

JUAN: Yeah. What’s the use of moving into a place and you have some friends over and somebody complains and they kick you out in a week? [angry, dejected, and disgusted] Hell, let’s just 

give it up. I don’t want to mess with this anymore. 

COUNSELOR: Okay, I appreciate that. 

[Juan abruptly leaves.] 

Master Clinician Note: The counselor knows that a lot is at stake for Juan; if he tries 

and fails, he might feel humiliated, so he’s avoiding the risk of failure. This is a 

common response for people experiencing homelessness who are considering 

making a change. Some clients may experience ambivalence about change more 

intensely because failure causes them intense humiliation. Understanding this makes 

it easier for the counselor to accept Juan’s ambivalence. 

Visit 3 (soup kitchen) 

Juan disappears for a few days. When he shows up at the soup kitchen, he looks like he hasn’t 

slept for several days, seems to have been using, appears especially unkempt, and has a black eye 

and other bruises. The counselor asks if she can sit down. He shrugs with a disgusted look but

says okay. She takes a seat. 

The counselor says that Juan doesn’t really look like himself today. Juan explains that he was attacked by someone outside the shelter. She asks whether he’s had any medical attention. Juan says 

no and that he’s not interested in getting any. He’s not seriously injured, though his bruise looks 

ugly; the counselor’s anxiety increases on seeing Juan’s condition. She notices her anxiety and

consciously relaxes so she can honor his freedom of choice instead of trying to push him to accept health care. She also notes that Juan gets into pretty serious fights despite portraying himself

as someone who stays out of them. Juan agrees to have the counselor check in with him later. 

The counselor discusses Juan’s condition with her supervisor, and they decide that she should

continue to check on him over the next couple of days and watch for any changes in his functioning. If she notices a decrease in his ability to function, she will address this again with him and

with her supervisor. 

Visit 4 (soup kitchen) 

When the counselor finds Juan in the soup kitchen several days later, he looks better. His eye is 

healing, he’s sleeping and eating better, and he has a decent spot on the street where he can get

out of the weather. Her goal is to engage him into housing and other services. 

COUNSELOR: So you’re feeling like staying at this construction site is working for you? 

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JUAN: Just a little while. I mean, when they start opening up the fence and bringing in the big


equipment and stuff, I won’t be able to stay there. Are you still putting people in those apartments?
 

COUNSELOR: I certainly am. You think you might be interested in that?
 

JUAN: I don’t know. There’s all that rules stuff, people telling you what to do.
 

COUNSELOR: Well, it’s a tough decision.
 

JUAN: On the other hand, I might only be able to stay at this construction site for another week.
 

COUNSELOR: You’re getting to the point where you need a more permanent plan for where 


you stay.
 

JUAN: Yeah, it would be nice.
 

COUNSELOR: Yeah. You want to talk about it some more?
 

JUAN: Yeah.
 

COUNSELOR: One thing we ask is that you stay in the shelter a few nights before going into


an apartment so we can get to know you a bit. We want to ensure that the housing fits your style 


and priorities.
 

Master Clinician Note: The counselor avoids confrontation and allows Juan to save 

face while also emphasizing his need for success. Note: Housing First models 

generally don’t require potential clients to spend any amount of time in a shelter 

prior to entering housing. Getting to know or assessing the client can occur on the 

street, in the Housing First program offices, or at sites in the community. 

[Juan is concerned about returning to the shelter where he had the fight, because they made him 

leave. The counselor says some of the shelter staff members are familiar with Juan and his situation, and she’ll talk to them about helping him possibly get his shelter housing back. Several days 

later, when they discuss Juan’s situation with the shelter staff, Juan agrees to the shelter’s rules 

and says he’d like to stay there until the apartment paperwork is complete and approved.] 

Visit 5 (shelter) 

Megan talks with shelter staff the next day and checks in with Juan. Her goals for the visit are to:

• Collect information for the housing application. 

• Create a plan to address the issues that have caused Juan to lose housing in the past. 

The counselor tells Juan that he has impressed the staff by staying out of arguments and not

causing problems. She emphasizes this as Juan’s accomplishment to reinforce his sense of pride in

adaptive behavior. As we pick up the session, the counselor is collecting information about Juan’s 

housing history. 

COUNSELOR: So far, there are a couple of things I know. I know you’ve had an apartment before. And we’ve talked about what happened with that apartment. I’m wondering about other 

places you’ve lived. 

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Part 1, Chapter 2 

JUAN: Actually, a couple different places. I had a friend, Tom. We shared a place for a while.
 

COUNSELOR: And how did you get that place?
 

JUAN: He got it. I don’t know. He just asked me if I wanted to move in and split the rent.
 

COUNSELOR: Okay. And how were you affording your rent at that time?
 

JUAN: I was hustling, moving product—drugs and stuff. I didn’t have a regular type job.
 

COUNSELOR: That’s how you were getting the money to pay the rent and to use?
 

JUAN: Right.
 

COUNSELOR: So, that was one apartment you had with Tom. How long did that last?
 

JUAN: I guess about 2 months.
 

COUNSELOR: What other places?
 

JUAN: Well, when I was working for that landscaper, I had my own place for more than a year.
 

COUNSELOR: Oh, so that worked out well. That’s a long time to hold on to a place.
 

JUAN: Yeah.
 

COUNSELOR: So you had the job first, and then got the apartment on your own.
 

JUAN: Yeah, those were some good times!
 

COUNSELOR: You liked that work, and you were good at it.
 

JUAN: Yeah. I liked being outside, working with the plants, seeing stuff grow and look nice.
 

[The counselor gathers the rest of Juan’s housing, substance abuse, family, financial, and health
 

history. The longest he’s been housed is a year. He loses housing because of drug use and fighting.
 

It’s important to him to spend time with friends.The counselor notes that he will need positive 


social supports to maintain his housing. He reveals that he’s on parole but hasn’t seen his parole 


officer (PO) in 10 months. He’s worried about an outstanding warrant. They discuss the need to


address his legal issues, and the counselor offers her support through the process. Juan expresses 


some discomfort talking about his parole issues. Agreeing to set this aside for now, the counselor


shifts the focus to Juan’s relationship with his family.
 

Juan’s brother lives upstate, and his parents live in town; he hasn’t had contact with them for 3
 

years. He doesn’t make contact with them because he believes that they’re going to worry about
 

him. The counselor believes his family could help support Juan’s recovery. Once he’s settled, he 


may be interested in inviting his family to his apartment, which could open a discussion about


how his having an apartment is great but may also prompt conversation about his drug use.


When the time comes to create a plan with Juan for substance abuse treatment, the counselor


will ask about his interest in including his family in that plan.
 

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The counselor assesses Juan’s substance use and other likely problems based on what she already 


knows. They will use the information to create a plan to support housing stability and recovery.


The counselor continues to gather information on Juan’s substance abuse.]
 

COUNSELOR: We talked already about your use of crack. I wonder what other drugs you 


might use.
 

JUAN: I smoke a little grass every once in a while. Not on a regular basis.
 

COUNSELOR: So every so often, some pot. What else?
 

JUAN: I drink to come down. Wine helps me get to sleep.
 

COUNSELOR: Wine. What else?
 

JUAN: That’s pretty much it, and all that other stuff I mentioned.
 

COUNSELOR: So you use some grass and some wine to come down. But the one you use most


is crack.
 

JUAN: Yes.
 

Master Clinician Note: Asking “what else?” and reflecting the client’s response 

invites the client to elaborate. This lets the counselor explore client motivation for 

substance use without evoking resistance. Similarly, in the next exchange, she uses 

“tell me more” to gather details about psychiatric symptoms. 

COUNSELOR: Okay. I’d like to ask you a couple of questions about just how you have been

feeling. Have you been feeling depressed, sad, like you are not enjoying things that you might

usually enjoy? 

JUAN: I haven’t been too good up here [points to his head] the past few weeks, so— 

COUNSELOR: Well, tell me more about the past couple of weeks. 

JUAN: I always wake up in the middle of the night and can’t get back to sleep with guys playing 

music at the shelter and stuff, and that pisses me off. 

Master Clinician Note: The counselor is attempting to maintain and build the 

relationship with Juan through reflection, restating, and paraphrasing his comments. 

This is an effective technique from MI, although the counselor needs to be aware 

that the technique can be overused. If overused, rapport with the client will suffer. 

COUNSELOR: So you are having some trouble sleeping. What else is going on?
 

JUAN: That’s pretty much it.
 

COUNSELOR: That’s pretty much it. What about feeling anxious or irritable and angry?
 

JUAN: Well, yeah. All those things.
 

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How To Summarize for Your Client 

Be concise. This makes for clarity and easier processing for the client. When summarizing: 

• If possible, use the words and phrases the client has used. 

• Be as accurate as possible in restating what the client seems to be trying to say. Try to not exaggerate or minimize what the client has said. 

• Use phrases such as “What I am understanding is...” or “It seems that you're saying...” and check 

with the client to see if your understanding is correct. 

• If the client says you are not understanding, ask him or her to tell you again and use the client’s 

words in your feedback. 

• Sometimes, it may be important to let the client know that understanding what he or she is saying does not imply approval of potential actions. For instance, if a client says they want to hurt 

someone else, be sure your feedback does not imply that you agree with their intent. 

 

Part 1, Chapter 2 

COUNSELOR: All those things from time to time. Is there ever a point where they are really 


causing big problems for you or getting in the way of other things you want to do?
 

JUAN: Yeah. I walked off that job. That was a dumb thing to do.
 

COUNSELOR: So that’s one case of feeling angry and making a choice you didn’t really want to
 

make.
 

JUAN: Yeah, that wasn’t a good thing to do. It happens.
 

COUNSELOR: I hope that when you get settled in your apartment and when things are going


better, we can talk about what happens when you get angry and get yourself in trouble.
 

JUAN: Yeah.
 

COUNSELOR: Juan, tell me some more about your sleep problem.
 

JUAN: Well, the wine just levels me off, helps me get to sleep. But then, when I drink a lot of


wine, I wake up in the middle of the night and I can’t go back to sleep.
 

COUNSELOR: Yeah, so that’s sort of interfering with your sleep, too, you’ve noticed.
 

JUAN: I can’t get to sleep without it, but then I wake up in the middle of the night.
 

[The counselor is supporting the client’s growing awareness of the relationship between sleeping
 

problems and substance use patterns.]
 

COUNSELOR: You drink wine to come down and fall asleep, but you’ve noticed that when you 


drink, you wake up in the middle of the night.
 

JUAN: Yeah, but it’s better than going for a couple more days without getting any sleep.
 

COUNSELOR: How much sleep do you usually get?
 

JUAN: Don’t know... 4 or 5 hours, maybe.
 

COUNSELOR: How much do you think you need?
 

JUAN: Maybe 6 or 7, 6 and a half hours.
 

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COUNSELOR: How often do you usually get that?
 

JUAN: Huh! Almost never.
 

COUNSELOR: Not very often. So you walk around sleep deprived most of the time.
 

JUAN: Well, I never really thought about it that way. I’d like to sleep longer.
 

COUNSELOR: Yeah. You and I could work on ways to get a good night’s sleep, and you’ve already connected wine with trouble staying asleep, and you have trouble falling asleep.
 

JUAN: Yeah. Without the wine, I lie in bed a long time before I drop off.
 

COUNSELOR: We could see what we can do to help you, if you would like us to do that.
 

JUAN: I don’t know what, but yeah, if something can be done, I’m all for it. Maybe later.
 

Master Clinician Note: The counselor suspects, from the symptoms Juan has 

described, such as depression, anger, and anxiety reactions, that he might have a 

trauma disorder, but she avoids probing his trauma experience, which might, given 

his situation now, destabilize him and/or disrupt their developing rapport. Instead, 

she focuses on Juan’s main related concern: sleep. She helps him see how these 

symptoms may be related to substance use. Once Juan has stabilized in housing 

and is possibly more receptive to engaging in counseling, she will help him access 

care for both his substance use disorder and, if necessary, his trauma disorder. For 

more information on working with clients who have trauma symptoms, see the 

planned TIP, Trauma-Informed Care in Behavioral Health Services (SAMHSA, 

planned h). 

COUNSELOR: Okay. Do you ever have any beliefs that other people don’t have, or do you see 


things other people don’t see or hear things other people don’t hear?
 

JUAN: No. I’m not crazy, man.
 

COUNSELOR: That’s not you. Are there other problems you want me to be aware of at this 


point? Anything else that you would like us to work on?
 

JUAN: Just the apartment.
 

COUNSELOR: The apartment. So at this point, we’ve completed this paperwork. The housing


program will discuss this application, and we will get an arrangement that we can all agree to.
 

JUAN: Okay.
 

COUNSELOR: So, some of the things we’ve talked about working on are sleep, legal issues, anger, and how to manage things when situations aren’t fair. Is that about right?
 

JUAN: So when can I move in?
 

Master Clinician Note: Juan doesn’t respond with “yes,” which shows that he’s not 

yet committed to working on these issues. The counselor must reexplore the issues 

with Juan to identify which ones he’s ambivalent about. 

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How To Prepare a Client for a Conversation With a Parole Officer 

When your client agrees to contact his or her PO to explore options, help prepare as follows: 

• If your client isn’t ready for treatment yet, it’s reasonable to expect him or her to leave if the PO 

says going back either to jail or to treatment is necessary. Discuss the consequences of leaving 

(e.g., the possibility of being remanded to jail) and tell your client that, no matter the outcome, 

he or she is welcome to come back for help in the future. 

• If your client is ready for substance abuse treatment, you can indicate that sometimes, when people agree to accept treatment and stay in it for a while, POs agree to remove the warrant. 

• If parole concerns are a significant burden to your client, help him or her envision what it will be 

like to be rid of them. The PO might require substance abuse treatment or enforce jail time, but 

after, it will no longer be a concern. If needed, the two of you can work together on a plan for 

making it through treatment or jail time. 

 

 

 

 

Part 1, Chapter 2 

COUNSELOR: Well, we went over a lot just now. We want to make the housing plan really 

work for you. Next, we’ll review your application and get our agreement in place. You can have a 

little more time to think about what I just summarized as part of your plan. Tomorrow, let’s review the whole thing and make a housing plan we feel really good about—one that will give you 

the best shot at making it stick with the landlord. Now, let’s talk about contacting your parole 

officer and get that sorted out. 

JUAN: Yeah, well, I’m outta here if the PO’s got a warrant on me. 

[The counselor and Juan proceed to discuss what is going on between Juan and the PO. Juan and

the counselor briefly role-play Juan talking to the PO.] 

COUNSELOR: Do you want to call him now, while I’m here? 

JUAN: That sounds okay. If he doesn’t go along with this, then everything else is out. 

COUNSELOR: Right. We should talk with the PO first. We can use the speaker phone to hear 

both sides of the conversation. We’ll see how that goes, then decide about talking to the team 

about your plan. 

JUAN: Yeah, let’s do that. 

COUNSELOR: Juan, I’ll need you to sign this “release of information” form that authorizes me 

to talk with your PO and provide him with information about our work so far. Is that okay? 

JUAN: Okay, where do I sign? 

[The counselor helped Juan prepare for his meeting with the PO by using some of the guidelines 

noted in the how-to box above. Juan’s PO determined that he could avoid incarceration if he 

stayed in the shelter for homeless services. Juan did move into the Housing First program, and he 

and the counselor continue to work on his multiple problems. Likewise, the counselor continues 

to work on engagement, helping Juan move from precontemplation to the contemplation stage 

with his substance abuse. The counselor, using MI methods, has helped Juan examine how his

ambivalence and sensitivity often prevent him from initiating actions that could be helpful to

him.] 

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Behavioral Health Services for People Who Are Homeless 

Summary 

Juan’s story took place in the O&E phase. The work focused on: 

•	 Establishing a trusting relationship through nonintrusive persistence. 

•	 Identifying acceptable goals to work on. 

•	 Maintaining teamwork among the counselor, Juan, and the interagency O&E team. 

Teamwork was central to Juan’s willingness to talk to the counselor, see the apartment, regain access to the shelter (and thereby move toward housing), begin the application process, and explore 

his legal status. 

The counselor helped Juan move through the stages of change by prioritizing Juan’s most important goals. Juan began in precontemplation for substance use and mental disorders and the 

contemplation stage for housing. Housing became the highest priority goal; this let the counselor

and Juan identify barriers to maintaining stable housing and reasons to engage in other services.

Juan is now in the action stage for obtaining housing and the contemplation stage for substance 

abuse, mental illness, and legal issues. 

Juan’s personality problems, such as his hypersensitivity to criticism, his feelings that people are 

against him, and his sudden anger, may be his most challenging issues. They will be identified as 

concerns in his treatment after he becomes abstinent, manages trauma disorder symptoms, and

develops a resilient, trusting relationship with his treatment team. At this phase of homelessness 

rehabilitation, the clinician can address behavioral issues by:

•	 Demonstrating respect for and acceptance of his feelings (e.g., anger, sense of unfairness). 

•	 Helping him see how his behavior (e.g., hosting loud parties, leaving his job) contributes to

his homelessness. 

•	 Setting a goal of working on alternative responses to problem situations. 

Longer-term goals for this client will include:

•	 Creating a plan that Juan is confident he can accept and comply with for housing. 

•	 Reconnecting him with family and other natural recovery supports. 

•	 Working with treatment providers to engage him in substance abuse treatment. 

•	 Reconnecting him with employment and other meaningful roles in the community. 

•	 Addressing his parole obligations. 

•	 Evaluating him for mental disorders. 

Vignette 2—Francis 

Overview 

Francis is in the outreach and engagement phase of homelessness rehabilitation. This vignette 

demonstrates approaches and techniques for responding to his health and safety concerns. 

Francis is a 54-year-old man who is chronically homeless and has limited interpersonal and intellectual resources. He is now a loner and has had difficulty in the past maintaining a place to live.

He currently lives in a subway tunnel, is suspicious of anyone who approaches him, and worries 

that the transit authority will put him out. He can be personable, and he often spends his day at

the entrance to the subway. The outreach team has learned that Francis has occasionally gone to 

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Part 1, Chapter 2 

the local community health center, which is a Federally Qualified Health Center (FQHC; see 

the text box on p. 81), during the past 4 years. According to his clinic records, he has mild intellectual disabilities (intelligence quotient [IQ] near 70) and may have cognitive impairments as a 

result of a head injury incurred many years ago. He receives a small disability check monthly. The 

money is managed by a designated payee, a person who is authorized to help Francis manage his 

money. He also receives Medicaid as a result of his disability. 

The program has been in contact with Francis for some time. He has always walked away after

insisting that he is fine and doesn’t need anything.The O&E team has new information from 

area shelters that he’s building cooking fires in inappropriate places. In addition to his cognitive

impairment, he has significant health problems, including diabetes and nutritional deficiencies.

This information, along with an impending severe cold spell, mobilizes the O&E team to persist

in trying to engage Francis in services. 

A team of two counselors plans to meet him, briefly assess his situation, offer material goods, and

establish a relationship. Getting him to accept shelter, health care, and ongoing support are longterm goals. The present goals are to engage him in any possible way to improve his safety and to

find opportunities to offer other services. 

Maintaining the safety of O&E team members is a critical element of this type of work. Francis’s 

location has been reviewed and approved as safe by the team. (Sample safety policies and procedures are located in Part 2, Chapter 2.) 

Setting 

The counselor team is part of a multiservice organization serving homeless populations; its street

outreach component is staffed by peer counselors, substance abuse specialists, psychiatric social 

workers, and consultant psychiatrists. It has a drop-in center, housing resources, a working

agreement with a local FQHC, and ties to community homelessness programs. 

(Note: The designation of FQHC is based on specific funding and reimbursement criteria. There 

are a number of community health centers that may have an FQHC designation; however, there 

are other community health clinics and health centers that may not.) 

Learning Objectives 

•	 Build rapport (offer material goods; engage in casual conversation; work at the client’s pace; 

show empathy, respect, and genuineness). 

•	 Assess the severity of the client’s problems (e.g., safety, health) and develop responses. 

•	 Work with others as part of a team. 

Strategies and Techniques 

•	 Outreach 

•	 Match client and counselor 

•	 Service coordination with a local health clinic, a Federally Qualified Health Center 

Counselor Skills and Attitudes 

•	 Build rapport. 

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How To Engage People Who Are Living on the Street 

Several tools can help outreach workers engage a person who is living on the street: 

• Observe from a distance to get a sense of what the person may need and how he or she is doing. 

• Approach respectfully. Ask to join the person at his/her bench, campsite, or other personal area. 

• Offer safety-related items that he or she appears to need (e.g., food, shelter, blankets, water). 

• Resist the temptation to offer items solely for comfort rather than safety, as this may support the 

client in refusing services. The goal is to develop an empathic relationship that respects the client’s wishes and creates opportunities to help the person become housed and enter treatment. 

• Unless the individual indicates a willingness to have a longer conversation, keep your interactions 

brief (about 2 minutes) to avoid wearing out your welcome. 

Behavioral Health Services for People Who Are Homeless 

• Work collaboratively with the client and others. 

• Recognize and accept the client as an active participant in prioritizing needs. 

Vignette 

Visit 1 (Francis’s camp) 

During this visit, the team will:

• Initiate a relationship, begin to build trust, and establish rapport. 

• Offer Francis food and a blanket. 

• Tell Francis the weather is turning cold and offer to take him to a shelter. 

• Assess Francis’s condition. 

The two counselors slowly but casually approach Francis, who is seen lying down and snoozing

among some of his belongings. He’s bearded, disheveled, dressed in dirty clothing, mildly malodorous, and grimy. He is a large man, but he seems physically weak and malnourished. He awakens spontaneously as they approach but is unfocused and seems confused. Team members 

introduce themselves and shake Francis’s hand. He doesn’t know who they are and, fearing police 

or transit officials, he gets up, covers some items, picks up others, and begins moving away. 

COUNSELOR 1: Hey. 

FRANCIS: Hi. 

COUNSELOR 1: How are you doing? 

FRANCIS: I’m good. 

COUNSELOR 1: Good. My name is Alex, by the way. [gestures to colleague] This is Tommy. 

[Francis acknowledges them minimally.] We were just coming by here and noticed that you looked

kind of down in the dumps a little bit. How are you doing? 

FRANCIS: I’m fine. 

COUNSELOR 1: Good. Did we startle you? 

FRANCIS: Are you the police? 

COUNSELOR 1: Oh no. We work down here in the tunnels and meet people who may be living down here or staying down here. Have you been down here for a while? 

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How To Work as a Team Member on an Outreach and Engagement Team 

Agencies often have policies supporting teamwork during outreach. Successful O&E teams collaborate on plans for outreach visits and respect each other’s opinions. In Francis’s case, the team agreed 

on the following: 

1. O&E will proceed at the client’s pace unless there is reason to fear that this will endanger the client (see the decision tree on p. 77). 

2. Specific problems will be addressed as the client is willing. Team members work together to create opportunities to offer assistance in resolving these problems. 

3. Team members should define roles in advance, especially in terms of who will take primary responsibility for the interaction. 

4. Team members should observe which worker the client prefers to speak with and respect that 

choice. Workers not speaking directly with the client will help in other ways by remaining alert to 

the needs of both the client and their colleagues. 

 

Part 1, Chapter 2 

FRANCIS: Yeah.
 

COUNSELOR 1: What’s your name, sir?
 

FRANCIS: Francis.
 

COUNSELOR 1: Hi, Francis.
 

FRANCIS: Hi.
 

COUNSELOR 1: It’s getting kind of cold. Can I help you somehow?
 

FRANCIS: No.
 

COUNSELOR 1: Okay. Can we sit down?
 

FRANCIS: Yeah.
 

[After receiving permission to do so (it is Francis’s “home”), the outreach workers sit down. This 


encourages Francis to stay and talk with them. He makes eye contact and starts to pay attention.]
 

COUNSELOR 1: So how long you been staying down here?
 

FRANCIS: Not long.
 

COUNSELOR 1: Um, I was thinking that it’s getting kind of cold out. You said that you were 


okay. I just wanted to check and see if we could offer you a place to stay indoors.
 

FRANCIS: No, I’m fine. I went to the health clinic.
 

COUNSELOR 1: You did? Is that the one over on Second Avenue?
 

FRANCIS: Yeah.
 

COUNSELOR 1: I notice that your ankles look pretty swollen and red. Does that hurt?
 

FRANCIS: A little, but not all the time.
 

COUNSELOR 1: Is that what you went to the health clinic for?
 

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[Counselor 2 suddenly notes that Francis is becoming uncomfortable, looking away and beginning to pick at his clothes. The counselor assumes that his partner is being too directive with

questions and, glancing at his partner, decides to take another approach.] 

COUNSELOR 2: How are you doing in the food department? Can I offer you a sandwich? 

FRANCIS: Yeah. 

COUNSELOR 2: [handing him a sandwich] Here you go. 

FRANCIS: Thanks. 

COUNSELOR 2: Sure. One of the reasons we are down here is that we’re moving into a real 

cold spell over the next couple of days and, you know, when it gets cold, how do you usually manage yourself? 

FRANCIS: [making eye contact] I’m fine. I have a bag. 

COUNSELOR 1: A sleeping bag, you mean? 

FRANCIS: Yeah. 

[Francis shows the counselor a warm sleeping bag in good condition.] 

COUNSELOR 2: Do you need anything else from us? Like a blanket, maybe? 

FRANCIS: Um... sure. 

COUNSELOR 2: [handing him a blanket] Here you go. 

FRANCIS: I’m through talking with you now. 

COUNSELOR 1: Okay, I’ll tell you what—we’ll come back and see you another time. Can we 

do that? 

[Francis agrees, and the outreach team says goodbye and walks away. After the visit, the two

counselors report to the rest of the O&E team (consisting of a psychiatrist, a social worker, peer

counselors, and a substance abuse treatment provider) and discuss the temperature and whether

to do something to ensure Francis’s safety. They decide that his situation isn’t that bad; he responded appropriately to all questions, is sheltered from the weather, and has a good sleeping bag.

They’re concerned that he’ll move now that he’s been approached but decide that his camp

looked well set up. That, coupled with his making eye contact and accepting food and a blanket,

suggests that Francis will be in his camp the next day. They’re concerned about his health and 

make a plan for the counselors to visit him frequently to monitor his general condition and the 

condition of his ankles, along with his ability to take care of himself in the cold. If the opportunity arises, they’ll try to look at his feet. They plan to engage him in medical and other services at

his pace and to take him some socks. 

The decision tree on the following page indicates how providers might decide whether and how 

to intervene when a person who is homeless declines services.] 

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Decision Tree: Appropriate Follow-Up Care When Concerned About a Person 

Who Refuses Services 

When you detect a client problem in terms of health, cognition, possessions, inclement weather, or 

change in baseline, you must decide how to respond. In Francis’s case, the team decides to monitor 

him closely and seek opportunities to get him to medical services or bring the services to him. How 

did they make that decision? This decision tree maps out their process—the team’s decisions are in 

bold. 

 

 

Part 1, Chapter 2 

Visit 2 (Francis’s camp) 

The next day, the O&E team members visit Francis again. Their goals are to:

• Offer him their business cards so he has a way to contact them. 

• Offer him information about a new, smaller shelter that has opened up nearby. 

• Make sure he knows that the weather is going to get even colder tonight. 

• Observe his overall condition, the status of his feet, and his ability to take care of himself. 

• Give him some socks. 

COUNSELOR 1: Francis? It’s Alex and Tommy. Remember us from yesterday? 

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FRANCIS: Yeah.
 

COUNSELOR 1: Good. Man, it was cold last night! How did you do?
 

FRANCIS: I did fine.
 

COUNSELOR 1: I see you’re fixing up a little bit more space for yourself here. 


FRANCIS: Yeah.
 

[Francis attempts to stand and stumbles. He appears to be physically uncomfortable.]
 

COUNSELOR 1: Can we give you a hand?
 

FRANCIS: No, I’m fine.
 

COUNSELOR 1: Okay. Hey listen, you know—that shelter up on Avenue A has opened up and


there’s a spot in case you need it, because it’s getting really, really cold. Is that something we can
 

help you with?
 

FRANCIS: No. I’m fine. 


COUNSELOR 1: Okay. Well, we brought some socks for you; would you like some socks?
 

Master Clinician Note: Giving Francis socks is a nonverbal intervention that shows 

concern for his health and safety. It shows Francis that the team is connecting with 

his needs and is interested in building an alliance. 

FRANCIS: Yeah. Thanks.
 

[Tommy hands Francis the socks.]
 

COUNSELOR 1: We’d also like to give you our cards in case you need to go to the shelter. We’ll 


be around. Is it okay if we come back and see you again?
 

FRANCIS: Thanks. Yeah, you can come back.
 

COUNSELOR 1: Okay. Good. Give us a call if you need to. There’s an 800 number there. Feel 


free to just call that number if you need us. We’ll come back and see how you’re doing in a while,
 

okay?
 

FRANCIS: Okay.
 

COUNSELOR 1: There is a telephone right up at the top of the subway entrance, and this is an


800 number, so you don’t need to use coins. You just dial this number. Is that okay with you?
 

FRANCIS: Okay.
 

Visit 3 (Francis’s camp) 

On their third visit to Francis’s camp several days later, the O&E team has the following goals in 

mind: 

• Continue to develop a relationship with Francis. 

• Introduce Francis to the idea of getting follow-up medical care. 

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• Look for ways to connect him to housing opportunities.
 

COUNSELOR 1: Hey, Francis.
 

FRANCIS: Hey, how you doin’?
 

COUNSELOR 2: Hey, how you doing, Francis?
 

FRANCIS: Good.
 

COUNSELOR 1: I heard that you were in the shelter the other day.
 

FRANCIS: Yeah. I was there for a couple of days.
 

[Francis struggles to stand up—even though he is obviously in some pain—and he stumbles. The 


counselor reaches out his hand to help Francis stand and steady himself.]
 

COUNSELOR 1: Let me give you a hand there.
 

FRANCIS: Ow! I went to the clinic ’cause my foot was hurting a little bit, and they said I should
 

go to the shelter. 

Master Clinician Note: Francis has shown that if he really needs medical care and 

shelter, he can get them. This indicates that, despite some cognitive impairment, he 

uses good judgment in at least some situations. Cognitive impairment has a broad 

range of severity, from mild forgetfulness to full disorientation as to time, place, and 

person. Cognitive impairment may also be temporary or chronic. Because thinking 

can become disordered or inefficient, cognitive difficulties can impair judgment by 

compromising a person’s ability to evaluate the risks and benefits of any choice. The 

causes of cognitive impairment are many, but it may result from a head injury, 

malnutrition, alcoholism, or acute physical illness. The presence of clear cognitive 

impairment signals the need for a prompt medical evaluation. 

COUNSELOR 1: Yeah, it looks pretty raw right down there. Looks really painful.
 

FRANCIS: No, it really don’t hurt that much.
 

COUNSELOR 1: Really? I see that your shoes are in kinda bad shape too. So you’ve been walking around in shoes with holes in them, and it snowed the night before last, too, didn’t it?
 

FRANCIS: Yeah.
 

COUNSELOR 1: The weather must’ve been pretty bad on your foot. That’s why you went to
 

the clinic?
 

FRANCIS: Yeah.
 

COUNSELOR 1: Well, you know, Tommy and I were talking, and we were thinking you could


probably use a better place to sleep at a certain point; you know, indoors, in an apartment. Is that


something you might be interested in at some point in time?
 

FRANCIS: Nah. I’m pretty fine out here. I mean, it’s not too bad.
 

COUNSELOR 1: But when it gets cold, it gets a bit rough, and right now it’s kinda tough.
 

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FRANCIS: I’m pretty much a tough guy.
 

COUNSELOR 1: Yeah. I know. How long have you been staying outside? When was the last


time you had your own place?
 

FRANCIS: Oh, about 3 years ago. Yeah, me and my buddy got a place. I moved in. It was pretty 


nice and everything. He kinda got sick a little bit. My friend passed away.
 

COUNSELOR 1: Oh, he did? I’m sorry.
 

FRANCIS: Yeah, it kinda was his place, so I couldn’t stay there any longer.
 

COUNSELOR 1: Got it. You had trouble making ends meet and stuff like that after he passed.
 

FRANCIS: Well, yeah. It was hard.
 

COUNSELOR 1: Well, Francis, we’d like to help you find some better housing if you are interested.
 

FRANCIS: I’m fine.
 

COUNSELOR 1: Okay. Well, it’s something to think about, and we would be glad to talk more 


about it.
 

FRANCIS: Okay.
 

COUNSELOR 1: I’m a little concerned about your foot, though, especially the pain you’re going
 

through.
 

FRANCIS: It’s not much pain. I’ve seen worse. [rubs his shoulder] I was shot a long time ago.
 

COUNSELOR 1: Oh really? Can you use that shoulder pretty good?
 

FRANCIS: It’s fine. Sometimes it hurts a little bit.
 

COUNSELOR 1: Just so you know, at the clinic there’s a nurse in charge of foot problems, and
 

if you’d like, we could take you down there to have her take a look at it if you want.
 

FRANCIS: You mean Miss Kate. I know her. She’s nice. But I don’t know. Like I said, it don’t
 

hurt that much.
 

COUNSELOR 1: Okay. It’s a little raw. I’m concerned about you with your shoes in bad shape 


and stuff. You know, at the clinic, they might be able to set you up with a new pair of shoes.
 

FRANCIS: Can you get me some shoes?
 

Master Clinician Note: This is the first request Francis has made of the O&E team, 

and they take this window of opportunity to let him know that they want to help 

him get what he needs. Offering concrete aid like this fosters engagement because 

it shows Francis that the team will respond to his manifest needs. Counselors will 

want to be sensitive to clients making a request as a test of whether the counselor 

and other members of the staff will really respond to the client’s expressed needs. 

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What Is a Federally Qualified Health Center? 

A Federally Qualified Health Center is one that is qualified to receive Federal Medicare and Medicaid 

funds for delivering services to persons enrolled in those programs. In addition, an FQHC program 

may be eligible for grants to provide services to special target populations, such as individuals and 

families experiencing homelessness. Typically, FQHCs are found in areas that have large populations 

of medically underserved individuals and/or in areas with high concentrations of migrant and seasonal 

agricultural workers, significant numbers of people in public housing, or high rates of homelessness. 

FQHCs are located in every State. 

FQHCs are directed by a community-based board of directors and provide comprehensive primary 

health care regardless of a person’s ability to pay. Fees are based on the individual’s ability to pay. 

Additionally, many preventive services are offered, including screening, brief intervention, and referral to treatment (SBIRT) for individuals at risk of substance abuse and substance use disorders. For 

more information, see https://www.cms.gov/MLNProducts/downloads/fqhcfactsheet.pdf. 

 

 

 

Part 1, Chapter 2 

COUNSELOR 1: Yeah, we can bring you some shoes the next time we come. Would it be all 

right with you if I bring a worker from the clinic? They can help you get medical care for your

feet. 

FRANCIS: Yeah. 

COUNSELOR 1: Okay, great. Take it easy, all right? By the way, what size shoes do you wear? 

FRANCIS: I don’t know. Size 10, I think. Okay, see you later. 

[The team will ask the FQHC clinic’s homeless program case manager to join them on their

next visit with Francis. They intend for the clinic staff person to become Francis’s case manager

and help him access medical care, possibly obtain permanent supportive housing, and access other services. During the visit, the clinic case manager will take engagement and intervention cues 

from the O&E team. 

The team feels hopeful that they will get medical attention for Francis’s feet on their next visit. 

Francis has demonstrated that he’ll go to the clinic when the pain becomes limiting, but the immediate risk to Francis is that his feet are probably numb as a consequence of his diabetes. This 

creates a risk of injury and infection, which can lead to serious complications.] 

Visit 4 (Francis’s camp) 

The team approaches this visit with the following goals and strategies in mind:

•	 The clinic case manager will accompany them and begin to establish a relationship with 

Francis. 

•	 The team will offer Francis food, shoes, and a ride to the clinic, where he can have his foot

examined. 

•	 If Francis fears being coerced into unwanted services, they’ll promise to return him to his 

camp. 

Francis is at his camp and is irritable. He didn’t go to the shelter and is cold and obviously unhappy. The two counselors introduce the clinic case manager to him. 

COUNSELOR 1: Hey, Francis. 

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FRANCIS: Hey.
 

COUNSELOR 1: You know, I said we’d be back in a day or two, but we’ve been thinking about


your situation with your foot. We called up the clinic, and they were concerned. Let me introduce 


Jesse to you.
 

CLINIC OUTREACH WORKER: Hi, Francis. Yeah, I’ve seen you come by the clinic a couple 


of times. I think we spoke once. My office is just as you enter the clinic out of the waiting room,


on the right. You know, we can help you with that foot, man.
 

COUNSELOR 1: Yeah. We can take you to the clinic and then bring you back here if you want.
 

CLINIC OUTREACH WORKER: Yeah, we can do that. You don’t need to stay here.
 

FRANCIS: I don’t need no help.
 

COUNSELOR 1: A nurse can look at that foot.
 

FRANCIS: Didn’t I just tell you I don’t need no help?
 

Master Clinician Note: The counselor appraises the situation and realizes that the 

introduction of another person with whom Francis has not had a chance to develop 

rapport and, possibly, the pressure Francis perceives about getting help are causing 

Francis to resist. Rather than provoke the resistance, the counselor takes the 

opportunity to change the topic and talk about the weather for a few minutes. He 

then returns to the discussion of Francis going to the clinic for health care. 

COUNSELOR 1: Well, man, I hope you are going to be willing to let Jesse help you get over to


the clinic and get that foot taken care of.
 

FRANCIS: That’s all we’re gonna do, right?
 

CLINIC OUTREACH WORKER: Yeah. It’s your call. Can we take your stuff with us?
 

FRANCIS: Yeah. If you don’t take things around here, they...
 

CLINIC OUTREACH WORKER: Yeah, I know. They get taken by somebody else.
 

FRANCIS: So are we going to the clinic that I go to?
 

COUNSELOR 1: Yeah, that’s where the nurse is. She’ll look at your foot and we’ll get some 


food for you—a sandwich and some hot coffee. How do you like your coffee?
 

FRANCIS: All black.
 

[Once the team has promised not to leave him at the clinic, Francis agrees to go with the outreach worker. He’s now in the preparation stage for medical care and the precontemplation stage 


for assistance with housing.]
 

Summary 

This vignette demonstrates counselor skills and attitudes involved in outreach work, including:

• Patience, respect for client autonomy, and trustworthiness. 

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•	 Relationship-building skills. 

•	 Ability to respond appropriately to changes in the client’s behavior. 

•	 Ability to work as a member of a team and respond appropriately to safety and medical 

needs. 

In the O&E phase, the team’s interventions suited Francis’s stages of change: contemplation and

preparation for medical treatment, and precontemplation for housing. They prioritized the goal 

most pressing to Francis and his well-being: addressing his medical problems. Interventions to

build a relationship and increase readiness for services included:

•	 Asking for permission and respecting his decisions and personal space. 

•	 Offering incentives (e.g., socks, blanket, shoes, food). 

•	 Increasing access to services (e.g., bringing workers to him, helping with transportation,

helping him take his things with him). 

Given Francis’s willingness to engage on his terms, agreement to engage in additional services will 

also be on his terms. As shown in this vignette, Francis moves forward assisted by the creativity,

care, respect, and persistence of the counselors who work with him. The challenge for the counselors is to continuously balance Francis’s freedom of choice with the severity of his condition. 

Long-term goals for working with Francis include:

•	 Help him engage in medical treatment at the clinic to stabilize his current medical conditions. 

•	 Evaluate his mental health, particularly in light of his cognitive impairments. 

•	 Make a plan that he’s confident he can adhere to for housing. 

•	 Reconnect him with his family and other recovery supports. 

•	 Connect him with other peer-led community recovery supports. 

Vignette 3—Roxanne 

Overview 

Roxanne is in the intensive care phase of homelessness rehabilitation. This vignette demonstrates 

approaches and techniques for preventing homelessness and stabilizing a client who is in the precontemplation stage of substance abuse treatment. 

Roxanne is 32 years old, has been diagnosed with antisocial personality disorder, and is possibly 

dependent on oxycodone and other opioids. She occasionally has sex in exchange for money and

sells pain pills for income. Roxanne lives in a supportive housing program, but her behavior has

put her housing at risk. Her hostility, impaired ability to regulate her emotions, physical complaints, self-destructive and impulsive behavior, and impaired relationships may be indicative of a

trauma-related disorder as well as a personality disorder. 

These behaviors may evoke an emotional reaction (countertransference) in the counselor, evidenced in this case by the counselor’s anger, frustration, and helplessness. This makes it hard for 

the counselor to respond effectively to Roxanne’s needs. Supervision in such a situation is quite

important and can help the counselor clarify boundaries, responsibilities, and strategies for holding Roxanne responsible for her behavior while providing support to facilitate behavior change. 

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Behavioral Health Services for People Who Are Homeless 

Roxanne’s behavioral health counselor has talked to her many times about using drugs, bringing

men paying for sex to her single room occupancy (SRO), and “shopping for pills.” Even so,

Roxanne continues to have her clients “visit” her in her room. She also continues to seek drugs 

for severe chronic back pain—particularly oxycodone—in local emergency departments (EDs).

She has been evaluated on several occasions for pain (including comprehensive studies of her

back and spine in the hospital pain clinic), but no evidence of a physical disorder has been found.

About 2 years ago, she was referred to the hospital pain management program but did not follow 

through with their recommendations. She has had two admissions to a local mental health 

treatment center, both times following arrests for disorderly conduct and resisting arrest. 

The clinic suggested that she might have posttraumatic stress disorder (PTSD) and/or a substance use disorder in addition to her personality disorder, but these diagnoses were not confirmed, and Roxanne refused to continue to be seen at the clinic. She did agree to enroll in a

hospital case management program for ED users that includes consent to share information with

the behavioral health counselor in her SRO. The ED has called the counselor to report that 

Roxanne is now there and is refusing to leave without medication, even though she has been examined and released with a clean bill of health. 

Setting 

The behavioral health counselor provides case management services for a community program 

offering a variety of housing options to clients with a history of substance use disorders or SMI. 

All of the clients have had mental health and/or substance abuse treatment. The level of recovery 

varies from very stable to active symptoms that interfere with daily functioning. In most cases, a 

client’s level of recovery determines the housing options available to him or her. In this case, the

counselor provides services to clients housed in an SRO supportive housing program funded

through the U.S. Department of Housing and Urban Development (HUD). The housing consists of units with a kitchen and bath for occupancy by one person. 

Learning Objectives 

•	 Tailor treatment strategies, including the use of incentives, to match the client’s motivational

level. 

•	 Work with others as part of a team. 

•	 Recognize situations in which supervision is appropriate. 

•	 Work with clients experiencing homelessness who are in the precontemplation stage of

change for their substance abuse. 

Strategies and Techniques 

•	 Behavioral interventions, including contingency management 

•	 Structuring sessions 

•	 Managing and setting limits on inappropriate behavior 

Counselor Skills and Attitudes 

•	 Work collaboratively with the client and others. 

•	 Recognize and accept behavioral change as a multistep process. 

•	 Take responsibility for personal and professional growth (e.g., address countertransference). 

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•	 Adjust strategies to suit client characteristics (e.g., using a calm tone to convey safety and

control when clients feel out of control, making lists of priorities to structure sessions). 

Vignette 

Visit 1 (hospital emergency department) 

Because Roxanne’s behavior is sometimes inappropriate, two counselors go to the ED. Counselor 

1 is Roxanne’s assigned counselor. The counselors’ goals for this meeting are to: 

•	 Help Roxanne leave the ED before she is arrested. 

•	 Set up an appointment for the next day to discuss her concerns. 

•	 Transport her back to her SRO. 

•	 Preserve their organization’s relationship with the ED. 

They find Roxanne in the waiting area. When she sees the team arrive, she immediately begins 

insulting the ED staff, loudly complaining that no one is paying attention to her pain. 

ROXANNE: That b#*%! is ignoring me! Can’t you see I’m in pain? My God! No one here cares 

about anybody but themselves, God #*%! it! Maybe you can help me. Tell them I’m in pain! I’m 

in pain!!! 

COUNSELOR 1: Roxanne... 

ROXANNE: Thank God you’re here! Oh my God, thank you. You gotta tell them I hurt! I’m 

hurting! My back hurts so much! They don’t know what the #*%! they’re doing here! 

[Roxanne grabs Counselor 1’s shirt. Caught off guard by this, the counselor turns his head away.] 

ROXANNE: Make them pay attention to me! 

Master Clinician Note: Given Roxanne’s history and current behavior, it may be that 

she was not examined carefully. Barring any clear danger to the client, it is important to avoid confronting the ED staff with this possibility at this time. Issues 

about Roxanne’s treatment in the ED can be carefully examined away from the urgency of the moment. Moreover, Roxanne may further escalate her behavior if she 

senses disunity between the ED staff and her counselor. The team will address 

Roxanne’s own behavior and desire for medication after leaving the ED, minimizing 

disruption and breach of privacy in the public waiting area. 

COUNSELOR 2: Roxanne, listen...
 

[Counselor 2’s calm tone and kind manner catch Roxanne’s attention.]
 

ROXANNE: No, I’m really hurting! You gotta get me some medication, pleeeease! You understand. I’m a woman. I have problems. You understand. Can you help me, please!! Please! My back 


really hurts!!
 

COUNSELOR 2: Roxanne. Can you—
 

ROXANNE: [shouting] Let’s go to another hospital! I gotta do something!
 

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COUNSELOR 2: [calmly but firmly] Can you go back to the chair, please? Listen, they called us 

and said they can’t give you medication. We’d like to get you in the van and take you home. 

Master Clinician Note: Counselor 2’s calm, firm tone communicates safety and control, and the simple instructions help Roxanne, who feels out of control, focus and 

calm down. There are no easy solutions to this situation. If Roxanne had not deescalated, the counselor might next have opted to give her the choice of leaving 

the ED to discuss further options. She may have said, for example: “You say you 

want to go to another hospital. Let’s go outside, where we can speak more privately 

and discuss the options.” The short walk may have allowed Roxanne to collect her 

thoughts away from an audience in the ED. The counselor’s second option might 

have been to call security. Although always a potential tool for safety, using this option too hastily may have resulted in a power struggle and led to Roxanne’s physical 

restraint and sedation, the former being highly traumatizing and the latter unintentionally colluding with her demand for medication. This would have reinforced her 

repeated inappropriate demands. As Roxanne engages in treatment, her providers 

will assess her trauma symptoms, develop an understanding of how her behavior 

helps her cope with these symptoms, and integrate this conceptualization into her 

treatment plan. 

[In a quick, nonverbal exchange, the two counselors agree that Counselor 2 will take the lead in


interacting with Roxanne. Their training has prepared them for just such situations. They know 


that if both try to interact with Roxanne, it is likely to create an environment in which Roxanne


can play one counselor against the other.]
 

ROXANNE: What are we gonna do about this God #*%! pain?! That b#*%! isn’t helping me.
 

COUNSELOR 2: We’ll set up an appointment. Do you think you’ll be ready for one tomorrow?
 

ROXANNE: I want some meds.
 

COUNSELOR 2: They aren’t going to give you meds here. We already know they’ve made that
 

decision. 


ROXANNE: I hurt. I’m hurting. I’m really hurting! Please! Somebody help me, please!
 

COUNSELOR 2: Tomorrow we’re going to try and take care of it. Just let me—
 

ROXANNE: Well, you better. I’m gonna sue somebody. I’m gonna sue that b#*%! over there!
 

COUNSELOR 2: Forget them for now. You know the last couple of times we talked to you 


about some options, and we can do that again tomorrow.
 

ROXANNE: I need something for this pain. Can you get me something tonight?
 

COUNSELOR 2: I can’t get you something tonight.
 

ROXANNE: What am I gonna do, then?
 

COUNSELOR 2: We’re going to get in the van, we’ll take you home, and you can get some rest,


try to sleep, and get a fresh start in the morning. All right?
 

ROXANNE: What time?
 

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How To Intervene With a Client Who Is Being Disruptive in a Public Place 

1. Compassionate direction can help the client disengage from the situation and calm down. Speak 

calmly and firmly; give simple instructions (e.g., “look at me,” “please sit down”). 

2. Get the client out of the public place. One way to shift the client’s focus is to say, “Your pain is 

important to us—let’s go somewhere where we can talk and make a plan to deal with it the best 

way we can.” 

3. You may be tempted to agree to unrealistic requests, like a meeting at 7 a.m. It’s okay to set limits by saying, “I’m not able to meet with you at 7, but I can meet with you at 8:30.” 

4. If you give in, one way to rectify it is to say, “Look, I know we said 7. I was feeling your pain and 

lost my sense of what I’m really able to do tomorrow. I can’t come any earlier than 8:30.” Your 

client may not be pleased with waiting until 8:30, but you’re modeling how to handle inappropriate requests, and the client will appreciate that you are being clear about what you’re able to do. 

 

 

 

 

 

Part 1, Chapter 2 

COUNSELOR 2: You name it. 

ROXANNE: Seven o’clock. 

[During the van ride back to her home, Roxanne tests more limits by insisting that she needs 

pain medication and taking off her seatbelt. The counselors stay composed, calmly telling

Roxanne that they’ll pull over if she won’t put on her seatbelt. They give her the option of getting

aspirin at a drug store, which she accepts. As Roxanne begins to calm down, she throws a cup at a

counselor. Both counselors stay calm, explaining that her safety is important to them, so they can

only transport her if she stops doing things like throwing cups. They say that they want to take

her back home as long as she’s willing to use her seatbelt and refrain from unsafe behavior.

Roxanne agrees to accept the ride on those conditions.] 

Master Clinician Note: Reacting with harsh confrontation or a punishing tone to 

provocative behavior like Roxanne’s is tempting. However, the counselors understand that her personality disorder along with possible PTSD make it very difficult 

for her to regulate her emotions and that it is important to reinforce her sense of 

safety, control, and empowerment. Additionally, Roxanne has, in the past, often 

been successful in getting what she wants by escalating her disruptive behavior and 

becoming provocative. It is important that the counselors recognize the provocation 

as an attempt to get her needs met and refuse to be manipulated by it. The counselors believe that when Roxanne returns home, she’ll buy pills on the street. They 

could say, “I can see that you’re really hurting and I’m worried that you’ll do something that may put you at risk between now and tomorrow morning. Let’s talk about 

options.” The counselors know that this suggestion is unlikely to influence her immediate choices, but planting the seed helps her develop alternative coping skills to 

manage her discomfort, and they convey their concern that she might use a maladaptive coping behavior. The counselors also recognize that some of the irritation, 

agitation, and pain that Roxanne is experiencing may be residual withdrawal symptoms. In subsequent visits, the counselors will focus on helping Roxanne increase 

her motivation to obtain substance abuse treatment, return to the pain management clinic, and develop coping options when her subjective experience of pain 

feels like it is becoming unmanageable. 

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Visit 2 (counselor’s office) 

Roxanne sleeps past her appointment, although the counselor has telephoned to wake her. When

she finally arrives in the afternoon, she doesn’t want to discuss her behavior at the ED, preferring

instead to make demands on the counselor. The counselor’s goals for this meeting are to: 

•	 Reinforce the therapeutic relationship with Roxanne, particularly in light of their encounter

in the ED the previous evening. 

•	 Discuss her behavior at the clinic and her other options for pain management. 

•	 Engage Roxanne in a screening process to assess for a possible substance use disorder. 

•	 Help Roxanne understand the requirements of the SRO regarding drug use and visitors. 

Roxanne arrives with a list of complaints, including not having water last night and feeling back 

pain. In response to the counselor’s attempt to focus on her behavior at the ED, she becomes 

even more upset. 

Master Clinician Note: The counselor agreed to meet Roxanne at an early hour. 

When she doesn’t appear, he’s angry. He also expects Roxanne to be erratic and 

provocative in today’s session, possibly leading to a nonproductive or even 

contentious session. He needs to prepare for the session, first, by accepting his 

angry feelings and, second, by carefully preparing constructive responses (e.g., 

supportive limit setting, keeping goal expectations modest and prioritized) before 

the meeting. 

ROXANNE: I go ’cause I hurt and they ignored me last night! What are we gonna do about this

water situation? I had to go out last night to get water, to take some more pills. There was no water. By the way, I got a letter today from public assistance telling me they’re cutting off my benefits. Nothing’s happening! I don’t understand. Somebody here did something. Somebody’s got it 

in for me, I just know. 

Master Clinician Note: In almost every session, Roxanne has a pattern of raising 

multiple issues that seem unrelated. If the counselor begins to address one of these 

issues, Roxanne is likely to change the subject and move to another perceived 

problem. It is important for the counselor to identify the most pressing issues and 

help Roxanne stay focused on those issues. Some strategies the counselor could 

use include: 

1.	 Assessing and prioritizing problems to address. 

2.	 Considering which problems, if effectively addressed, will ease the pressure of 

or resolve other problems. 

3.	 Evaluating which problems Roxanne and the counselor can effectively address 

and which they cannot. 

4.	 Deciding how complex problems can be broken down into several less 

complicated problems that can be addressed. 

COUNSELOR 2: They’re concerned about your behavior at your building.The housing manager called and said you’re violating the visitor policy and getting into fights with your neighbor. I’m 

worried about your being able to stay there. If things keep going like this, I’m afraid you’re going 

to lose your apartment. 

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How To Keep a Client Focused 

When treating clients with many demands or problems, the following strategies may help: 

• Limit session length at the outset (e.g., “we have only half an hour today”). 

• Create a list of the client’s priorities to help you both maintain focus on treatment goals. 

• Stay consistent from session to session. Stick with the treatment plan. 

• Be firm but not rigid. Things will occur that dictate a need to change the treatment plan. 

• Set goals that are realistic and can be accomplished in a timely manner. 

• Identify realistic expectations for client behavior; recognize small successes as progress. 

 

Part 1, Chapter 2 

[The counselor decides to focus on the housing issue with Roxanne because if she does lose her

housing, it will be very difficult for her to maintain the gains she has made in other areas of functioning.] 

ROXANNE: I’m gonna lose my apartment if I don’t get my #*%!ing benefits turned back on. 

COUNSELOR 2: Well, we don’t want you to lose your apartment. So, the next time or maybe

the time after when you come in, bring that paperwork for your benefits, and we’ll see what you 

and I can do about you keeping your benefits. But Roxanne, we have to look at what is going on

in your apartment. Maybe we can meet—you, me, and the housing manager of your apartment—

and see how we can resolve some of these problems. Do you think we could do that? 

ROXANNE: That’s really not gonna do anything for my pain. My back hurts, and it hurts all the 

time! 

COUNSELOR 2: I agree; your pain is difficult. I hope you can get back to the pain clinic at the

hospital, but right now, let’s see what we can work out about keeping your housing. 

ROXANNE: The only thing that helps is oxycodone. It really helps. 

Master Clinician Note: The counselor realizes that Roxanne is not prepared to 

focus on any one issue except getting her drugs and that continuing to pursue 

issues about housing or obtaining substance abuse assessment is going to be futile. 

He anticipates that continuing to press Roxanne at this time will only increase her 

alienation and escalate her complaints. He decides to forgo more discussion at this 

time and wraps up the session with a summary of their visit, reminding Roxanne to 

bring her benefits papers when she returns for the next visit. 

[This was a particularly challenging session for the counselor. Feeling overwhelmed by Roxanne’s 

demands, the counselor knows he should seek supervision. The supervisor affirms the counselor’s 

choice to seek assistance. His supervisor helps him assess Roxanne’s problems and then structure 

sessions, assess Roxanne’s readiness for change regarding her possible substance abuse, and identify appropriate interventions while also providing support for the counselor. The supervisor encourages the counselor to continue to address the challenges of working with Roxanne in

supervision. Some of the supervisor’s suggestions and insights include: 

•	 Support Roxanne’s goal to keep her housing; this keeps the door open for her to accept indicated treatment later. Offer options, but don’t take responsibility for her choices. She will 

make her own. 

•	 Help Roxanne increase her motivation to obtain an evaluation for substance abuse treatment. 

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Trauma-Informed Care 

Trauma-informed care is an approach to working with clients who have histories of trauma that recognizes trauma symptoms and integrates this information into treatment planning and delivery. 

Roxanne’s counselors recognize that many of her behavioral symptoms may be a result of significant 

trauma in her history, and they use that recognition in helping Roxanne develop a treatment and recovery plan that incorporates mental health, substance abuse, and trauma care along with housing. 

One key strategy of trauma-informed care is empowerment: helping the client take responsibility for 

his or her own recovery and life. Observe how the clinicians, in cooperation with the housing manager, seek to empower Roxanne. For more information on trauma-informed care, see the SAMHSAsponsored National Center for Trauma-Informed Care Web site (http://samhsa.gov/nctic/) or consult 

the planned TIP, Trauma-Informed Care in Behavioral Health Services (SAMHSA, planned h). 

Behavioral Health Services for People Who Are Homeless 

•	 Use contingency management (described later in this vignette) to help her engage and stay in

treatment if it is indicated. Offer incentives she relates to (e.g., clothing vouchers) for meeting objectively measurable goals that are important to her (e.g., keeping her housing by behaving appropriately in response to complaints, attending pain management for treatment of

her back pain). This will help her develop internal motivation. 

•	 Encourage Roxanne to develop coping skills for managing anger. If she becomes hostile, end

the session in a compassionate, noncombative way and see her again when she’s able to speak

calmly. 

•	 Help Roxanne focus during sessions by making a list with her that includes her goals, such as 

getting help for her pain and addressing concerns about her apartment. 

•	 Spend the last 15 minutes of every session reviewing the items covered during the session,

keeping Roxanne focused on her list of goals and ways she can demonstrate that she has 

reached these goals. 

•	 Reframe her behaviors as strengths. She is skilled at reading people, focused on her own

agenda, actively engaged in getting what she wants, and persistent. This will increase her

sense of self-efficacy and help her see ways of shifting her behavior toward more adaptive 

outcomes. 

•	 Continue noting countertransferential feelings in response to Roxanne’s behaviors; seek supervision.] 

Visit 3 (housing manager’s office) 

After meeting with his supervisor, the counselor, with the cooperation of the housing manager of

Roxanne’s apartment building, schedules a meeting with Roxanne, the housing manager, and

himself. The manager has been confronted by other tenants who complain that Roxanne is loud

and argumentative and may be using her apartment for prostitution. The housing manager notes 

that if Roxanne cannot be more cooperative, she is going to lose her apartment. 

The counselor wants to foster a spirit of teamwork, hear firsthand about the problems Roxanne is 

creating, and support the housing manager in working with Roxanne to reduce the risk of losing

her apartment. The counselor’s goals for this meeting are to: 

•	 Assist Roxanne in keeping her apartment; the counselor sees Roxanne’s maintaining stable 

housing as a precondition to addressing other issues, such as pain management, substance 

use, and management of trauma symptoms. 

•	 Show Roxanne that her concerns are taken seriously. 

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How To Prepare for Joint Sessions 

1. Support a spirit of teamwork among the staff members who are present: Create a tone that emphasizes that everyone is working toward the same goal. 

2. Use the first minutes of the session to set boundaries for the focus of the session, being clear 

about the issues that will be discussed. Everyone comes to the session with a separate agenda, 

and things can get out of hand without clear agreement on session goals. Be sure all participants 

have an opportunity to state their goals. 

3. Prepare all participants for the client’s likely responses (e.g., coping styles): review the client’s history, current issues and goals, and past behaviors in similar circumstances. 

 

 

 

• Create an environment that reinforces adaptive behavior. 

• Show that the service team is unified in its approach to her problems. 

• Address specific issues raised by a neighbor who has complained about Roxanne’s behavior. 

The counselor and the housing manager agree that the housing manager will take the lead in the 

meeting. The counselor will step in to support Roxanne when she identifies positive changes she 


is willing to make regarding her housing situation.
 

ROXANNE: Someone stole my public assistance stuff, and I’m sure it was her, because that


b#*%! is just out to get me. She has nothing good to say about me. You’ve gotta take care of that!


She slips nasty notes under my door and threatens me for some reason. She’s just got it in for me,
 

and I’ve just had it with her!
 

HOUSING MANAGER: Well, she has some complaints about you too, Roxanne.
 

ROXANNE: What have I done?
 

HOUSING MANAGER: She says you’re always having a lot of men over at your place.
 

ROXANNE: [sounding superior] I’m allowed to entertain anybody I want.
 

HOUSING MANAGER: Well, I need you to do some things for me; I have a job to do,


Roxanne.
 

ROXANNE: You just do your job.
 

HOUSING MANAGER: Well, you’re going to have to help me do my job.
 

ROXANNE: How? You’re gonna pay me to do your job?
 

HOUSING MANAGER: No, this is what I want you to do: Cut down on the traffic to your
 

room.
 

ROXANNE: There’s nothing in the rules that says I can’t have people there. I’ve read the rules. I
 

know what they say. They don’t say that I can’t have people there.
 

HOUSING MANAGER: I have just told you I’ve had complaints from your neighbors, so I’d be 


willing to work with you if you’re not going to—
 

ROXANNE: She’s just got it in for me. I’m not going to say one word to that b#!*%! But I tell


ya, when I catch her stealing my mail, she’s gone!
 

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How To Manage Inappropriate Behavior 

When your client becomes inappropriately seductive and oversexualized with the staff: 

1. Pause and identify for yourself what he or she is doing. 

2. Consider how this behavior fits with your conceptualization of the client. Inappropriate behavior is 

part of chaotic relationships. 

3. By stepping outside the chaos and observing what is going on, you can identify the seductiveness 

and label it as an issue to work on in treatment. 

4. It is also important to kindly and firmly limit the inappropriate behavior. 

5. Use structure (e.g., a list of priorities) to help the client focus. 

 

Behavioral Health Services for People Who Are Homeless 

HOUSING MANAGER: Well, if you catch her stealing your mail, you should come tell me and


I’ll make a police report. What’s going on with your apartment?
 

[Roxanne continues by listing a variety of problems with her apartment: a leaky bathtub, peeling


paint, a problem with her refrigerator, a wall switch that isn’t working, and a request for a new


mailbox lock because she thinks her neighbor is stealing her mail. The housing manager listens 


carefully and takes notes of the items that need correcting. Although the housing manager does 


not commit to making all of the repairs immediately, he does seem to be listening carefully and


taking her concerns seriously.]
 

HOUSING MANAGER: Anything else?
 

ROXANNE: Well, that’s it for now. There’s always something. But those are the worst now.
 

HOUSING MANAGER: So you need a mailbox key, a refrigerator, a new paint job, and the tub


fixed.
 

ROXANNE: When are you gonna do it?
 

HOUSING MANAGER: What are you going to do for me?
 

ROXANNE: What do you mean, what am I gonna do for you? I don’t work for you!
 

HOUSING MANAGER: What are you going to give me when I fix these things?
 

ROXANNE: [a bit sarcastically] A “Thank you very much.”
 

HOUSING MANAGER: Now, can I tell you what I want from you?
 

ROXANNE: Something from me? I’ve got something. [seductively] You’ll really enjoy it.
 

HOUSING MANAGER: This is exactly what I’m talking about, Roxanne. This is not appropriate. Let’s talk about what we can do with the apartment.
 

ROXANNE: But you said I was going to have to give you something, so you set me up.
 

Master Clinician Note: The counselor steps in to interrupt the conflict and redirect 

the conversation and then steps back to let the housing manager take the lead 

once again. 

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COUNSELOR 2: Let’s listen to what he would like to have you do. [addressing the housing manager] What is it that Roxanne can do to help with this?
 

HOUSING MANAGER: The main thing that will help me speed up making the repairs is if
 

you’re willing to consider not having as many people over in one evening.
 

ROXANNE: What do you mean, not as many people?
 

COUNSELOR 2: Limit her guests to just one or two in an evening?
 

HOUSING MANAGER: Yeah.
 

COUNSELOR 2: Can you do that?
 

ROXANNE: Yeah, I can do that.
 

HOUSING MANAGER: Which of your apartment problems would you like me to address 


first?
 

ROXANNE: Uh, my refrigerator.
 

HOUSING MANAGER: Yeah, I’m not saying I’m going to replace it. I’ll replace it if it’s not
 

repairable.
 

ROXANNE: Okay.
 

HOUSING MANAGER: And we’ll take care of the tub.
 

ROXANNE: Okay. What are you going to do about my neighbor, though?
 

HOUSING MANAGER: I’m going to talk to her, and I’m going to ask her not to bother you.
 

ROXANNE: You do that. I won’t bother her, believe me. She’s gotta stay away from my mail!
 

COUNSELOR 2: If you think that she’s in your mail, will you come to me and let me handle it?
 

ROXANNE: Yes.
 

COUNSELOR 2: Okay. So, can we go look at her refrigerator now?
 

HOUSING MANAGER: Yeah, sure.
 

[The housing manager leaves the meeting to get the repairman to work on Roxanne’s refrigerator. After his departure, the counselor spends a few minutes with Roxanne, supporting her for


working toward resolving the problems. He also reinforces the need for Roxanne to limit visitors


to her apartment and to bring complaints to the manager rather than confronting other residents


directly. The counselor notes that during the entire meeting, Roxanne did not complain of pain


or the need for pain pills. He does not mention this to Roxanne, but decides to wait for Roxanne


to raise the issue again. He schedules the next appointment with Roxanne for later in the week at 


his office.
 

After returning to his office, the counselor calls the housing manager to express appreciation for


his skillful work in the meeting, thus building teamwork.]
 

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How To Use Lists To Keep Clients Focused 

1. Ask, “What are the three most important things for you? It helps me to make a list of what’s important.” Lists create structure and help the counselor and client stay on the same page. 

2. Help the client prioritize his or her most important concerns. 

3. When the client veers off, the counselor can say, “Well that’s not on the list. Let’s talk about your 

list because those are the most important things. If they aren’t the most important, we can 

change the list.” 

4. Agree on the time needed for each item to increase structure. “How long do you think we need 

to handle this item? Also, I need to speak with you about a few things, so I’ll need 15 minutes at 

the end to talk about... ” 

 

 

Behavioral Health Services for People Who Are Homeless 

Visit 4 (counselor’s office) 

After another meeting with his supervisor, the counselor sets these goals for his next visit with 

Roxanne: 

•	 Use a list to structure and prioritize the conversation. 

•	 Help Roxanne accept medical treatment with Dr. Thomas, the program physician, who is 

associated with a local community health clinic. The counselor would like to use the visits 

with Dr. Thomas as an entry point for getting Roxanne to return to the pain clinic at the

hospital, hoping that pain management may be a way to engage her into addressing her substance use. 

•	 Identify some strategies to help Roxanne move from the precontemplation stage to the contemplation stage for addressing her substance use. 

Roxanne arrives late, looking exasperated and preoccupied. She apologizes for being late and begins a rapid-fire complaint about her neighbor. The counselor helps her focus on making a list of

priorities for them to work on. 

COUNSELOR 2: What I’d like to do is talk about the most important things for you right now. 

There are so many things going on. What’s the most important thing for us to try to help you 

with right now? 

ROXANNE: What do you mean, “help?” I mean, there’s all kinds of things going on. 

COUNSELOR 2: Yes, there are a lot of things. Let’s see if we can decide which are most important to focus on right now. 

ROXANNE: So, you want me to choose which is the most important thing? 

COUNSELOR 2: Yeah. 

ROXANNE: My back. 

COUNSELOR 2: Okay, so we want to concentrate on... 

ROXANNE: Then my neighbor. 

COUNSELOR 2: Your neighbor? 

ROXANNE: My public assistance is still cut off. I got this leaky faucet. 

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COUNSELOR 2: So, there are four things. 

ROXANNE: I’ve got this guy after me—I’m real worried about that. And my back. 

[The counselor and Roxanne settle on three issues to focus on today: her pain, the man who is 

after her, and relationships with other tenants at the SRO housing facility.] 

COUNSELOR 2: All right, so let’s talk first about getting you an appointment with Dr. Thomas 

about your pain. 

ROXANNE: I don’t like him. 

COUNSELOR 2: He’s the physician we can use in this program. 

ROXANNE: Can’t you find me somebody else? Can’t you find me a woman doctor? 

COUNSELOR 2: Sorry, we don’t have a woman doctor. I understand that you would rather see a

woman doctor, but Dr. Thomas is the only doctor assigned to this program. If you see Dr. Thomas and then still want to see another doctor who is female, I can see if we can arrange a referral. 

Master Clinician Note: The counselor thinks that Roxanne wants another physician 

because Dr. Thomas has not given her pain pills on past visits, but he is sensitive to 

the possibility that Roxanne may want to see a female physician because of a history 

of sexual traumatization. He doesn’t explore that issue right now with Roxanne, but 

he makes a note to explore it in the future with her. 

ROXANNE: [sighing] Oh, all right. But he doesn’t give me pills for my pain.
 

COUNSELOR 2: Roxanne, I understand that your pain is a real difficulty for you. But the drugs 


you want are very addictive, and I don’t think you are going to find doctors who will consistently 


give you the drugs you want.
 

ROXANNE: No, I need it. It takes away the pain. I’m not addicted to it.
 

COUNSELOR 2: I know you don’t think you are addicted. But we need to find some other ways 


to manage your pain and your drug use.
 

ROXANNE: Yes. I’m not addicted to it, I mean... I just need something for the pain. I mean,
 

look, if I can’t get oxies, I’ll buy something else off the street.
 

COUNSELOR 2: They help?
 

ROXANNE: Yeah, because the pills take away the pain.
 

Master Clinician Note: The counselor is preparing Roxanne to have modest but 

substantive expectations of the consultation with Dr. Thomas. By acknowledging 

Roxanne’s pain and eliciting the relationship between Roxanne’s pain and her drugseeking behavior, the counselor enhances rapport and identifies one of Roxanne’s 

needs. The counselor also demonstrates acceptance that Roxanne is in the precontemplation stage of change for addressing her drug-seeking behavior and the contemplation stage for exploring alternatives to oxycodone for managing her pain. 

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COUNSELOR 2: You can talk to Dr. Thomas about what you might do to manage the pain.

You and he can make a plan for what you can do about the pain. 

[The counselor raises the issues of the man who is “after” Roxanne and her relationship with the 

other tenants in her housing, but Roxanne shows little interest in addressing either issue now.] 

Master Clinician Note: The counselor suspects that Roxanne’s complaints have 

diminished as a result of her feeling understood and having her needs recognized. 

With another client at a more advanced stage of change, the counselor might ask if 

the client feels more comfortable or less distressed than when she came in, and 

then proceed to explore what happened to initiate the change. But with Roxanne, 

the counselor suspects this intervention might just invite Roxanne to begin focusing 

on all that is going wrong in her life and lead her to feel more agitated. 

[Roxanne lets the counselor schedule the appointment, and the counselor agrees to talk to Dr.

Thomas about attending to Roxanne’s concerns. He will also ask Dr. Thomas to consider talking

with Roxanne about the pain management clinic and encourage her to accept a referral. 

Besides the meeting with Dr. Thomas, Roxanne agrees to continue to bring her concerns about

the apartment to the housing manager and not the other residents. Roxanne has a letter from 

public assistance that she doesn’t understand, so she will bring it with her when she goes to see 

Dr. Thomas, and the counselor can help her with it. This contingency makes it more likely that

Roxanne will show up for her appointment.] 

Visit 5 (counselor’s office) 

The counselor speaks with his supervisor about his countertransference with Roxanne and his 

concerns about forming a treatment contract. They agree on specific goals for the counselor’s next 

visit with Roxanne, which include:

•	 Remaining consistent with the list of priorities. 

•	 Following up on Roxanne’s visit to Dr. Thomas. 

•	 Developing a contingency management program for Roxanne that will support her continuing in treatment and reinforcing changes she has made in pain reduction, drug use, interpersonal relationships, and continuing in treatment. 

•	 Expecting Roxanne to present urgent issues and responding by maintaining a firm but flexible focus on treatment goals. 

•	 Helping her form reasonable expectations of what can be accomplished; keeping the list 

manageable. 

Roxanne reports that, as a result of seeing Dr. Thomas, she’s scheduled for a magnetic resonance 

imaging scan (MRI) of her back and asks what an MRI is. The counselor explains, and Roxanne 

expresses disappointment that the doctor gave her no medication. She also agreed to schedule a

visit to the pain clinic to reenter the pain management program, part of which is a comprehensive

evaluation for substance abuse, brief intervention, and referral for treatment, if needed. 

ROXANNE: I’m really pissed off ’cause I’m still hurting, and he didn’t give me anything. 

COUNSELOR 2: Well, I’m really impressed by the fact that you’re hurting and yet you came to

meet with me, and you worked to get some things done in the apartment. 

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ROXANNE: My bathtub still isn’t fixed.
 

COUNSELOR 2: Some things are taken care of.
 

ROXANNE: Yeah, he gave me a new key. I got that.
 

COUNSELOR 2: Good. I think when you focus, you get things done and people respond to


you. That is a real strength that you have.
 

Master Clinician Note: This intervention identifies and positively reinforces
 

Roxanne’s adaptive behavior, thus building her self-confidence and esteem.
 

ROXANNE: I guess... people just keep bothering me.
 

COUNSELOR 2: Well, look. I read over your letter from public assistance. It’s just a confirmation of your status. Your status hasn’t changed. I can be a witness to that.
 

ROXANNE: What happened?
 

COUNSELOR 2: It’s just a routine evaluation to see whether you’re eligible to have continued


assistance. You have to sign this to confirm it and I can sign off on it.
 

ROXANNE: [after reading the document] Where do I sign?
 

COUNSELOR 2: Right here. [Roxanne signs the document.] Good. I’ll sign as a witness.
 

ROXANNE: Can I get a copy of that?
 

COUNSELOR 2: Absolutely. So, you’ve shown up for the appointments with the housing manager and Dr. Thomas, and you brought your letter as I asked, so I think you’re really making some 


progress here.
 

ROXANNE: My pain is still there, though.
 

Master Clinician Note: The counselor is participating in a pilot program in the 

agency to use a newly developed cognitive–behavioral strategy, contingency 

management, with a few selected clients. Contingency management reinforces 

positive behaviors toward treatment goals by rewarding the client with vouchers for 

items that most people would like. Rewards might include special recognitions or 

program benefits, such as additional hours away from the treatment program. The 

rewards need to be tied to specific, identifiable, clearly measurable goals, such as 

clean drug screens, attendance at self-help meetings, and consistent treatment 

program attendance. Contingency management is generally implemented in 

settings with a number of clients participating. In this vignette, contingency 

management is used with just one client. Contingency management is often used in 

concert with cognitive–behavioral therapy. For more information on contingency 

management, refer to SAMHSA’s National Registry of Evidence-Based Programs 

and Practices (NREPP). Contingency management is also a term sometimes used in 

housing services, where contingencies, such as staying abstinent, are a condition for 

housing. 

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[The counselor briefly explains the contingency management program to Roxanne in terms of

rewarding positive, objectively measurable steps toward treatment goals. Roxanne seems quite 

interested in obtaining vouchers or coupons for products that she might not otherwise be able to

purchase.] 

COUNSELOR 2: I want to give you a coupon because you kept your appointments with the 

doctor and the housing manager. I’ve got a voucher that will get you a free hair appointment. 

How would you like that? 

ROXANNE: I’d like that. Thank you. 

COUNSELOR 2: Okay. Next week, if you keep doing well and I get no calls from the housing

manager or from the ED, you’ll get a voucher for Interfaith Clothing Closet to get some outfits. 

How’s that sound? 

ROXANNE: Now what do I have to do? 

COUNSELOR 2: I don’t get any calls that you’ve been into the ED. 

ROXANNE: What if I’m sick? 

COUNSELOR 2: Well, you’re working with Dr. Thomas. You’re having an MRI next week, so 

we have a plan that you’re working on. If you get sick in the meantime, call Dr. Thomas. 

ROXANNE: What if I have a pain in my back again, like a stabbing pain, and I can’t stand it 

anymore and it’s, like, in the middle of the night, and Dr. Thomas is not available? 

COUNSELOR 2: If something happens and you have an emergency, then you can go to the 

emergency room. But if you’re going to ask for oxycodone, that wouldn’t be following our agreement. 

ROXANNE: So I can go to the emergency room, but I can’t ask for any pills? 

COUNSELOR 2: Right. 

ROXANNE: Okay. 

[The counselor educates Roxanne about how stress and pain are related, and how there may be 

other ways to address the pain that may be more helpful than pills. Roxanne refuses to consider

going to the pain clinic and steers the conversation back to the emergency department.] 

ROXANNE: [dismissive] Well, I just know what’s gonna happen. I’m gonna wake up in the middle of the night, and I’m gonna be in pain, and I’m not gonna be able to go back to sleep, and I’m 

not gonna be able to get help because you’re telling me I can’t go to the emergency room and get 

some oxies. 

COUNSELOR 2: I didn’t say you couldn’t go to the ED. I said it’s not consistent with our 

agreement if you go to the ED and try to get oxycodone. 

ROXANNE: I’m gonna go to the emergency room to get some relief or something. 

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COUNSELOR 2: So that will be our understanding. If the ED tells me you were requesting

oxycodone again, I won’t give you the voucher for the Clothing Closet. Do we agree about the 

voucher and the ED? 

ROXANNE: [tolerant] I suppose. 

COUNSELOR 2: Okay. Well, I think we have everything set up. Now, I’d like for us to put our

agreement in writing. Would you like to have that? I promised you a voucher for the Clothing

Closet. You could go there and pick two outfits, but in return, the understanding is that you won’t 

go to the ED and ask for oxycodone, and you’ll follow through with your appointment with Dr. 

Thomas next week. 

ROXANNE: [a little confrontational] And if I don’t sign? 

COUNSELOR 2: We won’t have an agreement, and you won’t get a chance to get a couple of 

new outfits. This is how we both understand what we’re agreeing to. What have you got to lose? 

[Roxanne challenges the counselor; his calm response enables her to go along with the plan.] 

ROXANNE: Can I get some shoes with that? 

COUNSELOR 2: I don’t know whether they have shoes, but the voucher gets you a couple of

outfits. If the outfits include shoes, you could look at shoes. 

ROXANNE: Okay. 

Master Clinician Note: Committing the plan to paper is a good idea for Roxanne; 

she’ll have it to help her remember what she is supposed to do in order to get the 

clothing voucher. It also assures her that as long as she follows through, the 

counselor will, too. Some clients may not need written cues, but when structure 

and/or ability to remember details are issues for clients, it is a good idea to put 

agreements in writing. 

Summary 

The counselor now has the tools to respond effectively when Roxanne is demanding and chaotic.

He understands that he can’t realistically meet all her needs and doesn’t have to. Clinical supervision helped him become aware of his countertransference (i.e., feeling angry, weary, manipulated,

challenged, and provoked) and develop ways to manage it so he can respond to Roxanne calmly 

yet firmly. This approach helps her form a plan to keep her housing, address her back pain, and

consider alternatives to oxycodone. 

When Roxanne was in the ED, she was in the precontemplation stage of change for finding alternative ways to manage pain, substance use, high-risk behavior, provocative behavior, and housing problems. The counselor’s respectful and empowering intensive-care approach (goal setting

and reinforcement of appropriate behaviors) has moved Roxanne into the preparation stage for

alternatives to managing pain and the action stage for keeping her home and changing problem

behaviors. As she succeeds in managing pain and maintaining housing, she may be more motivated to engage in substance abuse treatment. 

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Behavioral Health Services for People Who Are Homeless 

Long-term goals for working with Roxanne include:

•	 Continuing to support and reinforce behavior that allows her to maintain her housing. 

•	 Continuing to pursue pain management. 

•	 Obtaining treatment for her substance use, if warranted. 

•	 Increasing motivation to engage in services by exploring and resolving ambivalence; creating

a plan that she is confident she can make work. 

•	 Connecting her with acceptable recovery supports (e.g., mutual support groups, faith-based

supports). 

Vignette 4—Troy 

Overview 

Troy is in the intensive care phase of homelessness rehabilitation. This vignette demonstrates approaches and techniques for preventing homelessness and engaging the client in substance abuse 

treatment. 

Troy is a 32-year-old single father who is dependent on alcohol and marijuana. He had one brief

episode of homelessness in his early twenties, was in substance abuse treatment 2 years ago, and

attended Alcoholics Anonymous (AA) regularly until about a year ago. He relapsed about 6

months ago and lost his roofing job. Until his relapse, he had been abstinent for 18 months. The 

relapse seems to have been triggered by his wife leaving the family, financial difficulties, and

dropping out of AA. He says he quit attending AA because he could not arrange child care for

his sons, ages 6 and 8. He got custody of his children 8 months ago, after his wife left. 

He lacks good childcare, parenting, and time management skills and is easily overwhelmed.

When he becomes overwhelmed, he tends to “shut down” and withdraw from others, which increases the environmental stressors. He has food stamps and public assistance but can’t cover his 

rent. Troy has a Section 8 voucher and is afraid that he is about to lose his apartment. For more 

information on Section 8 housing assistance, see the note on page 103. 

Some of the stress-related symptoms he currently experiences include:

•	 Difficulty staying focused on one issue; when he tries to focus on one issue, he tends to become overwhelmed. 

•	 Lack of energy and no desire to take on problems that really need to be addressed. 

•	 Difficulty remembering things, which leads to missed appointments. 

•	 Feeling like he has so many problems that he doesn’t know where to start. 

Troy remembered that his old behavioral health counselor was very helpful to him, so he called to

see if the counselor could help him with his housing. 

Setting 

The counselor works in a community-based, multiservice substance abuse treatment organization. Some of the program staff members specialize in housing and employment assistance. 

Learning Objectives 

•	 Adapt counseling strategies to unique client characteristics and circumstances. 

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•	 Coordinate treatment and prevention activities and resources that suit client needs and preferences. 

•	 Understand the interaction of co-occurring substance use and mental disorders with homelessness. 

•	 Work with others as part of a team. 

Strategies and Techniques 

•	 Homelessness prevention 

•	 Cognitive restructuring 

•	 Working with persons who have co-occurring substance use and mental disorders and are 

homeless 

•	 Interventions for substance abuse relapse 

Counselor Skills and Attitudes 

•	 Assess basic life skills and functioning. 

•	 Recognize and address underlying issues that may impede treatment progress. 

•	 Respond appropriately to the client’s environmental stressors, employment situation, and 

childcare responsibilities. 

•	 Accept relapse as an opportunity for positive change. 

Vignette 

Visit 1 (counselor’s office) 

The counselor has not seen Troy for 10 months and begins the first session with the following

goals:

•	 Reestablish the working relationship. 

•	 Identify the concerns that have prompted Troy to seek treatment. 

•	 Understand the circumstances for Troy’s relapse. 

Troy arrives at the session looking down in the dumps, tired, and distracted. His speech is soft,

and he is slow to respond to the counselor’s questions. He appears to be having difficulty concentrating. 

COUNSELOR: Tell me about why you wanted to see me. 

TROY: Well, I dunno. Because I’m using a lot of weed and stuff. I been using it for a while; a lot 

of stuff ’s going down. I’m behind on the rent and it’s really hard to keep up. It takes the edge off, 

you know? 

COUNSELOR: Last time you were in, we spoke of coping with stress. Have you been using

those skills? 

TROY: A little bit. I’ve been trying to keep up with my kids and stuff. 

COUNSELOR: All right. 

TROY: I put the kids to bed at 9, and it’s my time after that, you know. 

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COUNSELOR: Around what time do you go to bed? 

TROY: It depends. Midnight, 1 o’clock. Sometimes the guys are over and we stay up a little bit

late, you know, smoke a little, drink a little. But I’m so tired when I get up in the morning. 

COUNSELOR: You’re really tired in the morning. 

TROY: [affect is somewhat flat] I have to get them to school. It’s good that I do that, you know?

Then I go home and... I messed up a couple months ago. I go to sleep sometimes after I drop

them off, and I didn’t show up to work, and now it don’t even matter to me if I work. I got 

enough with the boys. 

[Troy and the counselor spend a few minutes talking about his wife abandoning the family, his

dropping out of AA, his relapse, and the loss of his job. Troy thinks his most pressing problem 

right now is the possibility of losing his home.] 

COUNSELOR: Yeah, having children can be challenging—it’s a new life that you have, right? 

TROY: Yeah, I guess so. It just gets the better of me. I didn’t know it was going to be like this. 

COUNSELOR: I remember when you were in treatment; we talked in group one night about 

your fear that your wife might leave if you got clean. As I recall, you thought you were definitely 

the better parent for the boys and that, if she left, if you got custody of them, it might be good for 

everyone. 

Master Clinician Note: The counselor empathizes with the challenges of single 

parenthood and reminds Troy how proud and excited he was to get his boys. This 

helps Troy to decrease negative self-assessment and increase his confidence in his 

ability to make a change. A key treatment effort in early recovery is to help clients 

increase self-esteem, improve self-confidence, and learn to evaluate the impact of 

their actions before they act. 

TROY: Maybe. I just gotta get back to my house to just see the kids, I dunno.
 

COUNSELOR: Where are your kids now? In school?
 

TROY: They should be getting home any minute. I gotta leave here in just a few minutes.
 

COUNSELOR: Okay. I can see that you are under pressure to be there when they get home.


Can you give me at least 5 minutes? Let’s list what we talked about. You’re worried about losing
 

your apartment, it’s hard managing the kids, and you’ve relapsed—is that correct?
 

TROY: Yeah, like, it’s just not happening for me now. Sometimes I guess I get to the point where 


I just say, #*%! it. And, maybe that’s why I smoke and I been drinkin’.
 

Master Clinician Note: The counselor empathically reflects Troy feeling 

overwhelmed, letting Troy open up more about feelings of hopelessness, irritability, 

and the role of substance abuse. Taking time to gather more information and 

develop rapport with the client before working on the problems the client and 

counselor have identified decreases client resistance to change. 

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How To Work With a Client Who Is Overwhelmed 

Once you recognize that your client is overwhelmed with life problems or with the information you’ve 

shared in a counseling session, change your expectations for what you can accomplish in sessions 

until he or she is doing better: 

1. Keep your sessions short (15–30 minutes). 

2. Don’t overload the client with information or tasks. Have realistic expectations based on the client’s abilities. 

3. Keep the information you provide brief; speak in simple, short sentences. 

4. Offer assistance with accomplishing a task if the client isn’t able to do it independently. 

5. Create a list of urgent, important tasks; work to address those as the client is able. 

6. Schedule brief sessions often during the week until the urgent, important tasks are done. 

7. Monitor the client’s body language, facial expressions, and responses for signs of overload. Offer 

to take a break or offer water to help the client be able to continue and feel understood. 

A Note on Section 8 Housing 

Section 8 Housing is a voucher program funded by HUD. It assists very low income families in obtaining decent and safe housing in the private housing market. Once they are deemed eligible, participants find their own rental housing in their communities. HUD (through its designee in each State) 

then pays the landlord the difference between a specific amount (generally 30 percent of the of the 

tenant’s adjusted income) and the fair market rent of the housing unit. Eligibility for participation is 

determined by the household’s gross income, which generally may not exceed 50 percent of the median income of the county in which the family resides. Special programs are available for families with 

disabilities and to reunify families with children placed in foster care due to inadequate family housing. Involvement in drug-related or violent criminal activity is grounds for loss of Section 8 housing. 

Source: HUD, n.d. 

 

 

 

 

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COUNSELOR: So let’s put that on the list of things we need to work on: the drinking and the


weed, getting back into your AA program. We need to look into some emergency housing support until you can get back on your feet. Do you have any income now?
 

TROY: My brother sometimes has a little work for me; he’s a contractor. But, you know, nobody


is working in construction these days. So I hardly get enough to feed us.
 

COUNSELOR: Okay. Do you agree that these are the things we need to work on first: getting


clean, going back to AA, getting you emergency housing support, and getting back to work?
 

TROY: Yeah. Well, I really gotta get out of here.
 

COUNSELOR: So, real quick, did you talk to your Section 8 representative?
 

TROY: Uh...nah.
 

COUNSELOR: Okay. Here’s the representative’s name and number; call her and say that you
 

lost your job. They’ll recertify your income, which will lower the rent you have to pay. [The counselor writes down Sherri’s phone number and a note reminding Troy to explain that he’s lost his job.]


She’ll be there until 6 tonight.
 

TROY: Uh-huh.
 

COUNSELOR: We can work together to help ensure that you won’t lose your home. I have an
 

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How To Handle Late-Shows and Missed Appointments 

How you address late-shows and missed appointments depends in part on the client’s ability to plan 

and organize sufficiently to arrive on time: 

1. If this is the client’s first late-show or no-show, consider whether memory or concentration problems may exist that make it difficult for the client to remember appointments and arrive on time. 

2. In the absence of cognitive problems, explain the importance of punctuality. Don’t take the client 

into your office to negotiate; don’t go out of your way to extend session time or reschedule (remove positive reinforcement). You may also give the client an appointment card, express regret 

that the client missed the appointment, and focus on what will be accomplished in the next visit. 

3. If the client has cognitive problems, ask him or her to explain the tardiness and schedule another 

appointment. Don’t take the client into your office to negotiate. Offer an appointment card to be 

kept in a wallet, or suggest putting it on the refrigerator. 

4. If this is not the client’s first late-show or missed appointment, and the client is tentatively engaged in services (e.g., client is chronically homeless, client’s willingness to engage in services is 

itself a significant accomplishment), it may be unrealistic to expect punctuality. One effective approach that reinforces showing up is to allow the client to walk in and wait for the next available 

appointment. 

5. If the client has been late or missed other appointments, but has shown the ability to be on time, 

then lateness or missed appointments may be a way of demonstrating ambivalence about the 

counseling process. Explore this briefly, as he or she walks in or calls, to enhance the relationship 

and make the client more likely to return. You can also express regret that the client missed the 

meeting and focus on what will be accomplished in the next visit. 

 

 

 

 

 

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appointment available tomorrow at 11:30 if you’d like to come back. 

TROY: I’ll come tomorrow. 

Master Clinician Note: Troy has made some progress on his own getting food 

stamps, public assistance, and setting up an appointment for the visit today. The 

counselor recognizes these steps as strengths and hopes to build on Troy’s ability to 

mobilize to get him back to AA and to help him focus on staying abstinent, 

developing stronger parenting skills, and getting a job. If the counselor gives him 

too much to do, Troy will feel overwhelmed and spiral downward, so he doesn’t 

push these issues in the first visit. The two most pressing problems—from the 

counselor’s perspective—are helping Troy regain abstinence and maintain his 

housing. Without abstinence, it will be challenging for Troy to attain the other goals 

of improving his parenting skills and getting a stable job. Without stable housing, 

the counselor suspects it will be difficult for Troy to maintain abstinence. He is also 

concerned about Troy’s level of depression and decides to talk with him on his next 

visit about consulting with the staff psychiatrist. 

[After the first meeting with Troy, the counselor follows up with the Section 8 staff, explaining

Troy’s concern about losing his housing due to unemployment and mentioning that Troy now 

has custody of his boys.The counselor and the Section 8 representative agree to work together to

help Troy recertify his current rent, access a local rental assistance program to help pay his back 

rent, and engage in substance abuse treatment.] 

Visit 2 (hallway outside counselor’s office) 

Troy doesn’t make his 11:30 a.m. session, but shows up later on in the lobby. The counselor is between sessions with clients, so he talks to Troy in the hallway for a couple of minutes. Troy vaguely 

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remembered that he had an appointment but wasn’t sure what time it was supposed to be—

another indication of his difficulty with memory and his inability to focus. The counselor says 

there’s an opening at 2:00 p.m. if he wants to wait. Troy agrees, and the counselor asks if he called

the Section 8 representative. Troy hasn’t, so he tells him to ask the receptionist to let him call 

while he’s waiting. Troy finds it helpful to have this specific task to do while he’s waiting. 

The counselor meets with Troy at 2:00 p.m., but Troy announces that he can stay for only 15

minutes because he has to get his kids. The counselor’s goals for these 15 minutes are to: 

•	 Verify that Troy called the Section 8 staff and is no longer at immediate risk of losing his 

housing. 

•	 Focus on connecting Troy with resources for getting clean and sober. 

•	 Get Troy’s cooperation in scheduling a psychiatric consultation. 

COUNSELOR: So, what did Sherri say? 

TROY: Sherri said it’s all right. She gave me some information about a program I could contact

for help paying the back rent. She did mention something about wanting me to stay in treatment,

though. 

COUNSELOR: Right. She said that you need to show that you’re working on a plan for abstinence that’ll help you keep your housing. You did a great job working with her; you must feel 

pretty good about that. 

TROY: Yeah, okay. 

COUNSELOR: So that piece is taken care of. There are a couple of things I want to talk to you

about. First, I need you here on time for our meetings. We were scheduled for 11:30 today. 

Master Clinician Note: In situations when a counselor must rapidly change gears 

and abridge the content of the session (starting late and/or ending early), it is 

necessary to select simple priorities that can be accomplished in the time allowed. It 

is important to be clear with the client that the agenda is reduced specifically 

because of time constraints. 

TROY: Well, you know, I got the kids to school, came back, had some stuff to do. I was tired.
 

COUNSELOR: What kind of stuff did you have to do?
 

TROY: I needed to sort of catch up on some sleep, and then I had some business to do.
 

COUNSELOR: You’re sleeping more in the daytime.
 

TROY: You know, I’ve been sleeping a good bit. I gotta catch up on it sometime.
 

COUNSELOR: Sounds like you’re exhausted. It’s hard to get things done with a lot on your
 

plate.
 

TROY: Uh-huh. I got a call from Jimmy’s teacher. He’s been getting to school late and they’re 


talking about some meeting. She mentioned calling child welfare, and I gotta get out of here to


pick them up. They get out at 2:45.
 

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COUNSELOR: You sound worried. You’re starting to get your life back together and be a good 

parent, and I can see you’re very concerned about getting them on time. Can we spend 5 minutes 

going over a few things, and we’ll get you out of here? I want to get back to that child welfare 

issue for just a minute. 

TROY: Okay. 

COUNSELOR: Okay. Well, we’ve got to make sure you keep your housing. That’s a big priority. 

The other thing I think is important is your getting clean again. 

TROY: Uh-huh. Well, I haven’t used now in a couple of days. I haven’t slept worth a damn, but 

other than that, it hasn’t been too hard. 

COUNSELOR: Okay. What do you need to keep on staying clean? 

TROY: Well, I just need to keep on. I’ll keep on seeing you, if you want. I gotta keep people out

of the house after the boys go to bed. That’s when it gets lonely, and I’m tired, and people drop 

over. 

COUNSELOR: I want us to talk more about this, but I know you need to leave in just a minute,

so I want to get back to the child welfare issue. When do you meet with the teacher? 

Master Clinician Note: The counselor would like to continue solving problems and 

building strengths with Troy to help him stay abstinent, but he recognizes that Troy 

has only a few more minutes left. He wants to return to the issue Troy raised of child 

welfare being contacted about his kids. The counselor also decides to forgo the 

issue of psychiatric consultation. He doesn’t want to raise another issue, which 

might overload Troy. He respects Troy’s need to get to the school on time and 

doesn’t want to end the session on a possibly contentious note, should Troy decline 

to get the psychiatric consultation. 

TROY: [seems frightened] Well, I guess 3 o’clock. I don’t know what’s going to happen. 

COUNSELOR: You seem kind of frightened about what that meeting is about. 

TROY: Yeah. 

COUNSELOR: She may discuss the importance of them arriving on time or other things. I’ll 

support you as much as I can. Call me if you want to talk about the meeting before our next session. 

TROY: Okay. 

Visit 3 (counselor’s office) 

The counselor has the following goals for this session with Troy:

•	 Have Troy accept a referral to the staff psychiatrist for evaluation of potential depression. 

•	 Support Troy’s abstinence and help him build strengths to continue to stay clean. 

•	 Support Troy in taking action on behalf of his sons—for instance, by attending meetings at

the school. 

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Working With Clients Who Are Homeless and Have Co-Occurring Disorders 

A wide range of substance use and mental disorders can co-occur with homelessness. In most cases, 

homelessness makes treatment of and recovery from mental and substance use disorders more problematic, and the co-occurrence of substance use and mental disorders limits the person’s ability to 

address critical life problems such as homelessness. It is imperative to treat all three conditions— 

substance use disorders, mental illness, and homelessness—concurrently using an integrated approach. For more information on the impact of CODs and homelessness, see SAMHSA’s Homelessness Resource Center Web site (http://homeless.samhsa.gov/channel/co-occurring-disorders

457.aspx) and the SAMHSA Web site’s section on CODs (http://www.samhsa.gov/co-occurring/). 

In the following sessions, observe how the counselor and Troy work together to obtain a psychiatric 

evaluation of Troy’s depression, implement treatment for this condition, support his recent abstinence, continue his attendance at AA, and help him maintain secure permanent housing through the 

Section 8 housing program. 

How To Manage the Stress of Seeing Clients Who Have Multiple Problems 

Counselors have many responsibilities during and between sessions. It’s frustrating to work with a 

client who has urgent problems and fails to show up for appointments or follow through with assignments. It’s even more stressful when children are involved. How do you address these needs and 

avoid burnout? 

1. Know the system and resources currently available in your area. 

2. Help the client get access to these resources quickly. 

3. Remember that you help clients handle urgent and important issues, but you’re not responsible 

for their choices. 

4. Resist the urge to rescue the client from his or her emergency and/or feelings of being overwhelmed; attempt to respond concretely to what is presented as an urgent need. 

5. Remember that helping the client prioritize multiple needs is an important part of the work. Help 

the client create a list of the urgent, important things that need to be done and prioritize them. 

6. Identify teammates who should be brought in (e.g., psychiatrist, Section 8 representative, childcare specialist). 

7. Seek supervision frequently. 

 

Part 1, Chapter 2 

Troy arrives for the session on time. He still feels overwhelmed, very tired, and doesn’t have much 

motivation to look for a job, but now has 7 consecutive days of abstinence. The session begins 

with Troy describing the meeting with the teacher and assistant principal of the school. The 

school authorities had not contacted child welfare but stressed that if the boys continued to act 

out at school and didn’t arrive on time, they would have to take some action on behalf of the 

boys. The counselor supports Troy in staying clean and in addressing the needs of his sons. The 

counselor then decides to raise the issue of the psychiatric consultation to rule out depression. 

COUNSELOR: Troy, I’m concerned that you seem tired all the time, overwhelmed, don’t have 

much energy for doing things, and are having trouble concentrating. I think it would be good if

we could get some consultation on whether or not you are depressed, and if so, what we can do

about it. So, I’m wondering if we could schedule an appointment for you with Dr. Moore, our

psychiatrist, to have you checked out for depression. 

TROY: [seems a bit helpless in attitude] Yeah, I don’t know. I don’t wanna go see Dr. Moore. A

friend of mine, when she went to see the psychiatrist, they took away her kids. 

­

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How To Use Assignments Between Sessions 

Assignments between sessions are a useful tool in counseling. They help learning carry over from the 

session into daily life and put what has been talked about in the session into action. Assignments also 

make change a part not just of counseling, but of everyday life, and they keep change as an “up

front” activity in the client’s mind. When giving assignments, it is useful to: 

1. Make sure the tasks are attainable in the time period of the assignment and, to the extent possible, can be repeated several times during the assignment period. 

2. Try not to overload the client with too much to do, so the task does not seem overwhelming. 

3. Make tasks behaviorally specific and measurable, a “to-do” rather than a “not-to-do” list. 

4. Have clients record their successes and difficulties in achieving the tasks. 

 

 

 

 

 

 

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Master Clinician Note: The counselor resists assuring Troy that meeting with the 

psychiatrist won’t cause his kids to be taken away. It is important that the counselor 

never promise outcomes that are out of his control. The counselor can support the 

client (as shown here) to take constructive action to obtain a positive outcome. 

COUNSELOR: I know you’re reluctant to see Dr. Moore, but I’m concerned about how stressed 

you are. This may affect keeping your home and your kids. Meeting with Dr. Moore could help

with that. 

TROY: Yeah. Okay. When do I need to go? 

COUNSELOR: I’d like to get you in as soon as possible. I’ll call and see if there’s anything on 

Monday morning or, if not, as soon as possible. Okay? 

TROY. All right. When will I know? 

COUNSELOR: I’ll call now. Give me a couple more minutes. 

[The counselor calls and arranges the psychiatric consultation for the following Tuesday morning

at 10 a.m. After passing along the information to Troy, he engages Troy in problem-solving about

staying abstinent, not having friends over late at night, not being around people who are using,

being especially careful during times when he is feeling stressed or hopeless, and particularly, going to AA again. Troy engages in the problem-solving efforts with the counselor, and the counselor helps Troy identify strengths to address each of these issues. He is reluctant to return to AA; 

he says he quit going because his sponsor was putting too much pressure on him to complete his 

work on the program steps and because his best friend in the program had “gone out,” which

Troy found really discouraging. He did agree to a noon meeting later in the week, while his boys 

were in school. Troy also agreed to ask his mom, who lives in the neighborhood, to babysit while 

he attends a meeting on Saturday night. The counselor and Troy talked about how he would respond if he ran into his program sponsor, and they developed several options for this scenario. 

The counselor continues to be sensitive to Troy’s potential for becoming overwhelmed with too

many issues and defers other issues (parenting, employment) until future sessions. 

In closing, he reinforces Troy’s assignments of not being around people who are using, not staying

up late at night (even if he is not sleepy), staying abstinent, and attending AA. Together, they

make a list of things Troy is to do and behaviors that will make it easier to accomplish them.] 

­

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Visit 4 (counselor’s office) 

The counselor’s goals for this session are to: 

• Follow up on Troy’s psychiatric consultation. 

• Follow up on how abstinence is progressing. 

• Check on how Troy is doing with his sons. 

• Ask Troy about his plans to resume employment. 

Troy arrives on time and looks somewhat less distressed and tired than he has on previous visits.

He reports that his visit with the psychiatrist went well and that he liked Dr. Moore. The doctor 

had already reported to the counselor that he thought Troy’s difficulties in focusing on tasks, not

sleeping, feeling overwhelmed, and not thinking clearly were more a function of stress and alcohol and drug use than depression. He did not recommend medication but suggested that he 

would be glad to reevaluate Troy if he continued to have difficulties in thinking, feeling overwhelmed, or completing tasks. For more information on depression and substance abuse treatment, see TIP 48, Managing Depressive Symptoms in Substance Abuse Clients During Early 

Recovery (CSAT, 2008). The session continues as Troy talks about a meeting with the teacher of

his 8-year-old son, Jimmy. 

TROY: I had another meeting with Jimmy’s teacher. 

COUNSELOR: How did that go? 

TROY: Well, he’s having some anger problems in school, and he’s been getting there late. Actually, both of them are getting there late. 

COUNSELOR: Tell me about that. 

TROY: Well, they take a long time to get out of the house. They aren’t exactly cooperative all the 

time, you know? It’s hard to pull ’em out of bed in the morning; I oversleep a little bit myself. 

COUNSELOR: Okay. 

TROY: I talked to Dr. Moore a little bit about it, and he said that maybe you guys could help. 

COUNSELOR: There are some things we can do to help. For example, you said sometimes you 

guys oversleep. We can work out a better way to manage that. 

TROY: Okay. 

COUNSELOR: What time are they supposed to be in school? 

TROY: They gotta get there at 8:30. 

COUNSELOR: Okay, 8:30. What time were you getting them up when they were getting there 

late? 

TROY: I don’t know. I’d try to get them up around 7, but they’d get up at 8 or so. 

COUNSELOR: It does take them a while to get ready for school, and they have to be there at

8:30. How far is school from your home? 

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TROY: About 15 minutes. 

COUNSELOR: 15 minutes. So, you’re going to need to have at least 15 minutes to get them to

school. What else do you do in the morning before leaving for school? 

TROY: Well, they eat breakfast, usually cereal. I try to get them up around 6:30 or 7. 

Master Clinician Note: The counselor’s technique is called cognitive structuring. He 

uses questions to model and encourage problem-solving about how Troy can more 

satisfactorily manage his time. The counselor also distinguishes Troy’s intention 

(waking at 7:00 a.m.) from the reality (waking at 8:00 a.m.). 

COUNSELOR: So let’s say you get them up at 7:00. You need 15 minutes to get to school, so

that leaves an hour and 15 minutes to dress and feed them. Can you do that? 

TROY: I can do it. 

COUNSELOR: So, can we make a plan for that? Today is Wednesday, so for 2 more days of

school— 

[The counselor writes up a schedule for Troy to follow in the morning. Troy reads it and agrees 

that he will try it out. Troy then changes the subject to his kids.] 

TROY: I get a real hassle from the boys. They fight me, and they fight each other. 

COUNSELOR: What do you think they need? 

TROY: Oh, I don’t know. I guess I fought with my brothers every day when I was a kid, too. 

[The counselor continues to explore the issue of the children’s behavior with Troy, and they decide that if things don’t get better in a month or if things get worse in the interim, they’ll look 

into counseling options for the boys. The counselor is reluctant to jump right into seeking counseling for the boys, expecting that things might get better if Troy stays abstinent and the home

situation stabilizes.] 

COUNSELOR: Troy, I would like to raise the possibility with you of having the boys participate 

in some after-school activities at the Boy’s Club right down the street from our center. They have 

a bunch of good programs, including sports, helping them with homework, and giving them 

some time to socialize and play with other kids. Plus, it would give you some extra time away 

from having to watch the boys to get some stuff done. So, I’m wondering if you would be willing

to drop by there and see what is available that might be right for your boys and consider it. 

TROY: Well, I could do that. I know where it is; I used to walk by it every day. I never knew 

what they did in there, other than play basketball. 

COUNSELOR: Well, actually, they do a lot of things, and some might be helpful to you and to

your boys. 

TROY: Okay, I’ll look into it. 

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Brief Strategic Family Therapy 

If the children continue to show behavioral problems in school, the counselor might consider adapting an evidence-based practice, brief strategic family therapy (BSFT). Although Troy’s sons are a bit 

younger than the typical age when BSFT is applied, it might prove helpful. 

BSFT is designed to (1) prevent, reduce, and/or treat adolescent behavior problems, such as drug 

use, conduct problems, delinquency, sexually risky behavior, aggressive/violent behavior, and association with antisocial peers; (2) improve prosocial behaviors, such as school attendance and performance; and (3) improve family functioning, including effective parental leadership and management, 

positive parenting, and parental involvement with the child and his or her peers and school. BSFT is 

typically delivered in 12 to 16 family sessions but may be delivered in as few as 8 or as many as 24 

sessions, depending on the severity of the communication and management problems within the 

family. Sessions are conducted at locations that are convenient to the family, including the family’s 

home in some cases. Hispanic families have been the principal recipients of BSFT, but African American families have also participated in the intervention. 

BSFT considers adolescent symptomatology to be rooted in maladaptive family interactions, inappropriate family alliances, overly rigid or permeable family boundaries, and parents’ tendency to believe that a single individual (usually the adolescent) is responsible for the family’s troubles. BSFT 

operates according to the assumption that transforming how the family functions will help improve 

the teen’s presenting problem. BSFT’s therapeutic techniques fall into three categories: joining, diagnosing, and restructuring. The therapist initially “joins” the family by encouraging family members 

to behave in their normal fashion. The therapist then diagnoses repetitive patterns of family interaction. Restructuring refers to the change-producing strategies that the therapist uses to promote new, 

more adaptive patterns of interaction. For more information, see the BSFT Web site 

(http://www.bsft.org). 

 

 

Part 1, Chapter 2 

COUNSELOR: Troy, I just want to be sure your rent situation is taken care of for now. Where 

do we stand with that? 

TROY: Well, I think it’s okay. I have emergency assistance that has paid what I owed for the past 

2 months, and I’m current now. Section 8 housing has reduced my rent because I’m unemployed, 

but, you know, this #*%! public assistance doesn’t really pay for crap. I got these two kids I gotta 

keep going. I’m not a rich man! I’m just not making ends meet. 

COUNSELOR: Do you think you’re ready to look for a job? You think you can handle that right 

now? 

TROY: I don’t know if I want to go back to work right away, because then I got a problem on 

the other end; we sometimes work until 6 at night. What are the kids gonna do for 3 hours? 

COUNSELOR: Okay, let’s work on child care if you need that. We need to make a plan that’ll 

help you in the long run, so when you work and can’t get home on time, the boys will still be 

cared for. 

TROY: Does that mean they’re gonna take the kids away from me? 

COUNSELOR: No. This is all about helping you. We have a temporary childcare program here 

that will help you for up to about 2 months. That’s the longest they will help you. It allows us to

develop a plan for you. One option is for your mom to keep the boys in the afternoon. We did

talk about your mom; you were concerned about the money you owed her. 

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TROY: [worried] Yeah. We’re not talking much. 

COUNSELOR: Tell me about when you were being raised up. Did you ever do anything that 

may have upset your mother? Like miss school, and she caught you, and she was upset about it? 

TROY: Yeah. Well, we had our days. 

COUNSELOR: And after those days happened, was your mom still talking to you? 

TROY: Yeah. Yeah. I mean she’s—yeah, she’s all right. 

COUNSELOR: So she continued to talk to you? 

TROY: [sounds anxious] Yeah, but like, you know, I’m trying to do the best that I can. I gotta 

show her that I’m doing my thing, but I owe her all this money. 

COUNSELOR: Do you think she would be proud of your being able to take care of a lot of the 

things you have taken care of, like your housing? 

TROY: Yeah. Yeah. I see where you’re going with this. I still feel kinda uncomfortable. You know, 

I don’t feel so good about this, but maybe, maybe... 

COUNSELOR: Okay. Let me ask you this. Let’s practice for a few minutes what you might say 

to your mom and how she might respond. Then, what if you called your mom from here at the 

office to see if you can make some headway in how y’all get along. Do you remember how we did 

role-play when you were here in treatment? 

TROY: Sure, I’d go with that. 

COUNSELOR: Okay, let’s start with you being your mom, and I’ll be you. And talk to me, as if 

I’m Troy, about how you feel about me and how things have been going. I want you to really listen to your mom, see what she says. You may be surprised; she may be supportive, strong, and not

worried much about the money. And I want you to hear what her concerns are about how you are 

doing and what she expects of you. 

Master Clinician Note: Role-play is an excellent counseling resource for helping 

clients prepare for difficult interpersonal situations. A description of how to set up a 

role-play and how it can be used is presented in the next vignette (René). 

[Troy and the counselor proceed to role-play an interaction between Troy and his mom. Afterward, Troy believes that he understands more of where she is coming from and can more comfortably talk with her about the money he owes her and about her helping with child care.] 

COUNSELOR: Let me change the subject for a minute and ask you how you are doing with not

drinking or smoking weed. 

TROY: Well, I had one beer the other evening, standing around outside with some other guys,

and then I got to feeling bad about it. I had 9 days put together. But I know from here and AA

that a beer is a beer. But that is all I’ve had, and no dope now for almost 2 weeks. 

COUNSELOR: What about AA? 

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TROY: I’ve been twice, both to noon meetings because I didn’t have anyone to watch the kids. I 

didn’t see my old sponsor either time. I guess when I run into him, we’ll have to get straight with 

each other. 

[The counselor and Troy continue to talk for a few minutes about the need to remain clean and

sober. They discuss the people, places, and things that might provoke a return to use. The counselor is supportive of Troy in finding alternatives to drinking or smoking marijuana.] 

COUNSELOR: Okay. I appreciate all the hard work you’ve put into this. I think you’ve done a 

lot. I think you’ve made some positive changes. Do you agree with that? 

TROY: So far, so good. 

COUNSELOR: Okay, so what if we continue to meet once a week? If and when you get your

roofing job back or another job, we’ll look at how we can arrange counseling around your schedule. I remember that Carl often lets people take off an hour or two around lunch if they are going

to a counseling session. And I think we have goals and priorities pretty set now: staying clean, 

keeping your housing, helping the boys get settled, handling stress and life problems, managing

your finances, and getting back in good graces with your mom. Does that pretty well handle it? 

TROY: Well, I’m better off than I was a month ago, that’s for sure. 

Summary 

Troy experienced a number of significant stressors that were aggravated by marijuana and alcohol

abuse and his difficulties in coping with stress. On presentation, Troy was in the action stage of 

change for keeping his housing and his kids and the contemplation stage of change for drinking

and marijuana use. The counselor used a variety of techniques and multidisciplinary tools (for

instance, consultation with the staff psychiatrist, referral to AA, supportive problem-solving, cognitive structuring, and role-play) to help Troy move ahead in the stages of change for addressing

his marijuana and alcohol use and other life difficulties. Future sessions will focus on child care,

improving parenting skills, preventing relapse, and maintaining his job. Long-term goals include 

helping Troy:

•	 Maintain stable housing through the Section 8 voucher program. 

•	 Reduce his negative thinking and increase his hope and planning for the future. 

•	 Maintain contact with his family for help with child care and recovery activities. 

•	 Identify funds that he can use to pay his mother for helping with the kids. 

•	 Identify after-school programs so his children can stay at school while he’s working. 

•	 Support stable continuation of recovery using agency resources and self-help programs. 

•	 Continue to develop effective coping and parenting skills, problem-solving abilities, and

stress management techniques. 

Vignette 5—René 

Overview 

René is in the transition planning/ongoing homelessness rehabilitation phase. This vignette

demonstrates approaches and techniques for substance abuse relapse prevention. 

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René is a 44-year-old man in intensive outpatient (IOP) treatment for heroin dependence. He 

relapsed once during treatment but recovered and got back on track quickly. His treatment program ends in 3 weeks, and he needs a new place to live—his current apartment is attached to the

program. The stress of the impending transition contributed to his relapse. René used heroin after his last paycheck, but he did keep his job. He has a history of intermittent homelessness. His 

job doesn’t pay well but offers benefits. He’s a good fit for a sober living facility, which offers

quality housing and social and abstinence supports. 

Setting 

Working in a substance abuse treatment organization’s intensive outpatient program, the counselor offers case management and counseling services for transition into ongoing homelessness rehabilitation services and independent housing. 

Learning Objectives 

•	 Use counseling methods that support positive behaviors as objectively defined goals consistent with recovery and stable housing. 

•	 Help client identify and change behaviors that are not conducive to meeting objectively defined recovery goals. 

•	 Teach the client relapse prevention and life skills. 

Strategies and Techniques 

•	 Conceptualizing behavioral change activities oriented toward substance abuse recovery as

therapeutic goal management 

•	 Coping skills training conceptualized as short-term goals agreed to with clients to accomplish

longer-term sustained behavior change 

Counselor Skills and Attitudes 

•	 Recognize and address underlying problem behaviors that may impede the client’s recovery 

and housing stability. 

•	 Facilitate the client’s identification, selection, and practice of strategies, especially goal attainment, to sustain the knowledge, skills, and attitudes needed for maintaining recovery and

housing. 

•	 Recognize the importance of continued support, encouragement, and use of reinforcement

and contingency management. 

Vignette 

Visit 1 (counselor’s office) 

The counselor has worked with René throughout his time in the IOP program. He’s abstinent

but nervous about the future. The counselor begins the first session with these goals in mind:

•	 Conceptualize René’s recent relapse. 

•	 Encourage him to increase his attendance at Narcotics Anonymous (NA) meetings. 

•	 Discuss his housing options. 

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The counselor greets René and asks how he’s been. René is in a tough spot, having relapsed while 

preparing to transition out of the program. If he didn’t trust the counselor, he might respond with 

“I’m okay, I can deal with it,” but they have good rapport. René believes she’ll help him, so he offers an opening for help. 

RENÉ: Man, life has been crazy. Working on that bull#*%! job, it ain’t payin’ nothing. I really 

don’t have no clue what I wanna do in about 3 more weeks. My girl, she’s trippin’. 

COUNSELOR: It’s a lot. I mentioned a halfway house and a sober living facility as steps toward

building some quality sober time. What do you think? 

RENÉ: I don’t know about that #*%!. I want my own spot, you know? 

COUNSELOR: I understand that you’d like your own apartment, and I hope we can work toward that. 

RENÉ: #*%!, it don’t make no difference! I don’t make enough money. I don’t know what I’m 

gonna do. 

COUNSELOR: Well, would you be able to accept the goal of moving to a halfway house, and

then, when you have another 60 days under your belt, we can talk about moving into a sober living house? We could talk about how you’d deal with that time in the halfway house. 

Master Clinician Note: The counselor should be aware of local housing options, 

including single room occupancy housing, shelters, halfway and transitional living 

houses, sober houses, Housing First, and other community housing opportunities. 

Each meets a specific housing need, and all have unique requirements for 

participation. Some have no financial requirements; some, such as sober housing, 

involve a fixed monthly rent based on ability to pay; and some require an 

agreement to pay a percentage of earned income. Some have no requirements 

about drug use or maintaining sobriety, but others require abstinence from alcohol 

and any illegal or illicit drugs. Some are for relatively short periods of time and 

others are ongoing. Each meets a unique need in the community. 

RENÉ: I don’t want that #!*%!. I had lots of time in that kind of by-the-rulebook living. I guess 

it’s my fault, but I ain’t making no money on that job. 

COUNSELOR: You’re thinking it’s your fault? This situation? 

RENÉ: Yeah, ’cause I been shooting dope for a long time. This #*%! may not even work for me. I

probably waited too long, you know? 

COUNSELOR: Well, René, I really hope you will work toward getting your own place. 

RENÉ: Aw man, that #*%! is crazy. I’m tired of living with other people. You know how them 

places are? 

COUNSELOR: You’ve done really well here. Except for that relapse, you’ve managed to use the 

program to your advantage. Can you allow yourself to feel good about that? 

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How To Help a Client Identify Triggers for Relapse 

Working on relapse prevention is a good way to help many clients maintain housing. Identifying triggers is one way to start, and this can be done in several ways. Be respectful and kind; this conversation tends to evoke shame in clients: 

1. Open with, “Tell me about what happened the last time you relapsed.” The point is not to get a 

list of the triggers your client already knows about, but rather to really understand what happened this time. 

2. Ask the client to look back in time to identify each choice point that led to the relapse. 

3. Keep going back until you reach the point where the client veered from the recovery pathway 

into relapse. The choice point may be earlier than the client thought, or it may be a feeling he or 

she is reluctant to talk about. If it’s a feeling, identify the thought that led to the feeling. 

4. Help the client brainstorm and practice ways to handle the situation or feeling the next time. 

Role-play helps clients practice coping skills and develop a sense of mastery. It also increases 

self-esteem and provides further motivation to continue the recovery process. 

For more information on identifying and addressing triggers, see the planned TIP, Recovery in 

Behavioral Health Services (SAMHSA, planned e). 

 

 

 

 

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RENÉ: Yeah! I’d never been clean very long before, so I’m real happy about that. But I think 

maybe this is the best it’s gonna get for me. 

COUNSELOR: If this is the best it’s gonna get for now, let’s talk about how you’ll handle it. 

RENÉ: #*%!. I don’t know how. 

COUNSELOR: Well let’s talk about that relapse you had. What happened? I’m sure you’ve reviewed this in your treatment groups. We talked about this before, but let’s just go over it again. 

RENÉ: It was kind of a blur. I got off work and those dudes wanted to go out. They act stupid

every time they drink, so I didn’t wanna go with them. I was walking back to my place thinking 

about all this stuff that’s going on, and I seen Cheryl and we started kickin’ it. Next thing I know, 

I’m shooting dope. 

COUNSELOR: So you got paid, you saw your girlfriend, and sort of went off. 

RENÉ: Yeah. Now that I think about it, I can’t remember many times that I’ve had sex without 

using. Maybe I don’t think I can perform without dope. I don’t know how, but that #*%! comes 

together for some reason. 

Master Clinician Note: René has had this trigger for a long time. It’s important to 

address it because it’s a powerful trigger for relapse. The counselor can reflect what 

he’s struggling with, ask about how he can be helpful, and go back farther to 

identify relapse triggers that happened earlier than this one. 

COUNSELOR: So the main feeling that you’re working toward is that feeling you have when
 

you’re high and having sex? So it’s hard to imagine life without that?
 

RENÉ: Yeah. I guess so.That could be it.
 

COUNSELOR: Have you had sex with your girlfriend without being high?
 

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How To Help Clients Appreciate the Progress They Have Made 

You can help clients like René, who are mired in feeling one step away from homelessness, see how 

far they have come (general strategies applicable to all clients are followed by specific examples taken from René’s case): 

• Elicit information about the changes they’ve made in their lives (e.g., by asking René, “What 

makes this temporary move different from all the other moves you’ve made in the past 20 

years?”). 

• Shift focus (e.g., by saying to René, “Let’s think of some things you could do that wouldn’t lead to 

meeting Cheryl and getting high.”) 

• Reinforce recognition of triggers and insights (e.g., that René is scared about becoming homeless 

and having so much going on); unlocking triggers will help clients along the road to recovery. 

The goal is to boost clients’ self-confidence, which will continue to rise as they put together additional successes. 

Part 1, Chapter 2 

RENÉ: Yeah, a couple times.
 

COUNSELOR: And how was it?
 

RENÉ: We really couldn’t do the #*%! that I’m accustomed to doing, you know?
 

COUNSELOR: Um-hum. Was she high?
 

RENÉ: Yeah.
 

COUNSELOR: She was high and you weren’t.
 

RENÉ: I wasn’t. You can’t really enjoy yourself or have the fun you wanna have, so you need


something else to help you really enjoy it. Then you add on top of that the #*%! I’m going
 

through. It could be one of a thousand things. It could be that I’m about to be homeless. Maybe 


that’s it, and I don’t wanna do that #*%! no more. I know when I’m loaded I can hustle and get
 

some money and take care of my business.
 

COUNSELOR: So it’s pretty hard to find a substitute for that, and yet you have just said the 


fear of being homeless again almost is enough for you to imagine you can give it up.
 

RENÉ: Yeah, the thought of that alone makes my stomach hurt. Have me where I can’t breathe.
 

You’re asking me to see 6 months down the road.That’s too long. Everything I do, I need immediate results, immediate. I go steal something, immediately I sell it. So waiting 2 weeks for my 


check, I’m struggling with that, because for years, I didn’t have to delay nothing. And relationships—the first thing that I’m gonna do is get in a relationship, but in treatment and self-help
 

groups, they tell you not to.
 

COUNSELOR: So, René, is it fair to say the first thing you want to do is enjoy yourself?
 

RENÉ: Yes.
 

COUNSELOR: The first thing you want to do is have fun, and right now, it’s the old ways of
 

having fun that you’re thinking about. You’re not aware of the new ways.
 

RENÉ: I don’t know any new ways of how to really enjoy myself.
 

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COUNSELOR: I understand it has been a long time since you enjoyed much of anything without being high. I’m wondering if there is anything you have enjoyed here in the treatment program—the groups, visiting with other people, helping someone out, something like that. 

RENÉ: Man, that ain’t FUN. That’s just hanging out. 

COUNSELOR: So it seems like things have to be high energy, high excitement to really be fun. 

RENÉ: Maybe so. Otherwise it just seems boring. Like living in a damned halfway house or

something. 

COUNSELOR: Could we look for a minute at what would be fun that isn’t bad for you in the 

long run? 

RENÉ: Man, I don’t know. 

COUNSELOR: Well, it seems like we’ve raised several issues to work on here over the long haul.

The first is how to have fun without it having to be high energy or high risk. The second is how 

to have some high-energy fun sometimes without getting into stuff that is destructive for you,

like getting involved with drugs or maybe with Cheryl. The third may be to recognize when you

are having fun and enjoying something that’s just an everyday thing. 

RENÉ: Man, that’s high-level #*%!. I’m not sure I’m ready for that stuff. 

[The counselor is satisfied to have raised the issue of how René conceptualizes having fun for

right now. René has given a clear message that he is ready to change the topic. The counselor respects René’s wishes and moves on to another topic raised by René earlier.] 

COUNSELOR: Well, you said that the worst possible thing is to become homeless again. 

RENÉ: Yeah, I know once I become homeless, I’d probably be going crazy. I lose my place, I go

back on the street, I shoot dope and end up back in prison. And the nights are very scary. 

COUNSELOR: You have been in this program for several months, and you haven’t relapsed. 

Master Clinician Note: This is an example of strengths-based counseling: the 

counselor affirms René’s strengths, eliciting that one of his strengths is the ability to 

derive support from his counselor and people in recovery. This, in turn, supports 

René’s adaptive coping mechanisms. 

RENÉ: Well, I don’t wanna go back to prison. And then I was able to talk to you and the people 


in treatment. I have them for support, so...
 

COUNSELOR: So that is one way you helped yourself out of homelessness. [René is looking
 

away.] I feel like I’m losing you because you’re looking away. Can you look me in the eye?
 

RENÉ: Yeah, that’s kinda hard.
 

COUNSELOR: Why is that kind of hard?
 

RENÉ: Uh...
 

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COUNSELOR: Is it hard because I’m female and we’re talking about intimate things? 

RENÉ: [tearful] Well, I don’t feel good about it, you know. I’m supposed to be way past this, but 

it seems like I’m just spinnin’ my wheels. I’m not getting anywhere. 

Master Clinician Note: The shame that René is feeling can be challenging to a 

counselor. In this case, the counselor stays with it long enough to let René feel it. 

Then she reframes it as progress and helps him look forward to what he wants to 

do. As with all interventions, it is important that this intervention be handled in a 

culturally appropriate manner. 

COUNSELOR: I’m hearing that you’ve come a long way and that you’ve had an idea now about 

what are probably some of your most difficult triggers, but you’ve got your finger on it. 

RENÉ: Well, what’s that? 

COUNSELOR: We’re talking about Cheryl and payday and when she calls. And also about fearing homelessness and getting fearful and then wanting to go out and use. I think you understand

that it’s what you have to do to get to where you want to be. You think to yourself, “I didn’t like 

relapsing. I don’t want to be homeless again.” And yet here’s this temptation in the form of your 

girlfriend. So what else can you do on payday when she’s calling? 

RENÉ: I need to quit that. That’s for #*%! sure. If I wanna get myself in my own apartment, I’m

gonna have to struggle with that, to not hang out with her. 

COUNSELOR: So, how are you going to tell her? Or are you going to tell her that? 

[They discuss whether and how René will be able to make a break with Cheryl.] 

COUNSELOR: Well, how about trying that. Just not call her and not see her. Do you think 

that’ll work? Can you give it a try and we’ll see how it goes? 

RENÉ: Yeah, maybe. I’ll give it a try. 

COUNSELOR: Now, what about these friends? The guys out on the street that hang out and

want you to join them. We’ve talked a lot about that all through the program. It’s real hard to 

hang out on the corner with all those guys who are high and not use. 

RENÉ: Really, my friends are all in prison, so, it’s hard for me to make friends. I probably need to 

try and meet some other friends. I really don’t like the guys at NA. They’re like, “You can’t do 

this, you can’t do that.” I wanna be able to do everything anybody else does. 

COUNSELOR: Well, if you’re going to stay clean, you’re going to need a good support system. 

You’re talking about doing something that’s difficult. It’s payday, and you’re trying not to have any

contact with your girlfriend. There are people hanging around saying they want to be your friend

because you’ve got a paycheck. 

RENÉ: Yeah. 

COUNSELOR: So, what other people are there—people to hang with and have a good time 

with who won’t point you in the wrong direction? 

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RENÉ: You know, I really don’t have any fun with nobody but people that are active users.
 

COUNSELOR: Are you going to meetings?
 

RENÉ: Yeah, I go to meetings.
 

COUNSELOR: How often do you go?
 

RENÉ: About 3 times a week.
 

COUNSELOR: What would you think of increasing that?
 

RENÉ: Honestly? Yeah, I know I need to go more. My sponsor tells me I need to go more.
 

COUNSELOR: How often does your sponsor say you need to go?
 

RENÉ: If you asked him, he’d say 7 days a week.
 

COUNSELOR: That sounds like it might be a good idea.
 

RENÉ: That’s way too much. It’s bad enough sittin’ in those meetings. But, that could be an option. It’s only an hour. So, how about this halfway house you were talking about?
 

COUNSELOR: Well, it’s warm, it’s got beds, meals, a bunch of guys who aren’t using on site. It’s
 

not treatment, everybody takes part in taking care of the house, and if you’re interested, they can
 

help with things like getting a better job. It’s not treatment, but it’s a safe place for another 30 or 


60 days; after that, we can maybe get you into a sober living house.
 

RENÉ: How long would I have to stay there in sober living before I get my own place?
 

COUNSELOR: Well, it is going to be a while, probably at least a year or two, before you have a


steady income and are back on your feet. You want to go by and check it out?
 

RENÉ: I guess we can go by and take a look at it.
 

COUNSELOR: I think the other thing we’ll do is to plan to meet pretty often between now and


your discharge time a couple weeks from now.
 

RENÉ: Yeah, that would be good, because I have more of a relationship with you than I have


with anybody else. I feel comfortable talking to you about these kinds of things.
 

COUNSELOR: When is payday?
 

RENÉ: Uh, next week.
 

COUNSELOR: So, let’s start with that day. What do you want to happen?
 

RENÉ: I really don’t know.
 

COUNSELOR: What did you say before? Let’s talk about how it can be different from other
 

paydays.
 

[René and the counselor create a plan for payday, which includes avoiding Cheryl, buying something with his money so he won’t be tempted to use it to buy drugs, and going to the movies and 


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getting something to eat as a fun, substance-free recreational activity. René agrees to consider

staying at a halfway house after he leaves the IOP housing, to attend sessions three times a week,

and to continue to give urine screens.] 

Visit 2 (counselor’s office) 

René had an insight about why he has been stuck and risking relapse, and he seems ready to try 

out some ways to avoid further relapses. The counselor has the following goals:

•	 Review how René handled the weekend. 

•	 Assess his current ability to effectively manage high-risk situations like running into his exgirlfriend. 

•	 Practice refusal skills and other appropriate skills as needed. 

The counselor asks René about payday; he says he didn’t see Cheryl. He bought a cell phone, got

some food to eat, and saw a movie. The counselor reinforces this achievement and asks René to

tell her about it. 

RENÉ: Well, it was a lot of work, because I was thinking about it the entire night before. I was 

thinking about what I was gonna do when I get my check and how I was gonna do it, so it wasn’t 

easy. How not to go see Cheryl, what if I do see her? The more I tried not to think about seein’ 

her, the more I thought about seein’ her. So, it was good we talked about it in advance, because it 

was a struggle not goin’ into the store to cash my paycheck. But, I went to the cell phone store

instead. I kept telling myself, “Hey, look, I’m goin’ to get me a cell phone, you know, and that’s 

what I’m gonna do.” 

COUNSELOR: Did you have the thoughts of being homeless, being back in jail? 

RENÉ: No, because if I have thoughts about that, I’d have to see Cheryl. 

Master Clinician Note: The counselor notes the connection between Cheryl as a 

relapse trigger leading to René’s being homeless. She decides not to present this to 

René right now because it would lead their discussion in a different direction. The 

counselor wants to stay focused on managing high-risk situations, building refusal 

skills, and building other strengths. 

COUNSELOR: Okay, so, the fact that you got through that day is very commendable. And now 


it’s about having more clean time, building that into the future.
 

RENÉ: Yeah, it kinda put it into perspective—one day at a time.
 

COUNSELOR: I think we do need to deal with the fact that your ex is going to try to find you.
 

RENÉ: Yeah, I’m sure she is. Matter of fact, I know she is.
 

COUNSELOR: So, in a couple more days, you’re getting another paycheck, and this time she’s 


going to say, “I’m not letting that guy avoid me this week!” So I thought maybe we should play it


out a little bit. So, can you put yourself in her shoes and pretend you’re her?
 

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Master Clinician Note: In this situation, role-play can help René experience the 

immediacy of feelings he will face when he sees his ex and rehearse a plan to 

manage these feelings while interacting with her. The counselor and René will roleplay twice. The first time, the counselor will play René and model behavior. The 

second time, René will be himself in the role-play. René is already familiar with roleplays because they use them in the treatment program. When introducing roleplaying for the first time, you should expect that the client may feel silly or 

uncomfortable. Reinforce communication of this discomfort and provide an 

explanation for the purpose of the role-play. For more information about 

conducting a role-play, refer to the planned TIP, Recovery in Behavioral Health 

Services (SAMHSA, planned e). 

RENÉ: Yeah, because she’s been bullyin’ me for a while.
 

COUNSELOR: Okay, so we’re going to take ourselves to the store. Okay, the usual thing that


happens is you have the check, you go to the store.
 

RENÉ: Cash my check. Get me an iced tea and a couple of scratchers.
 

COUNSELOR: Okay, and there she comes. She pops in. So, I’m going to be you and you’re going to be Cheryl. Okay?
 

RENÉ: Okay.
 

COUNSELOR: So here I am as you, I’ve got my check and I buy my tea and scratchers, and I’m 


heading out to figure how to use that cell phone better and think about a movie, and there you 


come. Go ahead.
 

RENÉ/CHERYL: Hey, René, what ’cha doin’?
 

COUNSELOR/RENÉ: Hey, Cheryl, just, uh, mindin’ my own business. Just gonna go hang out.
 

RENÉ/CHERYL: Win any money on that scratcher?
 

COUNSELOR/RENÉ: No, not this time.
 

RENÉ/CHERYL: Well, you gotta be in it to win it. You win a million dollars, what ’cha gonna
 

do?
 

COUNSELOR/RENÉ: Get as far away from here as I can.
 

RENÉ/CHERYL: Gonna take me with you?
 

COUNSELOR/RENÉ: Cheryl, I gotta live my life without you. I can’t have you in my life. I
 

know that you didn’t see me last weekend and you probably thought, “Well, he forgot about me 


this week,” but you can’t go with me any longer.
 

RENÉ/CHERYL: Quit playing, René. #*%!, you know you love me.
 

COUNSELOR/RENÉ: I can’t do it, Cheryl.
 

RENÉ/CHERYL: You know you like me!
 

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COUNSELOR/RENÉ: Can’t do it, Cheryl.
 

RENÉ/CHERYL: Ain’t nobody gonna treat you the way I treat you.
 

COUNSELOR/RENÉ: I like the way you treat me, Cheryl, but I can’t go back down that road.


Seeing you, I see drugs, I see love, I see sex, I see disappearing into some bedroom with you. I’m 


never getting back from there, or goin’ in there with you again.
 

RENÉ/CHERYL: Well, what do you want me to do? Maybe I don’t want to live my life without
 

you. Did you think of that?
 

COUNSELOR/RENÉ: I gotta take care of myself. I don’t know whether I can tell you what you 


can do for yourself, but I know for myself that you gotta get out of my life, and I gotta get you


out of my life.
 

RENÉ/CHERYL: [forlorn] Look, I feel lonely, baby.
 

COUNSELOR/RENÉ: I’m going. I’m gonna go back to that telephone store, I’m gonna learn
 

how to work this thing, I’m gonna pick out a—
 

RENÉ/CHERYL: Oh! so you think you’re too good for me now! You go to a treatment program,
 

you get on this high-ass horse; you get a few dollars for bus fare, and now you too good for me!
 

COUNSELOR/RENÉ: No, I don’t think I’m too good for you. I just can’t be this close to you 


anymore.
 

RENÉ/CHERYL: You talk that #*%! about you care about me, and all that!
 

COUNSELOR/RENÉ: I’m done. I’m gone.
 

Master Clinician Note: The counselor models imperfect responses and struggles a 

bit so the client doesn’t end up thinking “I could never do that!” 

[The first role-play ends, and the counselor and René return to being themselves.]
 

COUNSELOR: Okay, René, how did you think that went, that little exercise that we just did?
 

RENÉ: I see she really don’t care about me. She’s just an addict. When she said “you think you’re 


better than me,” I believe that I’m better than the dope game. I work hard not to be a dope fiend,
 

so, yeah, I’m better than her.
 

COUNSELOR: Okay, well, you gave me a hard time during that. It was tough to walk away.
 

RENÉ: Cheryl would probably create a scene in that store, and I probably would have had to


leave—that’s the only way you can deal with it.
 

COUNSELOR: Okay, how about we reverse it now, and I’ll be Cheryl, and you be yourself.
 

RENÉ: All right.
 

COUNSELOR: So, you’re coming out of the store, and here I come.
 

COUNSELOR/CHERYL: Well, hey there, René, where ya been?
 

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How To Follow Up Role-Play 

In an individual session 

1. Keep having the client do brief (2 minutes or less) role-plays to build confidence that he or she 

can do it. 

2. If the client shows inability to follow through (e.g., the client gives in), one appropriate response 

would be, “Well, that didn’t go so well, what do you need to do the next time to walk away?” 

In a group session 

When using role-play in a group, the clients are often much tougher than the counselor. When the 

client is successful in coping under these conditions, he or she has gone through both an emotional 

and a behavioral experience. Following the role-play: 

1. Ask the person playing the client what he or she did well first; then ask, “How could you do it 

better?” 

2. Ask the clients in the group what they thought went well and what could have been done better 

without repeating what someone else has observed. 

3. Summarize the most important feedback: “Here’s what the group said you could’ve done; let’s 

do it again.” 

4. Repeat brief role-plays (about 2 minutes) until the client has a sense of mastery, and he or she is 

demonstrating an ability to handle the situation well. 

Very short, repetitive role-plays work best. Each time clients role-play, they learn something more. 

When they feel they’ve learned all they can, their sense of mastery has improved and they feel they 

are prepared to handle the situation. If clients experience craving at the end of the role-play, use this 

as an opportunity to teach them to manage cravings. 

Behavioral Health Services for People Who Are Homeless 

RENÉ: Hey, what’s up, Cheryl, how ya doin’? I don’t have time, girl, I’m on my way. I gotta go.
 

COUNSELOR/CHERYL: Hey, you know, you dissed me last week. I didn’t like that very much.
 

RENÉ: I ain’t never dissed you.
 

COUNSELOR/CHERYL: Did you miss me?
 

RENÉ: No.
 

COUNSELOR/CHERYL: Aw, come on now!
 

RENÉ: Cheryl, you don’t give a #*%! about me; all you interested in is dope and I—
 

COUNSELOR/CHERYL: [cooing] You know I love you, you know I love you.
 

RENÉ: Would you love me if I was broke?
 

COUNSELOR/CHERYL: Sure, I’d love you if you were broke. But, you know what? I got paid


today. I got us a room! Come on, come on, René. Let’s go.
 

RENÉ: No, no. I’m not cool with that.
 

COUNSELOR/CHERYL: Come on, I got some for us to share, baby.
 

RENÉ: No, no. I’m not cool with that.
 

COUNSELOR/CHERYL: I got some really good #*%! here, René.
 

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RENÉ: I can’t do that. 

COUNSELOR/CHERYL: Come on, come on! Let’s go, René. 

RENÉ: No. I’m not cool with that. No. I’ve had it. I’m outta here! [René gets up and walks away.] 

COUNSELOR/CHERYL: Come on, come on, René! You know we can feel good. 

[René agrees to go to NA more often and has practiced coping skills in case he sees Cheryl. In

the next session, it will be important to follow up on his use of these skills, explore how René 

manages his next encounter with Cheryl, and do more role-playing (if needed) to address any 

challenges that arise. He is ready to move into the boarding house and doesn’t feel as vulnerable 

to relapse.] 

Visit 3 (counselor’s office) 

René has decided he will stay in the halfway house until he is eligible to enter a sober living

housing unit. He completed the outpatient program last week and had to vacate his programprovided apartment. The counselor begins Visit 3 with the following goals in mind:

• Review his attendance and commitment to daily NA meetings. 

• Review relapse prevention coping skills. 

• Review skills he needs to practice for long-term recovery. 

The session begins with a review of how René is adjusting to the halfway house. 

COUNSELOR: All right, well, the past couple times we met, we’ve been talking about how 

things have gone on payday, and we did the role-play about what you’d do if you ran into Cheryl. 

RENÉ: Yeah, I really liked that. I saw her at a distance right before she saw me, so I got away. 

COUNSELOR: There you go. 

RENÉ: Yeah, I know, even though we went through that, you know, and I role-played, I really 

just want to keep myself from being in that position, so if I can see her first, I won’t come in contact with her. 

COUNSELOR: So, that’d bring up all kinds of feelings again. 

RENÉ: Yeah, not that I don’t know if I could deal with them or not, that’s not the real issue. If I 

can keep from dealing with Cheryl in any form, I’m okay. But I know I’m eventually gonna run 

into her. 

COUNSELOR: So, you’ve been going to your meetings? 

RENÉ: Yeah. That sponsor of mine, he’s crazy. He wants me to make a commitment, you know. 

I’m already working and #*%!, I can’t do that. He wants me to be the coffee person at the meeting, you know, go buy the stuff, go do my 4th step, make the commitment. 

COUNSELOR: So, what’s your reluctance about making the commitment? 

RENÉ: I don’t have time. I don’t wanna be the coffee person. 

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COUNSELOR: Okay. Well, at this time, you’re going to need as many places as possible to be 

that are good places for you to be. 

RENÉ: Yeah, that’s what he said, too. Safety. Responsibility. 

COUNSELOR: So, if it isn’t being a coffee person, what else can you build in right now? What

else are you doing besides the meetings and work and spending payday avoiding your girlfriend?

How is halfway house living coming? 

RENÉ: Well, it’s okay. Some of the people I knew in the program are there. I like playin’ chess, so 

I might start playin’ chess again. There is one guy in the house who says he will play with me. I 

really do have time to be the coffee person, you know. I guess that’s my own thing, not wanting 

the responsibility. 

COUNSELOR: Sounds like maybe you want to do it. Maybe you’re just talking yourself out of it. 

RENÉ: Yeah. 

COUNSELOR: It can be hard to make a commitment to another person. 

RENÉ: Yeah, this guy wants me to do it. When I say, “Why do I have to be the coffee person?”

he says, “Just be the coffee person.” He needs to tell me what I’m gonna get out of it. I don’t wanna just do it because he wants me to. 

COUNSELOR: Well, you’re always on time for appointments. You can keep an appointment. 

I’m wondering what it would do to how you think about yourself if you were responsible and dependable. 

RENÉ: Well, I just don’t think of myself that way.That ain’t me. 

Master Clinician Note: The counselor is helping René clarify how recovery-oriented 

relationships that include commitment and responsibility can be adaptive, healthy, 

and rewarding in contrast to his maladaptive relationship with Cheryl, his lack of 

responsibility in the past, and his reluctance to commit to anything. 

RENÉ: I may be getting to the point where I don’t need to go to meetings that often, you know?
 

COUNSELOR: So maybe you’re trying to get away from committing yourself to the meetings.
 

RENÉ: Well, #*%!, I don’t need to go 7 days a week.
 

COUNSELOR: Remember now, René, we’re working on finishing your 60 days in the halfway


house, then looking forward to moving into sober living. It’s going to be here sooner than you 


know.
 

RENÉ: Yeah, yeah.
 

COUNSELOR: You’re independent even in this, you know. And being in sober housing will be 


another step. In sober housing, there’s nobody cooking, just a few other guys around, doing their 


thing, no staff. You’ll be pretty independent.
 

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Master Clinician Note: The counselor senses that René has begun a significant shift 

in his thinking about abstinence, relationships with others, personal attributes (e.g., 

responsibility, commitment), and his own personal sense of worth and dignity. He 

has found hope that he can reach for and achieve a quality life. These shifts accrue 

as a result of abstinence, stable living (such as stable housing and new “clean” 

friends), and quality treatment in the program. René still needs to incorporate these 

changes on a consistent basis but is making significant efforts in all these spheres. 

The counselor wants to support René’s new view of himself in relation to the world 

and will continue to reinforce this growth in subsequent visits. 

RENÉ: Yeah, but, I’m thinkin’ he wants me to take the coffee commitment ’cause he thinks I’m 

gonna use if I don’t take it. I’m saying I don’t need to have a coffee commitment to keep me from 

using. 

COUNSELOR: This is a big concern of yours right now. Someone else is relying on you. 

RENÉ: Yeah, because now I can’t miss. I know he thinks that it’ll force me to have to go to the 

meetings. It gives me some responsibility, you know, so I’m gonna do it for a while. I can’t say that 

I’m gonna be there for every meeting as coffee person, but I’m gonna try. 

COUNSELOR: I think it’s a good thing for you to do. You’ve been focused on yourself and your 

recovery, so now you’re doing something for other people. It could be a good feeling, having people relying on you. 

RENÉ: Well, maybe. 

COUNSELOR: So, what else is going on? 

RENÉ: Well, I need to make more money. The job—I need a new job. I’m gonna try to buy me a 

car, you know, and I wanna move into my own place. 

COUNSELOR: Those are great goals, René. So, have you tried to get leads on something that

might offer more pay? 

RENÉ: That’s the thing, you know. I don’t know how to look for another job. The folks at the 

halfway house said they would help. 

COUNSELOR: Well, how about if we go back to the halfway house director, maybe on your day 

off, and see what he might have? They have some stuff posted on the employment board. 

RENÉ: Yeah, that’s not a bad idea. 

Master Clinician Note: The counselor is focusing on René’s natural supports (NA 

meetings, his job, and maybe his family) to help him develop supports for his 

recovery. 

COUNSELOR: Have you been in touch with your family at all? 

RENÉ: Uh, no, not really. Been away from them a long time. 

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COUNSELOR: What do you think about making some contacts? Pretty soon, you’ll have your


own place. You can maybe have them over for coffee. Or are you thinking that would feel like too


much pressure?
 

[They discuss reconnecting to René’s family, particularly an uncle.]
 

COUNSELOR: Now, I’m just thinking about another person who might show their face while 


you’re in sober living. Who do you think that might be?
 

RENÉ: Let’s see, who could that be? [laughs] You’re talking about Cheryl.
 

COUNSELOR: Yeah, I am. Have you thought about how that’s going to work?
 

RENÉ: Well, first, she don’t know where I’m staying. You know, I’d never give her my address.
 

Haven’t given her my phone number either. I don’t go to that store anymore.
 

COUNSELOR: Have you been feeling lonely?
 

RENÉ: Yeah, you know, that’s part of why my sponsor had me go to those meetings a lot.
 

Doesn’t give me a chance to be lonely. I’m still around a lot of people I can talk to.
 

COUNSELOR: You said you were not a real big people person, kind of a loner.
 

RENÉ: Yeah, but I’m in the room with them, so, it’s all right. Yeah, I saw a girl there and we’ve 


been talking. She’s in recovery, too, so it’s all right.
 

COUNSELOR: Someone to think about for down the line.
 

RENÉ: Could be. Could be a prospect, yeah. But, you know, I really want to change jobs.
 

COUNSELOR: You changed the subject pretty quickly.
 

Master Clinician Note: The counselor understands René’s abrupt shift to another 

topic as signaling his discomfort but decides to further explore the relational issue 

and help him begin to resolve it. 

RENÉ: Yeah. I’m—
 

COUNSELOR: Maybe you need to think about how to deal with women who aren’t using.
 

RENÉ: Well, my sponsor told me that I shouldn’t be in a relationship anyway, you know?
 

COUNSELOR: This sponsor sounds like a very important person.
 

RENÉ: Yeah, well, he thinks he is. He has some good information—some good, some bad, some 


I don’t agree with. But I have his number, and then if something happens, he tells me don’t call 


him after I get high, you know. Call him before. Can’t really do too much after I’m high.
 

COUNSELOR: So, it’s been a while since you’ve been high. How’s that going?
 

RENÉ: Going okay, you know? Got some good tools I use, you know. I do what they say; I play 


the tape all the way through, I see the consequences.
 

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COUNSELOR: There’s a lot going on. You moved, you’re still adjusting, there’s another move 

coming, you’re staying clear of Cheryl, you’re seeing other women, and you’re keeping off drugs. 

That’s a lot. 

RENÉ: Yeah, it’s tough! 

COUNSELOR: You’ve stayed with the plan on payday, you haven’t relapsed, you’re making the

best of being here, you’re doing more meetings, and you’re maybe thinking about making some

contact with your family.That’s all really good stuff. 

RENÉ: Yeah, well, it’s pretty good. I guess they say I’m well on my way, huh? 

Master Clinician Note: The counselor continues to affirm René’s strengths and what 

he has accomplished. This supports René’s confidence in his ability to maintain his 

recovery and continue the evolution of his identity toward becoming a contributing 

member of his community and away from homelessness and substance abuse as a 

coping strategy. 

Summary 

René has come a long way. He slipped but worked with his counselor to stay in the action stage

of change through the techniques used in transitioning from homelessness intensive care to ongoing rehabilitation (i.e., affirmation, identifying strengths and relapse triggers, role-playing, and

increasing and generalizing coping skills). He moved from precontemplation to action for ending

his relationship with his girlfriend and from contemplation to action about moving into a halfway house temporarily until he has enough time abstinent to enter a sober living home. He increased commitment to substance abuse recovery supports through involvement in NA. 

Longer-term goals for working with René include:

•	 Ongoing engagement in mutual support groups and the recovery community. 

•	 Reconnecting him with his family, including using role-play to practice asking his uncle to

go fishing, having dinner with his aunt and uncle, and facing recriminations from his family. 

•	 Finding a better job; using role-playing of job interviews until René has developed the skills 

he needs for telling the truth about his background. 

•	 Assessing René’s money management and living skills and improving them if necessary. 

Vignette 6—Mikki 

Overview 

Mikki is in the early intervention stage of homelessness prevention. This vignette demonstrates 

approaches and techniques for preventing additional trauma to her family during temporary 

homelessness. 

Mikki’s partner of 4 years has abandoned the family, leaving Mikki with sole responsibility for

their daughter, Emily, age 3, and for Madeline, age 7, Mikki’s daughter from a previous relationship. For a couple of months, he sent some money, but for the past 2 months he has not been

heard from. Mikki does not know where he is and does not expect him to return. 

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She presents in the local community health center with one child with a high fever and both

children with bad colds and coughs. On interviewing Mikki, the nurse practitioner picks up on

her significant depression and begins to question her about the family’s living situation. She is 

concerned that Mikki’s level of depression will not allow her to provide care for the children, particularly in emergency situations with their illnesses. 

In the discussion, the nurse learns that Mikki has been evicted from their apartment and that the 

family has been living in her car (which is not working) for the past week. Mikki takes the older

child, Madeline, to school each morning (except this morning, because Madeline is sick). She 

and the younger child, Emily, sit and play in the park all day. Mikki has no plans for coping with

the crisis and, with her depression, can barely make it from day to day. She has been receiving

some meals for her and the children at a local soup kitchen but has not told kitchen staff that she 

is homeless. 

The practitioner is faced with three immediate problems:

1.	 Intervening with the children’s health problems 

2.	 Intervening with Mikki’s serious depression 

3.	 Helping the family find temporary emergency housing 

The nurse contacts Bill, the behavioral health counselor/case manager at the community health

center. The vignette depicts Bill’s work with Mikki and the children. 

Setting 

Mikki and her two children present at a community health center. Bill, the caseworker, is called

in after the nurse practitioner identifies the family as homeless and in need of acute care. Bill

recognizes the complexity of this case, which, by his determination, calls for intensive case management and a team approach to care. He mobilizes resources within the health center and in the 

community to respond to the complex needs of this family. 

Learning Objectives 

•	 Recognize homelessness or incipient homelessness with individuals and families who present

with other problems and do not identify homelessness as the presenting problem. 

•	 Screen for and identify behavioral health problems and apply appropriate resources to address 

those problems. 

•	 Mobilize and coordinate resources to provide interventions for complex, multiproblem families. 

•	 Implement prevention strategies to limit the trauma of homelessness in families. 

Strategies and Techniques 

•	 Case management with families facing multiple problems 

•	 Using SBIRT as a strategy for identifying substance abuse and substance use disorders 

•	 Prevention strategies to engage children and parents in families experiencing homelessness 

•	 Using a team approach in working with families with complex behavioral health issues 

Counselor Skills and Attitudes 

•	 Develop rapport with someone who is depressed and overwhelmed. 

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Housing Options for Families in Crisis 

In any particular community, a variety of housing options might be available for families in crisis. At 

the same time, no community is likely to have the full range of necessary housing services for families. 

Some organizations may have a complete range of “wrap-around” services available, such as assertive community treatment, emergency and comprehensive health services, family counseling, employment assistance, and a food pantry. Other organizations may simply provide housing. Some 

programs have restrictions on the length of time families may stay, whereas others provide permanent supportive housing. Some resources may be limited to mothers and their children, whereas others accept intact families. It is important for you and your program to be aware of the services 

available in your community, as well as to be aware of the gaps in available services. 

 

Part 1, Chapter 2 

•	 Develop and implement a treatment/recovery plan for people in acute crisis who have cooccurring disorders. 

•	 Develop case management skills in work with complex, multiproblem families. 

Vignette 

Visit 1 (health center) 

The nurse practitioner has contacted Bill, a counselor who is currently seeing another client; Bill

says he can see Mikki in about 45 minutes. It ends up being more than an hour before Bill is free,

and Mikki becomes cranky. Emily, who waits with her mother, is restless and beginning to run up

and down the hallway near the waiting room. Madeline is still in the pediatrician’s office. 

COUNSELOR: I’m sorry you have had to wait today. Things are pretty hectic around here this 

morning. 

MIKKI: Will someone tell me when Madeline is through with her visit to the doctor? 

COUNSELOR: Yeah, the nurse is going to call us. When she does, Madeline can join us here. I

understand Madeline is feeling pretty bad today. 

[Bill wants to initiate some connection with Mikki and involve her in a conversation but doesn’t 

want to rush right into all of the overwhelming problems Mikki is facing. He engages Mikki in

talking about the children’s current health problems, and although Mikki continues to seem 

somewhat distant, she seems less cranky. Emily has put her head in her mother’s lap and is beginning to doze off. As Bill senses Mikki feeling a little more comfortable, he asks a general 

question about her current situation.] 

COUNSELOR: Mikki, it seems like you have a lot going on right now, some really tough stuff

happening in your and your girls’ lives. 

MIKKI: I don’t know how I’m going to handle all of this. 

COUNSELOR: Well, we want to help you. Right now, Madeline is getting taken care of and

Emily got a prescription from the doctor, so let’s talk about your housing situation. I understand 

you don’t have a place to live right now. 

MIKKI: Not since last Tuesday. 

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Family Shelters and the Need for Permanent Housing 

Shelter services provide emergency housing services to families without a place to live. Often, these 

services are limited to mothers and children who require immediate housing resources and are time 

limited in nature. A variety of dynamics drive families to shelters and other transitional housing resources: the lack of local low-cost housing, the disparity between housing costs and income, domestic violence, and limited availability of other social service resources, among others. Some of the 

barriers faced by families who are homeless are available cash for a rental damage deposit and first 

and last months’ rent, limited housing stock for larger families, and the reluctance of landlords to 

rent to individuals who have been previously evicted from housing or who have a poor credit history. 

These dynamics create a cycle of emergency homelessness crises for families in need. 

Shelters and other transitional housing meet a significant need in most communities. However, shelters are often just the first step needed by a family without housing. Most housing experts cite the 

need for intensive long-term housing assistance for families to stabilize and grow beyond the immediate crises that caused their homelessness in the first place. Supportive social services for employment, behavioral health services, physical health care, education, clothing, and food are required 

over a longer period of time than can be provided by most transitional services. 

Housing First is an option for emergency shelter/transitional housing. As the name implies, this program sees adequate and sustained housing as a precursor to support families as they get back on 

their feet. In addition, Housing First services provide social services to support families. The four 

stages of most Housing First programs are: crisis intervention and short-term stabilization, screening 

and needs assessment, provision of housing services, and provision of case management services. 

Source: National Alliance to End Homelessness, 2006. 

Behavioral Health Services for People Who Are Homeless 

COUNSELOR: Okay, Mikki. Let’s take first things first. In addition to getting Madeline well, it

seems most important right now that we help you get a place to stay for tonight that is safe and

out of the weather. 

[Bill proceeds to gather the information necessary from Mikki to arrange temporary housing. He 

also explains to Mikki that, for tonight (and maybe the next few days), he will arrange shelter

housing; in the interim, they can plan for more stable housing. Bill also realizes that Mikki is depressed and overwhelmed. It might be a problem for her to go to the housing office for assessment on her own because her car is not working, but he has no immediate resources for taking

her there. The office is about eight blocks from the health center. He therefore arranges for bus 

fare for Mikki and the girls.] 

MIKKI: I don’t have any money. 

COUNSELOR: Mikki, I’m thinking if you can return here tomorrow, we’ll start getting you

some income support until you can get back on your feet and maybe start working. 

MIKKI: That sounds okay. 

[Madeline now enters the room accompanied by a nursing assistant from the pediatrics department. She is a shy, thin child who does not make any eye contact with Bill. When the nursing

assistant leaves the office, Madeline sits quietly next to her mother. Emily begins to stir, but Mikki doesn’t seem to respond to Emily’s waking up.] 

COUNSELOR: Well, Mikki, if the kids are ready, maybe you should head over to the shelter 

132 
 

 

 

 

 

Part 1, Chapter 2 

offices to arrange for housing for tonight. Then tomorrow, be back over here at 9, and let’s see 

what we can do to start working on things like income and more stable housing. 

[Mikki bundles up the girls, takes the bus fare and a map to the shelter office, and leaves the 

health center with a return appointment for the next morning.] 

After Mikki leaves, Bill spends a few minutes developing some ideas for addressing Mikki’s 

needs. Some of the actions he identifies, in order of priority, are:

1.	 Find housing for the next couple of days, and, in the interim, arrange for more stable housing. 

2.	 Arrange for the family to receive intensive case management and social work services from 

the health center that will allow Bill and other support personnel in the center to provide 

more concentrated and intensive services. 

3.	 Address Mikki’s depressive symptoms. 

4.	 Find an income source that can support Mikki and her daughters until she can gain employment. 

5.	 Monitor the needs of the children; in particular, monitor Madeline for school attendance and

potential depression, ensure that the health and safety needs of both girls are met, and arrange interventions to mitigate any trauma they may experience due to their life situation. 

6.	 Help Mikki access resources she needs to apply for a job that can help her support herself

and her children. 

Visit 2 (counselor’s office) 

Mikki returns to the health center the next morning at 9 to see Bill. She is accompanied by her

3-year-old, Emily. Madeline went to school this morning. Mikki looks disheveled, despondent,

and overwhelmed and doesn’t seem to be responding to Emily’s efforts to stay close to her. After 

yesterday’s visit, Bill requested and got approval for increased intensity of casework services. This 

allows Bill and a case aide to see Mikki on a more regular basis and to accompany her to appointments that are critical to the family’s welfare. 

Bill invites Mikki and Emily into his office. 

COUNSELOR: I hope you got to the housing office okay yesterday. How’s it going? 

MIKKI: We got to the housing office yesterday after it closed, and the shelter wouldn’t let us in 

without a voucher, so we slept in the car again last night. 

COUNSELOR: Did you and the girls get any breakfast? 

MIKKI: We had some supper at the open kitchen down the street from the housing office. I

don’t have any money for breakfast. 

COUNSELOR: Okay, then as soon as we finish here, I’ll arrange a food voucher for you and

Emily to get something to eat. Would it be okay with you if I call Madeline’s school and see if we 

can arrange for her to get breakfast and lunch there each day she attends? 

[Mikki nods her assent to both statements, and Bill proceeds to complete a release of information form with her, which will allow him to communicate with the school counselor. Mikki

signs the form without really reading it. Bill notices this and proceeds to explain what the form

means.] 

133 
Effects of Homelessness on Children 

Children in families that are homeless are affected at all psychodevelopmental levels, from before 

birth to late adolescence. These effects influence physical growth, emotional and behavioral development, academic performance, and interpersonal and social skills development (Shegos, 1999). 

Additionally, homelessness for children, as well as for adults, rarely exists in isolation; rather, it occurs 

most often in the context of other dynamics such as the potential for violence, poverty, living with 

recurring crises, inadequate nutrition, and family breakup. As a result, children in families that are 

homeless are at particular risk for trauma and developmental and behavioral disorders. For more information on trauma-informed care for children and families who are homeless, see SAMHSA’s National Center for Trauma-Informed Care Web site (http://www.samhsa.gov/nctic/) and SAMHSA’s 

Homelessness Resource Center Web site (http://homeless.samhsa.gov/). 

 

 

Behavioral Health Services for People Who Are Homeless 

COUNSELOR: Mikki, I sense that you are pretty down in the dumps this morning. 

MIKKI: Have you ever tried to live in a car with two daughters and one sleeping bag? I don’t 

have any money. I’m tired. I don’t know where we will sleep tonight. I haven’t had a bath in 3 

days. 

[Mikki begins to tear up. Bill just sits silently for a few moments without interrupting her.] 

COUNSELOR: I understand that things are really overwhelming for you right now. It must feel 

very difficult for you to get anything done. But I’m here to help you, and together, we can begin 

to take these big problems and deal with them one by one. Now first, I’m going to arrange for 

Kate, our case aide, to go with you this morning after you’ve had breakfast to enroll you and the 

girls in the family shelter housing program for a few days until we can get something better

worked out. It’s safe, and you’ll have a place for your stuff, a bathroom, and a small breakfast meal 

to get you all going in the morning. 

Once we have that squared away, Kate is going to walk over with you and Emily to the Department of Human Services to help you get enrolled in some emergency financial assistance. It won’t 

be a lot of money, but it will help you get through the next few weeks. Are these plans okay with

you? 

MIKKI: Well, I don’t have anything else to do, that’s for sure. I do have to meet Madeline at the 

school at 3. She gets real nervous if she thinks I’m not going to be there. 

COUNSELOR: No problem, we should be able to get the housing and income assistance stuff

tucked away well before 3. Now, Mikki, there is one more thing I would like us to do this morning, and then we can arrange for you and Emily to get some breakfast—and that is, I would like 

you to see a doctor on our staff, Dr. Wright. I know you are really overwhelmed and pretty down

right now, and that is really sapping your strength. We’re taking care of the girls’ health, but your

health is important, too. So, I want you to see Dr. Wright, who is our staff psychiatrist. Let’s see 

what we can do to help you get more energy, get some good sleep, and feel more hopeful about

things. 

[For more information about depressive symptoms and their treatment, see TIP 48, Managing 

Depressive Symptoms in Substance Abuse Clients During Early Recovery (CSAT, 2008).] 

134 
 

Screening, Brief Intervention, and Referral to Treatment 

As described on SAMHSA’s SBIRT Web page (http://www.samhsa.gov/prevention/sbirt), SBIRT is a 

comprehensive, integrated public health approach to the delivery of early intervention and treatment 

services for persons with substance use disorders, as well as those who are at risk of developing 

these disorders. Primary care centers, hospital emergency rooms, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users before more severe consequences occur: 

• Screening quickly assesses the severity of substance use and identifies the appropriate level of 

treatment. 

• Brief intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change. 

• Referral to treatment provides those identified as needing more extensive treatment with access 

to specialty care. 

Please refer to the SBIRT Web page listed above as well as the text box on page 36 of this TIP for 

more information on SBIRT. 

 

Part 1, Chapter 2 

MIKKI: You want me to see a psychiatrist? 

COUNSELOR: I’m concerned that you may be depressed, and, like any illness, depression is 

likely to get worse if it isn’t treated. We have a lot of resources here at the health center that can 

help you, and Dr. Wright is one of them. 

[Mikki reluctantly assents. Bill takes a moment in the presence of Mikki to call Dr. Wright’s secretary and arrange for an assessment interview later in the week. He then writes down the appointment time for Mikki and arranges for her to come by his office for a few minutes before she 

is scheduled to see Dr. Wright. He then arranges for Mikki to receive two meal vouchers from 

the health clinic and schedules Mikki to meet Kate, the case aide, in 1 hour. While Mikki is having breakfast, he updates Kate on the case. Kate will be able to check in with Mikki regularly just

to make sure everything is going all right. He then calls Madeline’s school and speaks with the 

school counselor, who suggests that, in addition to enrolling Madeline in the breakfast and lunch

programs, she can meet briefly with Mikki this afternoon when she comes to pick up Madeline 

and see what support she can offer Mikki and Madeline. 

Bill prepares his case notes and a referral request to Dr. Wright, describing his concerns about

Mikki’s depressive symptoms and the efforts that have been taken to support Mikki and her

daughters.] 

Later in the week 

Mikki, with Kate’s help, got housing through the family shelter, arranged for Madeline to remain

in the school meals program, got emergency financial assistance, and kept her appointments with 

Bill and Dr. Wright. Dr. Wright suspected that alcohol use might be contributing to Mikki’s depression and conducted an SBIRT assessment. 

The screening indicated that Mikki was using alcohol in a manner consistent with substance 

abuse, particularly in the past month. The brief intervention consisted of a discussion with Mikki

about her alcohol use, helping her understand the ways in which alcohol might heighten her depression and interfere with her recovery. This elicited her cooperation in remaining abstinent 

135 
Transitional and Permanent Supportive Housing 

Two primary approaches to housing services include transitional supportive housing and permanent 

supportive housing. Transitional services are designed for people needing more than emergency 

housing assistance, but with an expectation that within a period of approximately 2 years, they will 

be able to move away from supported housing using their own resources. Many people are able to 

move from transitional housing sooner. Some examples of clients who often need transitional housing are families whose major breadwinner has lost a job and been unable to find other employment, 

people who are homeless when leaving substance abuse treatment, and families affected by domestic violence. Typically, transitional housing is accompanied by social, health, behavioral health, and 

other services to support the individual or family in rehabilitation from homelessness. 

Permanent supportive housing is more likely to be an appropriate choice for individuals who face 

long-term rehabilitation from homelessness and have co-occurring behavioral health or physical disabilities. Permanent supportive housing needs to be accompanied by a variety of social, health, behavioral health, financial, occupational, and interpersonal services to enable the individual to function 

optimally in the face of difficulties. 

In both transitional and permanent supportive housing, the type of appropriate housing depends on 

a variety of contexts, including housing availability in the community, the specific needs of the individual or family, cost, and the availability of adjunct services. The housing may range from SRO units 

to conventional apartments in the community. 

Source: HUD, 2008. 

 

Behavioral Health Services for People Who Are Homeless 

while in treatment for depression and her participation in continuing follow-up with Bill. She 

was encouraged to attend a weekly support group that meets at the family shelter. Bill will follow 

up with Mikki on her efforts toward abstinence and monitor her mood. She has a return appointment in a month to see Dr. Wright. Additionally, Dr. Wright prescribed an antidepressant

medication for Mikki. 

Visit 3 (one month later, counselor’s office) 

Kate, with Bill’s support and supervision, has continued to check in on Mikki twice a week. Mikki’s depressive symptoms are less intense, and she seems to be doing a better job of supporting

her children. After spending four nights in the emergency family shelter, Mikki and the girls 

moved to transitional family housing, where they continue to live. 

Bill has maintained contact with Annette, the counselor at Madeline’s school, who has helped

Bill understand some of the effects of homelessness on young children and some of the programs 

and resources that are available for children to prevent additional, compounding problems.

Through Kate, Bill has made time to see Mikki to check in with her before her appointment

with Dr. Wright. 

MIKKI: Hi. Kate said you wanted to see me. 

COUNSELOR: Hi, Mikki. It’s good to see you again. Things were pretty tough for you the last

time we were together. Kate has been keeping me updated; it seems things are going a lot better. 

MIKKI: Yes, they are. I need to get a job and a better place to live, but the girls are doing better. 

COUNSELOR: And you? How are you doing? 

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Part 1, Chapter 2 

MIKKI: Well, better. I’m sleeping at night, even though the Family Living Center is loud and

our room faces the street with traffic all night. I’ve got to find a better place to live, but that takes 

money. I’m also just sitting around all day. There isn’t much to do. They don’t like you downstairs 

watching TV all day. 

COUNSELOR: What about drinking? 

MIKKI: No drinking. When I saw the doctor, he told me I should quit, and the support group

has helped a lot, too. I really couldn’t afford it anyway. Mostly, I drank at night to sleep better, but 

I think I’m sleeping better now without drinking. My boyfriend drank every day, and I got to

drinking with him. Now I’m through with him and the drinking. 

Master Clinician Note: The counselor decides to monitor Mikki’s progress with not 

drinking as he continues to maintain contact with her; he also wants her to have 

options for help if she does begin drinking again. 

COUNSELOR: What do you think would be helpful for you if you did find yourself drinking


again?
 

MIKKI: Well, I don’t think that is going to happen, but I guess I would just stop.
 

COUNSELOR: And if you find that despite your intentions, you can’t stop?
 

MIKKI: Well, could I give you a call?
 

COUNSELOR: Sure, I plan to be around a while. But also, if you aren’t able to reach me, for instance, maybe you’ve moved away, would you be willing to contact some resource in the community that could help you—for instance, a local alcoholism clinic or AA?
 

MIKKI: Well, I really don’t intend to start, but sure—if I see that I’m drinking again, I can do
 

that.
 

Master Clinician Note: The counselor knows that Mikki would benefit from 

discussing how she would know when to seek help. He can also provide additional 

contact information that might come in handy in the future. He also wants to 

encourage Mikki to attend some AA meetings but decides to wait on that 

suggestion because of the multiple issues she still needs to address. 

COUNSELOR: Have you heard from your boyfriend? 

MIKKI: No, not a word. I don’t know if he would even be able to find me now. I’m not wanting 

to find him right now, either. Maybe he was more of a problem than a solution. 

COUNSELOR: Well, Mikki, I’m really happy to see you doing so much better. We have a few 

minutes before your appointment with Dr. Wright, so I’d like to talk with you about the girls. I 

know you’ve seen Annette, Madeline’s school counselor, at least once since we last met. I talked

with her last week. She would like to see Madeline get into some support programs if that’s okay. 

MIKKI: What kind of programs are you talking about? 

137 
Evidence-Based Prevention Practices for Children 

SAMHSA’s NREPP is an annotated list of programs for which there is empirical evidence of effectiveness (see http://nrepp.samhsa.gov/). Among those are the two to which Madeline has been referred. 

The Curriculum-Based Support Group Program is based on cognitive–behavioral and competenceenhancement models. It is designed to teach life skills and offer emotional support to help children 

like Madeline cope with difficult family situations; resist peer pressure; set and achieve goals; refuse 

alcohol, tobacco, and drugs; and reduce antisocial attitudes and rebellious behavior. The school has 

prepared a workbook for parents of children in the group and will host a late afternoon parents’ session with supervised games and activities for the children. 

The school’s Coping Cat program combines summer camp activities with cognitive–behavioral 

treatment that assists school-age children in (1) recognizing anxious feelings and physical reactions to 

anxiety; (2) clarifying cognition in anxiety-provoking situations (e.g., unrealistic expectations); (3) developing a plan to help cope with the situation (i.e., determining what coping actions might be effective); and (4) evaluating performance and administering self-reinforcement as appropriate. 

 

Behavioral Health Services for People Who Are Homeless 

COUNSELOR: Well, one is an after-school program that runs until 6 each school day. It would

help Madeline have a place where she could be with other kids after school. She would get a

snack, have a chance to rest, and get her homework done. Annette says she also thinks she can

get Emily into an afternoon preschool program that goes from 1 to 6 in the same building where 

Madeline would be. That would give you some time to yourself to begin getting things together

in your life. 

MIKKI: I could use some time to look for a job. What do I need to do about seeing this lady to

get help for Madeline and Emily? 

COUNSELOR: While you’re seeing Dr. Wright, I’ll see if I can reach Annette. Maybe we can

arrange a time for you to go by her office at the school. Why don’t you check with the receptionist’s desk after seeing Dr. Wright? If I’m with someone else, I’ll leave you a note there. If not, the 

receptionist will let me know you are available. 

[Mikki proceeds to Dr. Wright’s waiting room. Bill calls Annette’s office, and they arrange an 

appointment time for Mikki to visit with Annette tomorrow.] 

The next day 

Mikki arrives at Madeline’s school about an hour before school is let out, and she meets with

Annette. Annette does arrange after-school services for Madeline and also enrolls Emily in afternoon preschool services. Annette also arranges for two other important services for Madeline:

a support group similar to the Curriculum-Based Support Group Program she has read about

and a summer program based on Coping Cat, which she saw on the Internet. 

Five months later 

Mikki drops by Bill’s office while she is at the health center with Emily, who is getting immunizations. Mikki started out seeing Bill once a week for a couple of months, and then they decreased their visits to every other week. When she got a job, it became difficult to schedule 

appointments with Bill, so she began checking in via telephone. She is now working 6 hours a

day as a housekeeper in a local upscale hotel. Emily is in child care while she works. The family 

138 
 

Coping With Work and Family Stress 

This workplace preventive intervention is designed to teach employees 18 years and older how to 

deal with stressors at work and at home. The sixteen 90-minute sessions, typically provided weekly to 

groups of 15–20 employees, teach effective methods for reducing risk factors (stressors and avoidance coping) and enhancing protective factors (active coping and social support) through behavior 

modification (e.g., methods to modify or eliminate sources of stress), information sharing (e.g., didactic presentations, group discussions), and skill development (e.g., learning effective communication and problem-solving skills, expanding the use of social networks). The curriculum emphasizes the 

role of stress, coping, and social support in relation to substance use and psychological symptoms. 

Usually, a facilitator with a master’s degree who is experienced in group dynamics, systems theory, 

and cognitive and behavior interventions leads the sessions. For more information, visit the NREPP 

Web site (http://nrepp.samhsa.gov). 

 

 

 

 

 

 

Part 1, Chapter 2 

last week moved into supported housing, a program for formerly homeless families. Mikki has 

continued to see the psychiatrist and a social worker at the health center regularly and is much

improved. She continues to maintain abstinence and is able to help Madeline with her homework; last weekend, the three of them went to a local community fair and had a great time. This 

weekend, they are shopping at local used furniture outlets for furniture for their new apartment.

Mikki is taking advantage of a program offered by her employer (see text box above) to help prevent her stress from becoming a barrier to her keeping her housing and maintaining abstinence. 

Long-range plans for Mikki and her children are:

•	 For Mikki to continue receiving treatment and support services at the local health center: 

–	 To stabilize in remission from her depressive episode. 

–	 To learn more about how to manage her recovery from her depression and alcohol use 

and to act early if she perceives a relapse coming. 

–	 To continue to develop better coping and parenting skills. 

•	 To stay on the list for Section 8 housing and to move when this becomes available. 

•	 For Mikki to continue to make plans with her parents to possibly return to her hometown (in

the same county) to live with her daughters. These plans would include contingencies for: 

–	 Local supported housing. 

–	 Continuing mental health services. 

–	 Signs of trauma reactions in the children related to what they have experienced in the

past year. 

–	 Making plans to obtain long-term employment. 

–	 Maintaining abstinence from alcohol. 

Vignette 7—Sammy 

Overview 

Sammy is in the permanent supportive stage of homelessness rehabilitation. The vignette shows 

approaches and techniques for arranging PATH-supported services and housing for a client who

has SMI. 

Sammy, a 34-year-old man, was discharged from the State hospital last week and referred to a 

community mental health center (CMHC) for continuing care; he has yet to contact them. He 

139 
 

 

 

Behavioral Health Services for People Who Are Homeless 

spent his first night after discharge with his parents but argued with them the next morning and

left. He then spent several nights with a friend with whom he stayed occasionally before his hospital admission. Last night, he had a few beers and was arrested for public intoxication, creating a 

disturbance, and panhandling. He spent the night in jail and this morning, as an alternative to

incarceration, agreed to meet with the street outreach program staff. Street outreach in this

community is a joint venture of a coalition of homelessness programs and the local CMHC. After the initial interview in jail with a mental health PATH caseworker, it was decided that Sammy would go with the caseworker to Welcome Home, a transitional housing program, and apply 

for long-term supported housing. The PATH caseworker will follow Sammy’s progress and help

him transition to the community while maintaining housing at Welcome Home. 

Learning Objectives 

•	 Use community housing and behavioral health resources to help an individual live in the 

community and avoid rehospitalization. 

•	 Help clients learn about and access permanent supportive housing with support from the

PATH staff. 

•	 Provide client-directed, recovery-oriented services for housing. 

•	 Integrate community mental health services (e.g., ACT) into a client’s recovery program. 

Strategies and Techniques 

•	 Engage the client in community services to support recovery and get permanent supportive 

housing. 

•	 Support the client in making housing decisions. 

•	 Use community recovery resources (e.g., National Alliance on Mental Illness [NAMI]) to

create ongoing recovery support. 

Counselor Skills and Attitudes 

•	 Develop rapport with a client who does not easily engage with others. 

•	 Manage client resistance to accepting permanent supportive housing. 

•	 Assess client strengths and limitations in developing a housing plan. 

•	 Understand community resources for housing for clients with SMI. 

Vignette 

Visit 1 (Welcome Home offices) 

Mike, a mental health caseworker, spent a few minutes developing rapport with Sammy, gathering some history and assessing his current life situation. This information revealed that Sammy 

has not had a permanent residence for nearly 4 years. He has lived primarily at a deer hunting

camp in the forest about 20 miles from his hometown. He maintains the camp for the hunters 

who own it in return for a room of his own there. When he comes to town by bus or hitchhiking,

he may spend a night or two with his friend. He has had three admissions in the past 8 years to

the State psychiatric hospital, all related to going off antipsychotic medications and using alcohol.

Between hospitalizations, he has intermittently received care at the local CMHC. He doesn’t like 

taking medication due to side effects but recognizes that he needs to take it to stay out of the

hospital. 

140 
 

What Is PATH? 

Projects for Assistance in Transition from Homelessness is a SAMHSA-administered formula grant 

program that funds community-based outreach, mental health, substance abuse, case management, 

and other support services for individuals who are homeless or at risk of becoming homeless and 

have a serious mental illness or co-occurring disorders. The program was authorized by the Stewart 

B. McKinney Homeless Assistance Amendments Act of 1990. Monies are distributed by SAMHSA’s 

Center for Mental Health Services to States, the District of Columbia, Puerto Rico, and the U.S. Territories. States then distribute the monies to local programs to meet defined local needs. In this 

sense, each local PATH-funded program is different, reflecting the unique needs of the community it 

serves. For more information, visit the PATH Web site (http://pathprogram.samhsa.gov/). 

PATH providers work with service delivery systems and embrace practices that work by: 

• Partnering with Housing First and permanent supportive housing programs. 

• Providing flexible, consumer-directed, recovery-oriented services to meet consumers where they 

are in their recovery. 

• Improving access to benefits, especially through Supplemental Security Income (SSI) and Social 

Security Disability Insurance (SSDI), Outreach, Advocacy, and Recovery (SOAR). 

• Employing consumers or supporting consumer-run programs. 

• Partnering with medical providers, including Health Care for the Homeless and community 

health centers, to integrate mental health and medical services. 

• Improving access to employment. 

• Using technology, such as hand-held devices, electronic records, and Homeless Management 

Information Systems. 

• Training local provider staff on strategies to help people with serious mental illness who are 

homeless. 

Local PATH-supported organizations provide homelessness support services, including: 

• Outreach. 

• Screening and diagnosis. 

• Habilitation and rehabilitation. 

• Comprehensive community-based mental health treatment. 

• Alcohol and drug treatment. 

• Case management. 

• Supervision in residential settings. 

• Services to help clients access appropriate housing. 

Part 1, Chapter 2 

About 6 years ago, Sammy lived briefly in a group home, was involved in a local drop-in day program supported by NAMI, and was able to work part time at a local carwash. Sammy says he 

prefers to live alone; living in the group home was “too close” for him. He felt too many pressures,

and the staff ’s expectations were too high. 

The vignette starts with Sammy and Mike (the counselor) as they consider alternatives for housing. 

COUNSELOR: Sammy, let me see if I’m understanding you correctly. First, you need a place to

live, at least for a while, because the guys at the deer camp say you need to prove you can do okay 

and stay out of trouble before you go back out there to live. Second, going home to your parents 

doesn’t seem like a very good idea. Third, you need a place that you can call your own, without 

sharing a room, and lastly, you need a place you can afford. Am I correct about all of this? 

SAMMY: Pretty much. I don’t want to go back to my parents’ house or a group home. Been 

there. 

141 
 

 

 

Behavioral Health Services for People Who Are Homeless 

COUNSELOR: Okay. Here’s the way I see things. Let me know what you think. Number one is 

that we need a place for you to just hang your hat for a while until we can find a longer-term solution. 

SAMMY: [interrupting] What do you mean, “hang my hat for a while”? 

COUNSELOR: Just a place for you to stay, maybe a week, maybe longer, until we can help you 

find a place, arrange for financial support, get you hooked up with the ACT team at the mental

health center. That sort of thing. 

SAMMY: I could just live with my friend until you find me a place. 

COUNSELOR: Remember that the judge this morning made finding adequate housing, getting

involved with the mental health center, and getting settled in conditions for staying out of jail. 

SAMMY: I don’t want to go back to that jail. Place smells. And it’s noisy. 

COUNSELOR: Okay, Sammy, here’s what I’m thinking. I know I can get you a room, at least for

a week, at the local shelter. I was over there yesterday, and they have some room. Would you be 

willing to go over with me and take a look? 

SAMMY: Uh-huh. I guess so. 

COUNSELOR: Okay, just in summing up, let’s see what we need to do from here. We’re going

to take care of your housing for the next few days by going over to the shelter office. But also, if it

is okay with you, I want to call Jeanette, who is on the ACT team at the community mental 

health center; let’s get your appointment arranged. You’ve been through a tough 24 hours, and I 

want to be sure you have some support so you can minimize things turning tough again. And

then we have to get you some money so you can buy a few things like a razor, and maybe a duffle 

to keep your meds and stuff. 

SAMMY: I’ve got some money; my parents gave me $100, and I still had about $35 when I left

the jail this morning. 

COUNSELOR: Great! Maybe that’ll last you for 2 or 3 days. The shelter will take care of your

food. Now, I need your permission on a release of information form to call Jeanette. Is that okay? 

SAMMY: Uh-huh. 

[Mike proceeds to complete the release of information form and explains it to Sammy, who then

signs in the presence of the housing office secretary and Mike. Mike then calls the shelter office 

to be sure someone will be available to meet with Sammy and him in about an hour. He then

calls Jeanette at CMHC in Sammy’s presence, but she is unavailable and will return the call that 

afternoon. 

Mike and Sammy then proceed to the shelter office, where they arrange housing in an SRO setting for the next week. Back at the office, Mike gets the call from Jeanette and makes an appointment with Sammy for the ACT team tomorrow morning. He calls the shelter office, which 

passes the information about the appointment on to Sammy. Mike will accompany Sammy to his 

first visit at CMHC.] 

142 
 

What Is an ACT Team? 

ACT is an evidence-based practice (see http://nrepp.samhsa.gov/) developed in the late 1960s. ACT 

(sometimes known as PACT) teams provide intensive, individualized care, including direct treatment, 

rehabilitation services, and support services to persons with chronic and persistent mental illness 7 

days per week (sometimes 24 hours a day). ACT care is distinguished from traditional community 

mental health services in that ACT team members work collaboratively to provide most services. The 

client is a client of the team, not of an individual service provider. In traditional mental health treatment, services are provided by a variety of different practitioners in a variety of settings, leading to 

fragmented and sometimes contradictory care. Team members in ACT include psychiatrists, psychologists, social workers, licensed mental health counselors, nurses, rehabilitation counselors, and 

recently, peer counselors. 

Some principles of ACT, as identified by the Assertive Community Treatment Association, include: 

• The ACT team is the primary provider of services. 

• Services are provided in the client’s environment, as well as in the ACT office. 

• Services are highly individualized. 

• ACT teams act assertively to encourage clients to participate in recovery. 

• Services are provided over a long term. 

• There is an emphasis on vocational services. 

• The team provides substance abuse services and psychoeducation. 

• Family support services are provided. 

• Clients are supported in engaging and integrating into the community. 

• Healthcare needs are addressed through education, evaluation, referral, and follow-up. 

 

 

 

 

Part 1, Chapter 2 

Visit 2 (meeting with the ACT team) 

Before meeting with the ACT team, Sammy and Mike spend a few minutes in the park across 

from CMHC. Sammy says that his room at the shelter is “better than the jail, but not much.” He

is very interested in getting his own apartment as soon as possible. Mike agrees that they will 

meet tomorrow and begin working on finding an apartment through the PATH-supported services program. Mike is also concerned that Sammy needs a range of services to meet a variety of

needs: housing, mental health treatment, something to do during the day, developing interpersonal supports in the community, gaining income, achieving family reconciliation, ensuring proper nutrition, obtaining transportation, and so on. 

No one program in the community can address all of these needs, and Mike will be the initial 

linchpin in coordinating these services. Mike begins to prioritize mentally how he will approach

this task of coordination. As the ACT team engages Sammy, most responsibility for his care will 

be handed off to the ACT team; Mike will begin to withdraw from active participation in Sammy’s treatment. 

When it is time for Sammy’s visit with the ACT team, Mike accompanies him across the street.

Sammy first meets with Jeanette, an ACT team social worker, who completes the intake interview. Sammy and Mike then meet with the entire ACT team, and they jointly come up with a

short-term treatment plan that includes:

•	 Regular prescription medication and compliance monitoring by the ACT team with Mike’s

support. 

•	 Daily contact with the ACT team Monday through Friday for the first month, with a plan to 

143 
What Is NAMI? 

NAMI is a nationwide voluntary organization with 1,200 affiliates throughout the United States that 

advocates for better understanding and resources for people with mental illnesses. It provides a variety of services and resources, including the NAMI Center for Excellence. Some basic services that 

might be provided in a community program supported by NAMI or another organization could include psychosocial skill training, mental health rehabilitation, case management, designated payee 

services, and drop-in services for clients and, possibly, their families. 

 

Behavioral Health Services for People Who Are Homeless 

taper contact to three times weekly in the second month, then once weekly after 3 months. 

•	 Daily attendance at a local NAMI-supported recovery group at CMHC for 3 months. 

•	 Weekly attendance at a contemplation/preparation/action co-occurring disorders group at

CMHC. 

•	 Collaboration between Mike and Sammy in a transitional manner until Sammy is in permanent housing, then transfer of all services to the ACT team. 

•	 Contact information for 24/7 access to the ACT team in case of any psychiatric emergencies. 

[Sammy, Mike, and the ACT team agree to the terms of the treatment plan, and all participants

sign it. Sammy will begin the NAMI support group tomorrow morning and will check in with

the ACT team during his morning NAMI meeting. Mike makes an appointment with Sammy 

to meet the following afternoon to begin the application for a supported housing apartment.] 

Visit 3 (counselor’s office) 

Mike and Sammy meet to begin the application process for Sammy to obtain an apartment

through the supported housing program. 

SAMMY: I don’t like this shelter thing. People are everywhere, and they all talk too much. It’s 

just like the group housing thing I was in back a few years ago! 

COUNSELOR: You seem to be getting uncomfortable with all the people. How are you handling that? 

SAMMY: Well, they make you leave the place by 9 in the morning, so I go over to the NAMI 

program. And then they won’t let you back in until 4:30, so after NAMI is over, I just hang in the 

park. Don’t know what I’ll do if the weather gets bad. Then once I get back in the shelter, I just

go to my room. But I can still hear them through the walls. My room is right over the community room. They’ve got that TV blaring, and then the people have to talk even louder. I don’t like it. 

It’s too loud. At the deer camp, I could go 3 days without hearing anything but the crickets. 

COUNSELOR: Sammy, I really understand that, and I know that it’s making you uncomfortable. But I’m wondering if you can just hang in there until we can work out something better.

Maybe have your own place in a week or 10 days. Could you do it? 

SAMMY: Well, do I have a choice? 

COUNSELOR: I don’t know. What do you think? I hear that this makes you uncomfortable;

remember that you and I, working together, are going to try to get you a better place as soon as 

we can. You’re going to have lots of say in the place you get, where it is, how it looks. You’ll even 

meet with the landlord before we close the deal. Meanwhile, you need to decide if you can hold 

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Part 1, Chapter 2 

out until this lands, which it will. Let me ask you: In the past, when things have been noisy,

what’s worked best for you to deal with it? 

SAMMY: Well, I’ve had some beer. But I know I can’t do that right now. Sometimes I put on

headphones and listen to music. That helps sometimes. 

COUNSELOR: That sounds like a great idea to experiment with again. 

SAMMY: Okay. 

COUNSELOR: Let’s get some details about your housing needs, how you’ll pay, and your preferences. 

[Mike and Sammy continue to discuss the details of Sammy’s housing needs. Sammy has concerns about the neighbors, his privacy, rules that might be imposed on him, and who can access 

his apartment. Mike is concerned about public transportation availability, a cooperative landlord,

finding an apartment in the rental range Sammy can afford, and the quality of the apartment.

Mike encourages Sammy to apply for SSDI support, and his lead clinician on the ACT team will 

participate in arranging for him to have an appointment to begin the process at the local Social

Security office. A local NAMI recovery coach will also assist him in the process. This process can

take 6 months to a year, and, in the interim, the local homelessness coalition will pick up the 

costs of Sammy’s rent. After (if ) he is approved for SSDI, then 30 percent of his check will be 

applied toward the cost of the apartment. Likewise, if he doesn’t receive SSDI, but finds another 

source of income, a portion of that income will go toward his rent.] 

Master Clinician Note: The kinds of information Mike might want to collect to help 

Sammy find a suitable apartment could include the following: 

1.	 What area of town does Sammy want (or not want) to live in? 

2.	 Is Sammy aware of any apartments that he thinks would be suitable? 

3.	 What about bus routes or other available transportation in the area? 

4.	 Are there grocery and other stores in the area that Sammy can use? 

5.	 Are there laundry facilities in the apartment itself, in the apartment building, or 

nearby? 

6.	 Can Sammy easily access his mental health service provider for appointments? 

7.	 Are utilities included in the rent? If not, are there utility deposits, and who will 

pay the deposits? 

Visit 4 (in the community) 

The next day, Sammy and Mike go apartment hunting among the apartments approved by the 

local affordable housing program. They look at several furnished units, each having some disadvantages for Sammy’s particular situation. The fifth apartment visited seems to meet Sammy’s 

needs and seems to Mike like a good match. It is an upstairs one-bedroom unit in a building

with seven other apartments, about six blocks from CMHC, and it’s near a grocery store. The

unit has a small, parklike lawn in front, is on a bus route, and seems secure.The basement includes a washing machine and a clothes dryer. It has minimal but acceptable furnishings. Sammy 

was initially concerned that there was no TV but then said he thought his parents would let him 

have the old TV from his room at their home. The rent is $400 a month, which is within the 

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Behavioral Health Services for People Who Are Homeless 

range of affordability for the housing program. There are two other units rented to participants in

the PATH housing supports program. 

Master Clinician Note: The counselor needs to know how housing is approved or 

preapproved for supportive housing programs. All supportive housing programs 

investigate potential housing units prior to their eligibility in the program. Most 

programs have Housing Quality Standards criteria that must be met. The program is 

also likely to want statements from the owners of the available units that they are 

willing to work with the housing program. Before signing a lease, renters need to 

have a clear understanding of a variety of issues: for instance, whether the lease will 

be in the name of the program or the client, whether there is a deposit and how 

much it is, whether utilities are included in the rent, whether smoking is allowed in 

the apartment, arrangements for pest control, and whether there are rules about 

visitors. Many programs must complete a HUD-required Rent Reasonableness 

Survey to ensure that the rent is in line with community standards. 

Sammy and Mike meet with the apartment manager, who lives in an apartment on the second

floor adjacent to the unit Sammy will rent. He mentions that he would like to help Sammy and

that he himself was a patient at the State psychiatric hospital several years ago and, after obtaining housing in the building, had become the manager about 3 years ago. Sammy, although a bit

distant, seems to like him. The manager is interested in how Sammy will spend his day, goes over

the basic rules of the apartment building, and offers to help Sammy get settled in. 

After the meeting with the apartment manager, Sammy and Mike sit for a few minutes on a

bench in front of the apartment unit. 

SAMMY: So, when can I move in? 

COUNSELOR: Well, here are some things we need to do first: [Sammy sits quietly.] First, do 

you think it would be a good idea to let your parents know what’s up? 

SAMMY: Yeah, I can give them a call. They were paying my cell phone bill while I was in the 

hospital, and I have it back, so I can call them. 

COUNSELOR: Maybe they would like to see the place. 

SAMMY: Nah. They don’t need to see it. 

COUNSELOR: Okay, well, what else do you need to do to get moved in once we have everything arranged on our end? 

SAMMY: I don’t know. Move the little stuff I have, I guess. I’ll get Mom to give me some dishes 

and kitchen stuff. I can cook and they’ll give me a little money to buy some food—pasta and that 

kind of thing. I don’t eat much. This medicine makes me fat if I eat too much. 

COUNSELOR: What about sheets, toilet paper, that sort of thing? 

SAMMY: Well, I know I can’t keep my mom from coming over here, once she knows where I’m 

living, and she’ll bring that stuff. 

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Part 1, Chapter 2 

COUNSELOR: Okay, now, you’ll be going to the NAMI Recovery Program every day, and, for 

now at least, you’ll be checking in with the ACT team. Every week, you get your meds from 

them. I think you are all set, Sammy. 

Visit 5 (NAMI Recovery Program facility) 

Ten days later, Mike checks in with Sammy while he is attending the NAMI Recovery Program.

Sammy has moved into his new apartment and watched a football game with Frank, his apartment manager, last evening. He has made some acquaintances with other participants in the 

NAMI Recovery Program. Sammy and Mike find a quiet corner to visit for a few minutes. 

SAMMY: I’m going to go out to the deer camp for a few days next week. 

COUNSELOR: What about your participation in this recovery program and your ACT team 

visits? 

SAMMY: What about ’em? 

COUNSELOR: Well, my understanding of our agreement is that you are supposed to participate in these programs every day. 

[Sammy doesn’t answer, and there is a long pause.] 

COUNSELOR: So, Sammy, let’s see. If I understand you correctly, you want to go visit the deer

camp, and we need to find a way for that to happen that doesn’t interfere with your ACT team 

involvement and your participation in the NAMI Recovery Program. How do you envision doing

that? 

SAMMY: I’m just going for a few days—to check on things. 

COUNSELOR: And you would be going by yourself? 

SAMMY: Yeah, I’ll take a bus out. They let me out at the old road to the camp and then I walk 

the last mile or two. 

COUNSELOR: And Mr. Devereaux, the head of the deer camp group, knows you’re coming? 

SAMMY: Nah, but he doesn’t mind. We’re friends. 

COUNSELOR: Well, Sammy, I see a couple of problems. First, our agreement calls for you to

not miss daily contact with the ACT team for your first 30 days and for you to not miss NAMI

meetings. Second, I think we at least need to talk to Mr. Devereaux and let him know you’re 

planning to go out to the camp, how long you’ll be there, how you would get into the building, 

that sort of thing. 

[Sammy agrees to give Mr. Devereaux a call in Mike’s presence. Mr. Devereaux greets Sammy 

warmly, but reminds him that he left the deer camp “in a mess” and that he can only return when

others are there and the mental health center has given its approval. Following the call, Mike and

Sammy agree that Sammy will defer the visit to the camp for a few months. Sammy is disappointed but accepts the decision. Mike acknowledges Sammy’s disappointment and supports his 

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Behavioral Health Services for People Who Are Homeless 

trying to make it work by clearing it carefully with Mr. Devereaux as well as his continuing participation in his recovery efforts.] 

Three months later (follow-up) 

Sammy has been active in NAMI now for 3 months. Working with the ACT team, he has managed to balance the amount of medicine he takes so that it can control his symptoms while not

making him feel “dopey.” Mike is tapering off his involvement with Sammy, transitioning responsibilities to the ACT team. Sammy has made a couple of friends through the NAMI Recovery

Program and, with the help of the ACT team, has found part-time employment with a local 

moving company. He is also planning to enroll in a course on electronics repair at the community 

college next month. A core element of his recovery has been his ability to maintain supported

housing, which gives him an element of independence yet continues his access to treatment. The 

combination of PATH support, supportive housing, mental health services at CMHC, NAMI 

rehabilitation services, and interim financial support has given Sammy a strong foundation for 

recovery. 

Summary 

Sammy has a history of SMI and was at significant risk of relapse before adequate supportive 

housing was made a part of his recovery plan. It is also essential that he continue to be engaged

with local community behavioral health resources, such as the local ACT team and NAMI. He 

was able to accept temporary housing in a shelter until permanent supportive housing was arranged and, with a supportive landlord and community resources, has made a good transition to 

the community. 

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Part 2: An Implementation Guide 


for Behavioral Health Program 


Administrators
 

149 
150
 

 

 

 IN THIS CHAPTER 

• Introduction 

• Developing Services for 

Clients Who Are 

Homeless 

• The Housing First 

Approach 

• Challenges in Adapting 

Programs To Address the 

Needs of People Who 

Are Homeless 

• Modifying Behavioral 

Health Services To Meet 

the Needs of Clients Who 

Are Homeless 

• Interacting With 

Community Resources To 

Build a Continuum of 

Care 

• Collaborative 

Partnerships 

• Internet Resources 

• Integrating Behavioral 

Health Services With a 

Community System of 

Homelessness Services 

• Building Linkages Among 

Services 

• Funding Community 

Homelessness Services 

Part 2, Chapter 1 

Part 2, Chapter 1
 

Introduction 

Part 2 of this Treatment Improvement Protocol (TIP) is directed 

to administrators and senior staff persons and is designed to prepare you to help behavioral health staff persons in their work with 

clients facing homelessness and the specific challenges that homelessness presents. It can serve as a resource for you to use as you

support and challenge your staff to become part of a communitywide response to the problem of homelessness. How can you support your staff members in these efforts? Do they need further

training? What additional services and collaborative arrangements

does your organization need? Where does funding come from?

What do model programs look like? 

It is important to emphasize that homelessness is a problem that

deserves the attention of behavioral health organizations. Some of

the clients your program is currently treating may be homeless or at

high risk of becoming homeless within months of their discharge 

from the program. People who are homeless report more problems 

related to alcohol use, drug use, and mental disorders than those 

who are not homeless. Findings from studies of Midwest urban

samples of people in shelters, food programs, or living on the street

report high rates of problems related to substance use (58 percent

of women; 84 percent of men [North, Eyrich, Pollio, & Spitznagel, 

2004]; 55 percent of women; 77 percent of men [Forney, Lombardo, & Toro, 2007]). 

A meta-analysis of studies done between 1979 and 2007 (Fazel,

Khosla, Doll, & Geddes, 2008) revealed a pooled prevalence rate 

among homeless men for alcohol and substance dependence of

37.9 percent (10 studies) and 24.4 percent (7 studies), respectively.

Providing adequate shelter for people who are homeless can be the

first step toward engaging in behavioral health treatment. Transitional supportive and permanent supportive housing provided 

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Behavioral Health Services for People Who Are Homeless 

by either behavioral health programs or other

programs in the community have become integral components of recovery promotion in

both mental health and substance abuse 

treatment. (See the online literature review in

Part 3 of this TIP for more details.) 

Why Is an Implementation Guide 

Part of This TIP? 

Part 1 of this TIP provides the knowledge and

many of the tools behavioral health workers in 

your program will need for working with people who are homeless and those facing the 

immediate threat of homelessness. But without specific attention to program development,

staff support, and specific implementation

strategies, the tools your counselors have developed are likely to go unused or will be used

ineffectively. Part 2 will give you, in your role 

as program administrator or senior staff person, ideas and strategies for program development and implementation to support

programming for clients in behavioral health

treatment who are homeless or at risk of becoming homeless. 

Programming for people who are homeless 

and have behavioral health issues occurs in a 

variety of settings: criminal justice programs,

homelessness programs (e.g., shelters, outreach

services, permanent supportive housing services, intensive rehabilitation environments),

community assistance programs, community 

health centers, and other community settings,

in addition to more traditional behavioral 

health programs. Although this TIP is directed primarily at professionals working in

more traditional programs, much of the information will also be useful to administrators 

and senior staff members in other settings

serving people experiencing homelessness and

substance use or mental disorders. 

Developing Services for 

Clients Who Are Homeless 

Your behavioral health program may be interested in serving people who are homeless or at

risk of becoming so for a number of reasons, 

many of which also apply to homelessness 

programs that want to develop or expand services for clients with mental illness and/or

substance use diagnoses. 

First, serving people with substance abuse and

mental disorders who are homeless often is 

not a matter of choice. The clients are there! 

Implementing specific programmatic elements 

to meet their needs serves to make interventions more successful and cost-effective. It also 

enables staff to work more efficiently. In this 

sense, specialized homelessness services are an

essential ingredient for quality and effective 

care in your organization. Many of the clients

you serve are not homeless when they come 

into treatment but, for a variety of reasons, become homeless during treatment and have no 

place to live once they complete intensive 

treatment. Other clients receiving behavioral 

health services are just one paycheck or one 

personal or family crisis away from homelessness. Still others enter treatment because they 

need shelter. Having a staff with the

knowledge and skills to anticipate and address 

these issues will help your program run more 

smoothly and with better outcomes. 

As the behavioral health field moves toward 

outcome-based funding, serving clients more 

efficiently becomes a higher priority. When

program staff members are aware of the effects 

of homelessness on treatment, not only does it

lessen problems associated with housing instability; it also reduces the severity of social and 

behavioral crises that interfere with treatment. 

This, in turn, increases staff efficiency and client retention. 

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Part 2, Chapter 1 

Additionally, making homelessness services a

priority for your program will increase the capacity of the program and the skills of the

clinical staff responding to various other social 

and health needs your clients may have, such

as transportation services, health care, financial

management, and responses to criminal justice 

issues. In this sense, programming for homelessness benefits all clients, not just those who

are currently or potentially homeless. 

Specific services for homelessness may be an

opportunity for your program to find additional sources of funding to support client services. A variety of community funding

resources are available to address the needs of 

people who are homeless, particularly those in

need of behavioral health services. These additional funding streams can help stabilize your

funding base and increase your program’s capacity to meet the needs of clients. 

Some people in the community may question

the costs for intensive and supportive care for

people who are homeless and whether the 

benefits of such care are cost-effective. The 

reality is that supportive housing is costeffective when compared with alternatives.

The Corporation for Supportive Housing

(CSH) report, Costs of Serving Homeless Individuals in Nine Cities (The Lewin Group,

2004), presents estimates of the costs of serving people who are homeless in various settings: supportive housing, jails, prisons,

shelters, psychiatric hospitals, and acute care

hospitals (Exhibit 2-1). Estimates represent

the average cost of providing 1 day of service 

to an individual in each setting and capture

the underlying costs of providing services,

compared with the payments received from 

public payers. The CSH report defines supportive housing as a combination of programbuilding features and personal services to enable people to live in the community. 

The Housing First 

Approach 

One of the first decisions you will make in developing services for people who are homeless 

is whether a Housing First approach is suitable for the clients you expect to serve and for 

your community. Housing First approaches are

used to engage people into services who are 

homeless and have behavioral health conditions. They are low demand, offer permanent

housing for people who are homeless, and do

not require the client to enter treatment or

document abstinence. Many, though not all,

Housing First participants receive Federal disability benefits, and many programs encourage 

clients to participate in money management

programs that ensure payment for housing.

Housing First programs provide substance 

abuse, mental health, and medical services

through community case management or multidisciplinary teams. Clients choose which 

Exhibit 2-1: Range of Estimated 

Service Costs per Day by Setting 

Setting Cost per Day 

Supportive 

housing 

$20.54 (Phoenix, AZ)— 

$42.10 (San Francisco, CA) 

Jail $45.84 (Phoenix, AZ)— 

$164.57 (New York, NY) 

Prison $47.49 (Atlanta, GA)— 

$117.08 (Boston, MA) 

Shelter $11.00 (Atlanta, GA)— 

$54.42 (New York, NY) 

Psychiatric service hospital $280 (Phoenix, AZ)— 

$1,278 (San Francisco, CA) 

Acute care 

hospital 

$1,185 (New York, NY)— 

$2,184 (Seattle, WA) 

Ranges established across: Atlanta, GA; 

Boston, MA; Chicago, IL; Columbus, OH; Los 

Angeles, CA; New York, NY; Phoenix, AZ; San 

Francisco, CA; and Seattle, WA. 

Source: The Lewin Group, 2004. 

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Behavioral Health Services for People Who Are Homeless 

services to receive. More information about 

these programs is available on the Corporation

for Supportive Housing Web site 

(http://www.csh.org). 

Housing First programs demonstrate substantial enrollment into services and housing stability for individuals who are chronically 

homeless and have long-standing mental illness and, in most cases, substance use disorders (Pearson, Locke, Montgomery, Buron, &

McDonald, 2007). Enrollment status is determined more by continued contact with case 

managers and other service providers and less 

by whether the client is continuously residing

in program housing. Temporary departures 

from housing are not uncommon; program

staff continue to follow up with clients even

when they are away from their housing. Many 

programs hold units for up to 90 days and encourage clients to return. 

Housing First programs range from scatteredsite independent housing leased from private 

landlords (thus increasing individual choice in

both housing and neighborhoods) to congregate living programs in which the program

owns or controls the housing (allowing staff to

provide a high level of onsite supervision and

response to client crises). Staff members are

available around the clock to help clients 

maintain their housing and meet their other

needs. 

Implementing Housing First models in suburban or rural areas can present challenges 

that require modifications to the model. Staffing may need to be composed of smaller teams 

resembling assertive community treatment

(ACT) teams, which maintain low caseload

ratios and broker some services from community providers. Teams can feature interdisciplinary staff from different organizations.

Resources may be needed to purchase or use 

extra vehicles. Housing choices may be restricted to renting a room in someone’s home, 

sharing a house, or waiting until a single unit

is found. (For descriptions of Housing First

programs, see U.S. Department of Housing

and Urban Development [HUD], 2007b.) 

Communication among staff members is often

accomplished through daily team meetings so

that they can respond immediately to client

needs. Many programs also have automated

documentation services for collecting information on client status and outcomes. 

Funding for Housing First programs comes 

from diverse sources. The programs seek Medicaid reimbursement for mental health case 

management services and State or county 

funding for clinical services. Additional 

sources of funding might include foundations 

and other private sources. HUD assistance 

programs provide rental assistance. State or

local funds may cover short-term stays in a

hotel while a client seeks housing, or rental 

assistance may be provided to clients who are 

ineligible for HUD assistance programs. 

These programs often use a representative 

payee system to handle clients’ income. This is

a money-management system that assigns a 

third party to handle disbursement of funds 

for individuals receiving Supplemental Security Income or Social Security Disability Insurance (American Association of Community 

Psychiatrists, 2002). It is often a practical need

and helps people develop independent living

and money management skills. 

Many Housing First programs strongly encourage representative payee arrangements for 

certain clients. People with representative payees at baseline are more likely to stay housed

(HUD, 2007b). Although representative payee

arrangements can be a valuable intervention

for individuals who are severely disabled, you 

and your staff should carefully consider potential consequences of removing client responsibility for deciding how and when to spend 

154 
 

 

 

 

 

 

 

 

 

 

Part 2, Chapter 1 

money. Power struggles can result when a client’s request for money is denied to cover

higher priority needs (e.g., when the request

conflicts with paying rent). One way to reduce 

power struggles is to have personnel other

than the counselor act as the “banker,” permitting the counselor to work more effectively 

with the client on money management skills.

For more on representative payee arrangements, see the Social Security Administration’s 

Web site (http://www.socialsecurity.gov/

payee/). 

Unless you do adequate groundwork, the process of establishing a Housing First program 

may run into unexpected obstacles. First, it is 

important to separate a client’s clinical issues 

from his or her responsibilities as a housing

tenant (Stefancic & Tsemberis, 2007). This

may represent a significant change for staff. 

One challenge in implementing Housing First

programs is the presence of preexisting agency 

policies that couple housing with requirements 

that the client maintain abstinence. Rigid, rigorous housing eligibility requirements that often discriminate against clients with

psychiatric symptoms or substance abuse can 

also be challenging. Housing First programs 

usually accept clients on a first-come, firstserved basis. 

Another challenge is ensuring collaborative 

agreements with the immediate neighborhood

where any congregate facility is to be located.

Steps toward collaboration include:

•	 Involvement of neighborhood associations 

or boards on the board of advisors for the 

program. 

•	 Development of a good neighbor code of

conduct. 

•	 Development of shared responsibility in

use and maintenance of public resources 

(such as parks or gardens). 

•	 Rapid response to security or sanitary issues, including police attention. 

Challenges in Adapting 

Programs To Address the 

Needs of People Who Are 

Homeless 

You may decide to add homelessness rehabilitation services to your existing programming

rather than choosing a Housing First approach. When you decide to implement specialized homelessness programming in your

behavioral health organization, you will find

some special challenges, the solutions to which

can be ultimately productive for your program.

Still, to institute new services, you must overcome several hurdles. 

It is imperative to conceptualize, develop, and

implement services for homelessness in the 

context of your current programming. In effect, the new services need to be natural additions that complement existing programs. Not

to do this would mean having a unique homelessness program that is not integrated but rather a separate, isolated entity. In this context,

the new service elements have to be conceptualized in response to the question “How can

this new service integrate with and complement the services we already offer?” 

Second, instituting a new service component

for homelessness in your behavioral health

program means staff development to confront

the myths about people who are homeless, the 

services they need, and how the services can

and should be provided. Staff development

may mean additional skills development or

enhancing and specializing skills that already

exist among staff members, who will need to

learn about additional resources in the community and how to collaborate with the organizations and people that provide them.

They might need cross-training to work with 

the specific needs of people who are homeless 

while maintaining their skills in behavioral 

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Behavioral Health Services for People Who Are Homeless 

health services. Working with homelessness 

may require case management and outreach

skills unfamiliar to most of the staff. For instance, behavioral health counselors working

with clients who have substance use disorders 

may end up doing outreach with clients who

show no interest in changing substance use 

patterns; mental health workers may feel uneasy at first seeing clients in settings other

than their office. 

You and your staff will need to interact with a

different network of community services. Programs primarily addressing homelessness in

the community may have a different orientation to services. For instance, programs for

homelessness may have a social service orientation; behavioral health programs, a healthcare-focused perspective. Rehabilitation in

homelessness programs may be more oriented

to life skills development, whereas behavioral

health programs focus on treatment and specific psychological strengths. Thus, community

programs created for homeless populations 

may have different goals, staffing patterns,

funding streams, or client goals. Behavioral

health program administrators, who often are 

more experienced in working in the health,

substance abuse, and mental health fields, 

should recognize these different perspectives 

and view them as strengths, not impediments. 

In addition to formal relationships among organizations, an informal system of community 

involvement, interorganizational relationships,

and services planning is required to bridge 

gaps between traditional behavioral health and

homelessness services. Later in this chapter,

the discussion of collaborative partnerships 

and service modification highlights this issue. 

Special Needs of Behavioral 

Health Clients Who Are Homeless 

Most clients who are homeless and need substance abuse or mental health treatment (and 

many clients in substance abuse or mental 

health treatment who enter treatment without 

housing or become homeless during treatment) have needs distinct from those of other

clients. Some problems may resemble those

experienced by many clients but differ in severity and incidence. These problems extend

beyond lack of housing and include psychiatric

impairments, drug use, financial mismanagement, criminal justice issues, and healthcare

needs. Thus, special program elements may 

need to be developed. These include outreach

and client retention programs, specialized case 

management efforts, and treatment planning

and approaches that integrate life skills development and specialized resources for relapse 

prevention and recovery promotion. 

Different Clients, Different Needs 

The three groups of clients who are homeless,

as defined in Part 1, Chapter 1, present different needs to your program. Some clients are 

homeless for the first time in their lives. Your 

program needs policies and procedures to

guide counselors and clinical supervisors in

helping in these emergencies. Clients who are 

transitionally homeless and are recovering

from substance use disorders may benefit from 

transitional living facilities, such as Oxford

Houses, described in Part 1, Chapter 1, of this 

TIP. Most communities have a variety of established resources for clients who are transitionally homeless. For instance, the Salvation

Army, along with other faith-based resources,

offers services for the transitionally homeless 

in many communities. These resources are especially valuable for families facing the crisis 

of first-time homelessness and can serve to 

prevent the development or exacerbation of

other psychosocial and health problems. 

Clients who are episodically homeless need

clinical workers who recognize and focus on

the stressors that caused the homeless episode.

Administrators need to have established 

156 
 

 

 

 

 

 

Part 2, Chapter 1 

linkages with such community resources as 

vocational rehabilitation, employment resources, financial and health services, and other community resources so that people who

are episodically homeless can quickly get back 

on their feet once they are stabilized and on a

recovery path. It is useful for administrators to

have open conduits to local entitlement agencies (e.g., Social Security, public assistance)

and to ensure that counselors are well trained 

to negotiate these systems to help clients in

crisis obtain or maintain the financial supports

to which they are entitled. 

Clients who are chronically homeless are often

the most visible subgroup of people experiencing homelessness in a community. They also

may be beset with the widest variety of cooccurring mental health, health, financial,

criminal justice, and employment issues in addition to their homelessness. Seldom is a 

community behavioral health program capable 

of addressing all of the needs of people who

are chronically homeless; thus, they must depend on linkages with housing, medical, entitlement, and other resources to begin to bring

stability to the lives of these clients. 

Regardless of the housing status of your program’s clients at intake, it is important to build

in resources for eliciting housing information

early in treatment to ensure that potential or

actual homelessness does not present as a crisis 

when a client prepares for discharge. 

Modifying Behavioral 

Health Services To Meet 

the Needs of Clients Who 

Are Homeless 

To serve people who are homeless, your organization can adapt its programs to provide services that were not previously available. These 

service modifications to meet the needs of 

people who are homeless take different routes 

based on knowledge about the target population. A bottom-up approach to service modification (described below) begins by evaluating

the needs of the people who will receive the 

services. In a top-down approach, the impetus 

for change comes from administrators, boards 

of directors, funding resources, and the like. If

you are unfamiliar with your community’s 

homeless population, a bottom-up approach is

best; top-down integration works best when

you know the population well and can assess 

in advance the major barriers to care and the

broad initiatives needed to overcome them. 

Top-down modifications often require some 

bottom-up information to make the right

choices. You can tentatively commit to a plan

but then engage in community discussion before acting, making modifications as necessary. 

Bottom-Up Service Planning 

Bottom-up service planning is a process of

using peer workers, case managers, clinicians,

supervisors, and administrators to develop a

program that meets identified needs of a special client population. It often starts with a few 

unique, complex cases—for example, developing services for people who often use emergency shelters, emergency rooms (ERs), or

detoxification centers. The project scale increases incrementally as effective practices are 

established and resources become available. 

The first stage of bottom-up service integration is to identify the target population and

engage people in services and then develop

feedback mechanisms to identify what works 

and how to improve program efficiency. Ask 

people from the target population about their

priorities informally or via surveys or focus

groups. The National Health Care for the 

Homeless Council Web site 

(http://www.nhchc.org/advisory.html) offers a

manual for involving a formal consumer advisory board. 

157 
 158

Exhibit 2-2: Key Components for Bottom-Up Modification 

1. Sense of urgency. Frontline staff may fear that failing to engage people in services will lead to 

victimization on the streets, untreated physical illness, or deteriorating life situations. This fear 

propels the staff into a sense of urgency about helping people get the services they need. 

2. Support personal responsibility. Clinical supervisors and administrators support the frontline 

staff in embracing personal responsibility for the advocacy for each case. This includes understanding the staff’s experiences and providing flexible support (e.g., willingness to modify team 

structures) so the staff can more easily accomplish its work. 

3. Negotiate, collaborate, and advocate. Frontline staff members, supervisors, and administrators 

who are committed to providing services to the target population negotiate, collaborate, and 

advocate with other service providers to meet each client’s needs. Interorganizational partnerships facilitate this through joint supervision of day-to-day activities. 

4. Hold weekly frontline staff meetings. Case managers, clinicians, and supervisors meet weekly 

to capture the collective wisdom gained in this learning process and channel their enthusiasm into understanding how to do the work effectively. They discuss and develop methods to address 

missed opportunities to connect with other service providers and potential clients. 

5. Hold monthly administrator meetings. You and other administrators discuss the learning process and set principles of practice and procedures as needed (e.g., through case descriptions, 

understanding barriers to services and missed referrals, advocating for access to services on a 

case-by-case basis with State administrators). You’ll gain a better understanding of the work by 

meeting clients and providing some direct services. 

6. Include appropriate partners. As you identify new service needs and resources in your organization or in the community, include appropriate partners in the learning process. 

7. Obtain new funding resources. New funding allows the project to serve more clients. 

Sources: Rowe, Hoge, & Fisk, 1996, 1998. 

 

 

 

Behavioral Health Services for People Who Are Homeless 

Collaborating with partners to 

identify and engage the target 

population 

Bottom-up service modification can be a collaboration between nongovernmental organizations (NGOs) or between programs within

an NGO. The first step is small but dynamic:

collaborating with other service providers who

can help identify your target population and

introduce you to new clients. These collaborations can be informal or formal. Documentation at this stage is simple: tracking where 

people are identified and their progress 

through the system. Exhibit 2-2 lists some 

helpful elements in bottom-up modification. 

How do you perform bottom-up 

services modification? 

Step 1: Perform a needs assessment. The needs 

assessment includes gathering data not only 

on the demographics and expressed needs of 

the homeless population to be served, but also

on how those services can be most effectively 

delivered, which services seem to result in client change, and which services can be offered

over time (see needs assessment steps listed on

p. 164). 

Step 2: Get internal buy-in. Take your needs 

assessment to the CEO, chief clinical officer,

and/or board members and develop a plan for

how to proceed that includes identifying potential funding sources, stakeholders, staff

members, and services that can reasonably be 

added to drive the initiative. 

Step 3: Make contact with funding sources. Organization administrators seek funding to

meet the needs of the population. Once the 

possibility of funding exists, go to Step 4. 

Step 4: Identify stakeholders. Identify other participants in your effort, begining with your

clinical staff and fellow administrators. Other 

158 
 

 

 

Part 2, Chapter 1 

potential stakeholders include:

•	 Your board of directors. 

•	 The local continuum of care (housing providers; mental health, substance abuse, and

medical treatment providers; hospital 

emergency departments; and staff members of criminal justice programs). 

•	 Local business owners and legislators with 

whom your organization has strong relationships. 

•	 Program alumni and other community 

supports (e.g., faith-based institutions). 

•	 Community boards. 

•	 Private foundations for matching funds. 

Step 5: Create and formally present a concept paper. A strong grant-writing team or consultant 

creates the concept paper. Critical issues to

address include: 

•	 A clearly articulated problem statement,

proposed plan, implementation process,

timeline, and evaluation process. Describe 

the problem using a combination of statistics and short personal stories. 

•	 How the resources you are seeking fit your

organization’s mission/strategic plan. 

•	 The roles to be played by your partners. 

•	 If you are seeking private funding, a plan

for transitioning to public funding. 

Step 6: Conduct postpresentation activities. 

Homelessness is a politically charged issue;

handle contacts with funders with tact. 

Step 7: Receive funding. Designing and funding

your initiative ends; implementation begins. 

Adapting clinical services to meet 

the needs of the target population 

At this stage, you and the clinical staff learn to

adapt clinical practices to meet the needs of

clients and influence institutional policy. Focusing on individual cases of homelessness 

makes it easier to understand the context of 

counselor–client work and the barriers to doing the work. For example, counselors in a detoxification program (in the same organization

as an intensive substance abuse treatment program) request case-by-case exceptions for

people who are homeless to a policy barring

readmission of clients within 30 days of discharge. In each case, the counselors argue that

the policy is a barrier to rapid readmission to

substance abuse treatment, which would reduce the relapse severity and the length of

treatment needed by the client. As the cases 

brought to the administrator accumulate, he or

she eventually changes the policy. 

As project scale increases and clients engage,

you will identify other components of care:

•	 Frontline staff note good collaborative experiences with some NGOs, whereas others do not meet the expected clinical 

standards when working with people in

intensive substance abuse treatment who 

are homeless. Referrals are withheld from 

the latter, which may stimulate development of more flexible services in the community and a corresponding increase in

referrals. Counselors, case managers, and

supervisors realize the need for service and

policy modifications to better meet the 

population’s needs. For example, after observing that some people feel isolated

when placed in their own apartments, create an alumni program to facilitate connection to community recovery supports 

and help people successfully transition to

permanent housing. 

•	 Documentation and use of surveys and

feedback loops become more sophisticated

and formalized to enable sharing of information with funding sources and State authorities. 

•	 As clinical and administrative leaders formalize the integration of people who are 

homeless into the organization and the

treatment system, their bottom-up efforts 

lead, directly or indirectly, to top-down integration opportunities. 

159 
 160

 

 

 

 

Behavioral Health Services for People Who Are Homeless 

Top-Down Service Modification 

Top-down service modifications work when

you are familiar with the target population and

can assess and overcome the barriers to care. 

You can develop service modifications through

negotiations with other providers within and

across service systems. Such strategies are informed by bottom-up processes, such as solving dilemmas that arise in frontline work. 

How do you perform top-down 

services modification? 

Step 1: Allocate money. A request for proposals 

is issued or a service need is identified. 

Step 2: Identify stakeholders/collaborators.

•	 Identify stakeholders—representatives of

local governments, businesses, employers, 

recovery communities, and other service 

providers who will want to refer clients to 

your program. 

•	 Identify partners—outreach teams, housing providers, mental health treatment 

providers, vocational and recovery service

providers, financial and health benefit providers, and primary healthcare providers

who want to develop new capacities in existing programs or create new interagency 

programs. 

•	 Identify the scope of the project and the 

role of each partner. 

•	 Get letters of support from partners, recognized advocacy groups, and other stakeholders. 

Step 3: Find local or regional resources to help you 

develop the program. Bring in resources as 

needed to help you define the services you 

wish to provide, the adaptations your program

will need to make, and a timeframe for implementing services. 

Step 4: Write a proposal or concept paper. Include 

a budget; bring all collaborators to the table. 

Step 5: Implement the plan once a contract is

awarded. 

•	 Hold an upper-level advisory and implementation meeting: 

–	 Administrators involved in the partnership (interorganizational) or programs (intraorganizational) meet and

identify what needs to be done, what

needs further investigation, and who

will be responsible for doing so. 

–	 A memorandum of understanding

(MOU) or memorandum of agreement

(MOA) between the NGOs (interorganizational only) is drafted and describes tasks and roles. (A sample 

MOU appears in Part 2, Chapter 2.) 

•	 Assemble an implementation team: 

–	 During the startup period, program directors work together to coordinate

services. 

–	 The team identifies other committees 

(e.g., screening, case management) and

persons (e.g., consumers, senior clinical 

staff members, line counseling staff

members, peer counselors, program 

evaluators) to be involved in administering the project. 

–	 The team addresses confidentiality 

agreements, admission criteria, and intake forms. 

•	 Form a team of service providers; define 

their roles. Staff members from collaborating programs create a core team to provide

services and cross-train and educate each 

other about their programs, organizations,

and roles. Potential members include: 

–	 Peer counselors. 

–	 Outreach workers. 

–	 Case managers. 

–	 Substance abuse and mental health 

treatment counselors. 

–	 Team leader(s) who collaborate with

peers in other NGOs, provide some 

clinical services and supervision, and

are trained to work with people who 

160 
Part 2, Chapter 1 

 

 

 

 

have been diagnosed with co-occurring

disorders (CODs). 

–	 Consultants on medical and mental 

health needs of individuals who are 

homeless who facilitate petitions for

involuntary transport and hospitalization when necessary. 

–	 Liaisons to detoxification services,

criminal justice, and financial and

health benefits. 

Step 6: Schedule regular interorganizational

meetings. Address policies and procedures that

inhibit service provision to people who are 

homeless. Regular working groups can include: 

•	 Advisory board. Upper-level managers 

from each collaborating organization or

the head administrators from each organization to be involved in proposal creation,

addressing outcome measures, data, reports for the funder, and the like. 

•	 Client selection committee. Midlevel clinical/program directors from each organization. 

•	 Interorganization/interdisciplinary clinical

case management team. Direct service 

staff meet weekly to discuss new admissions, people in transition, and particularly 

challenging cases. 

•	 Stakeholder advisory group. Keeps community stakeholders aboard as program

starts. 

Example of successful service 

modification: Health Care for the 

Homeless 

In practice, programming changes often combine bottom-up and top-down strategies.

Health Care for the Homeless (HCH) in Baltimore, MD, provides an excellent example of

this combination, which results in comprehensive services provided when the client is ready. 

Bottom-up service modification 

Begun in 1985 as a small triage and outreach

unit, HCH is now accredited by the Joint

Commission on the Accreditation of 

Healthcare Organizations. By adding programs as needs were identified, HCH now 

offers a broad range of services: street outreach, primary health care, mental health services, intensive outpatient substance abuse 

treatment, medication-assisted treatment, and

referrals to residential treatment. A bottom-up 

modification resulted from an analysis of intakes that revealed that people purchased buprenorphine on the street when they could not

access detoxification services. This suggested a

need for a buprenorphine initiative to improve

engagement and treatment retention. Funding

for a nurse and case manager was sought and

won, but for only one position. A nurse/case 

manager was hired for a caseload of five clients 

daily. When he left, a substance abuse case 

manager was hired and an agreement was created with the health center staff to administer 

and store the medications. 

Top-down service modification 

A top-down modification was prompted by 

requirements from funding sources that influenced the length of service delivery and program development. Separate funding streams 

for mental health (mostly third-party billing

systems) and substance abuse treatment services (mostly public funding and grants) created differences in approaches to service 

delivery. Federal requirements for more formal 

data and reporting mechanisms led to State 

service outcome benchmarks for the substance 

abuse treatment program that focused heavily

on abstinence, program use, and retention. To

meet these benchmarks and the engagement

needs of people who are homeless, HCH created a pretreatment phase supported by the 

City of Baltimore. People in precontemplation

for substance abuse treatment receive readiness 

161 
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Behavioral Health Services for People Who Are Homeless 

counseling focused on health education that

engages them in treatment at their own pace. 

Interacting With 

Community Resources To 

Build a Continuum of Care 

HUD defines a continuum of care as a local 

planning process involving the range and diversity of stakeholders in a community in assessing and planning for the needs of people 

who are homeless. Normally, one superagency 

is designated as the coordinator of the continuum of care planning process, and one application is made on behalf of the community for

HUD funding. “Community” is defined by the 

continuum of care planning process as the geographic area included in the application. The

application is based on assessed needs for

three types of housing in the community:

emergency shelter, transitional housing, and

permanent housing, along with the supportive

services needed to address each of these housing needs. One of the features that makes the 

continuum of care process unique is that it

may include nonprofit agencies, governmental 

agencies, community-based organizations,

agencies in the community that provide supportive services (such as mental health and

substance abuse treatment programs), local 

businesses, law enforcement, and consumers 

who are homeless or were formerly homeless. 

Rarely is one program able to meet all of the 

client’s needs, as the continuum of care implies. As a result, collaboration among programs is essential. Although your program’s 

counselors may interact with other agencies at

the level of the individual client through outreach, treatment planning, case management,

treatment, and follow-up, administrators must

work to develop collaborative continua of care,

overcome interagency barriers, and ensure that

there is “no wrong door” through which to enter services. This is particularly true when addressing the needs of clients who have two or

more urgent, severe problems—homelessness 

and substance abuse or mental illness. Likewise, although a homelessness program may 

employ behavioral health counselors, they are

seldom equipped or funded to provide the full 

complement of services necessary for comprehensive substance abuse and mental health 

treatment. 

An integrated system of care that provides a

continuum of housing services increases communication among the organizations involved,

improves coordination among providers, and

serves more people who are homeless. Examples of the interrelationship of a continuum of

care, organizational strategies for supporting

program development and service modification, and strategies for effective service delivery appear later in this chapter. Exhibit 2-3 

highlights the benefits of an integrated system 

of services for people who are homeless. 

Collaborative Partnerships 

In interacting with other community resources 

and becoming part of your community’s continuum of care, you can establish collaborative 

partnerships with other agencies that serve 

substance abuse and mental health clients who 

are homeless. These partnerships can help

your organization expand its range of services, 

link up with other systems, and foster innovative programming, funding, and community 

acceptance (Substance Abuse and Mental 

Health Services Administration [SAMHSA], 

2006). 

Successful collaboration requires negotiation,

compromise, and commitment to address a 

problem about which all stakeholders experience a sense of urgency and responsibility. An

early step in forming partnerships is sharing

different perspectives on the problem (e.g.,

lack of treatment resources versus lack of 

162 
 

 

 

 

 

Part 2, Chapter 1 

Exhibit 2-3: Integrated System of Homelessness Services 

Components Description Goals 

Continuum of 

Care 

A plan and infrastructure of formalized operations and coordinated 

services provided by multiple organizations. Involves a continuum 

of care plan, MOUs, sharing of information, resources, and improved access to services. 

Collaborate to offer an array of needed services: 

• Develop procedures that allow for 

interaction of agencies as needed. 

• Document the changes in procedures. 

• Identify and share best practices. 

Service Providers Providers collaborate to secure 

funding and provide an array of 

housing, substance abuse treatment, mental health services, support services, health centers, and 

other services. 

Increase effectiveness of services delivered through organizational change 

processes: 

• Assess service outcomes and staff 

skills to deliver services. 

• Collect information to track and 

analyze change. 

• Engage in activities to support 

change. 

Services Housing, support services, and 

substance abuse treatment and 

mental health services are tailored 

to be responsive to the needs of 

people who are homeless. 

Identify and provide: 

• Acceptable services and treatment 

to help people access and maintain 

stable housing. 

• Effective strategies for people with 

complex housing, service, and 

treatment needs. 

Source: Leginski, 2007. Adapted with permission. 

appropriate housing stock) and establishing

guiding principles or assumptions for the collaboration. Failure to resolve different perspectives can cause covert power struggles. Other

barriers to overcome when pursuing partnerships include:

•	 Competition for scarce resources among

community organizations. 

•	 Unwritten policies of daily service delivery. 

•	 Service organizations that resist change. 

Creating Interorganizational 

Partnerships 

To address system and service delivery problems with people who are homeless, assess the 

problem and gather information about the

target population and the strategies needed to

resolve the problem. 

Interorganizational needs 

assessment 

To assess the needs of an interorganizational

continuum of care, determine the size and

characteristics of the population that is homeless and assess issues raised by community 

members, governmental agencies, and service 

providers. One way to start is by talking with

other service providers who work with people 

who are homeless and working with the organization that will apply or has applied for

HUD funds. In some localities, a single organization or agency represents the community’s 

needs. The information contained in the 

“Continuum of Care” application often provides a thorough review of strengths and gaps 

in the community’s services. 

163 
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Behavioral Health Services for People Who Are Homeless 

Intraorganization assessment 

To assess your organization’s ability to assist

people who are homeless, analyze the number

and characteristics of people seeking services 

who are homeless or at risk of homelessness. 

Start by counting the number of people who

are homeless or at risk of homelessness who 

are admitted to substance abuse or mental 

health treatment during a 2- to 4-week period.

Other measures include the number of people 

admitted with criminal justice involvement

and the number discharged without employment, job training, or stable housing. This type 

of assessment includes staff discussion of findings at team meetings to better understand

how organizational factors influence findings. 

Steps in the assessment process 

•	 Determine the population’s gender, ethnic, and racial makeup; criminal justice experience; family status; language; and

nature of homelessness (i.e., situational,

episodic, chronic). 

•	 Determine whether these characteristics 

are reflected in the staff providing services. 

•	 Identify gaps in the continuum: 

–	 Are people not staying in treatment? 

–	 Are some counselors seeing 1 client

who is homeless per month while others see 10? 

–	 Are clients referred from other services 

in a coordinated fashion, or are they

walking in without referrals? 

–	 Are clients transitioning out of substance abuse or mental health treatment 

without employment and housing? 

–	 Do clients have a primary care provider and affordable access to needed 

medication? 

–	 Are some programs in the organization

declining referrals because the clients 

are homeless? 

–	 Do some programs in the organization

have particular difficulty working with

clients who have either substance use 

disorders or mental illnesses? 

•	 Identify policies and procedures contributing to service gaps and consider how to

change them; use a formal continuous 

quality improvement methodology. See 

the Network for the Improvement of Addiction Treatment’s Primer on Process Improvement (2008). The Addiction

Technology Transfer Center Network 

(2004a,b) also offers useful publications on

the topic. 

•	 Identify issues in the community, such as: 

–	 More people living on the streets. 

–	 Legislation that handles homelessness 

through arrest rather than social services. 

–	 Insufficient affordable housing stock. 

–	 Insufficient mental health, substance 

abuse, and medical treatment services. 

•	 Determine whether this is an opportunity 

to partner with other providers to improve

access to services, create resources to meet

the needs of people who are homeless, and

reduce costs to the community: 

–	 If services to address these issues are 

compatible with your organizational

mission and strategic plan, then develop programming. 

–	 If these services aren’t part of your strategic plan or mission, look for community partners. 

–	 If other providers can’t offer needed 

services, consider developing them in 

your agency. 

Exhibits 2-4 and 2-5 provide information on 

forming and documenting partnerships. 

164 
 

Exhibit 2-4: How To Develop Partnerships 

1. Identify organizations in your community affected by homelessness and NGOs and government 

entities that already provide services or interact in the community with people who are homeless. 

2. Reach out to and become familiar with potential partners (e.g., police, emergency services, businesses, elected officials, neighborhood organizations, health centers); the key to partnerships is 

finding a shared objective. 

3. Agree on a definition of the problem; assess your readiness to partner with them and theirs with 

you. 

4. Form a partnership that benefits both organizations. 

5. Define the benefits for each partner. 

6. Identify the contributions each organization must make in order to realize these benefits. 

7. Sustain partnerships by negotiating agreements that capture the basis of the partnership and the 

active linkages between partners that allow monitoring of both challenges and successes. 

Source: SAMHSA, 2006. Adapted from material in the public domain. 

Exhibit 2-5: How To Document Partnerships 

A memorandum of agreement is a written agreement between parties (e.g., NGOs, Federal or State 

governments, communities, and/or individuals) to work together on a project or meet an objective. 

An MOA outlines the responsibilities and benefits of each partner. It can be a partnership agreement 

or a legally binding document that holds parties responsible to their commitment. 

A memorandum of understanding is less formal than an MOA. Many NGOs and government agencies 

use MOUs to define relationships between departments or NGOs and to ensure smooth operations 

of shared resources and service provision. MOUs can address intraorganizational connectivity, communications, escalations, and response patterns. See Part 2, Chapter 2, for a sample MOU. 

Part 2, Chapter 1 

Example of Successful 

Partnership: Downtown 

Emergency Service Center 

In Seattle, WA, the Downtown Emergency 

Service Center (DESC) has used partnerships 

to improve housing services, integrate treatment services, access other community resources, and create innovative housing

programming (SAMHSA, 2006). 

Internally, DESC integrated its shelter, clinical 

services, and housing programs. Staff members 

from each clinical program (i.e., outreach and

engagement case managers, substance abuse 

treatment counselors, and crisis respite program workers) are co-located in the shelter.

DESC provides intensive support for housing

stability by having one project manager supervise the staff responsible for supportive housing property management and the staff responsible for supportive services. DESC uses 

information technology to make information

about people receiving services available to

staff members in different programs. In daily

meetings, outreach and engagement, housing,

and clinical services staff members discuss new 

clients and emerging client problems. 

DESC partners externally with community 

services and political organizations. Community partners include the Seattle Department

of Social and Health Services, the police department, mental health and drug courts, and 

the local emergency center. Political partners 

include the county executive, mayor, and

downtown association president. To increase 

access to benefits for people who can’t tolerate 

the regular process, the staff represents them

and works directly with benefit managers, 

165 
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Behavioral Health Services for People Who Are Homeless 

resulting in more successful benefit applications. A mutually beneficial collaboration with

the police includes offering a standardized

program for police trainees to work alongside 

service providers, making shelter space available as an alternative to incarceration, assisting

with safety issues, and meeting regularly to

address issues. 

DESC provides case management, substance 

abuse treatment, and mental health and employment services to people referred by the 

drug court. Shelter staff communicate daily 

with the ER to increase the shelter’s access to 

emergency medical care. DESC obtains donations from businesses by showing that the 

housing program decreases the use of emergency services, jail, court, and detoxification,

and saves the community money while providing more humane, respectful services for people who are homeless. DESC maintains a

strong relationship with political partners by 

showing that programs effectively meet the 

needs of people who are homeless and by advocating for policies that facilitate innovative

programming, funding, and support. DESC’s 

relationship with political partners supported

the creation of an innovative housing and

treatment program in Seattle. 

Internet Resources 

Becoming informed about housing programs 

is one way you can help your program create 

relationships with other community agencies 

serving people who are homeless. A great deal 

of information is available on the Internet 

from the following Web sites:

•	 U.S. Department of Housing and Urban

Development: http://www.hud.gov 

•	 National Alliance to End Homelessness: 

http://www.naeh.org 

•	 Corporation for Supportive Housing:

http://www.csh.org 

•	 SAMHSA’s National Registry of

Evidence-Based Programs and Practices:

http://nrepp.samhsa.gov 

•	 National Health Care for the Homeless 

Council: http://www.nhchc.org 

•	 U.S. Department of Health and Human

Services (HHS) Health Resources and

Services Administration Information 

Center: http://www.hrsa.gov 

•	 U.S. Department of Veterans Affairs (VA)

Web site on reaching out to veterans who

are homeless: 

http://www1.va.gov/homeless 

•	 VA Web site on health benefits eligibility 

for veterans: 

http://www.va.gov/healtheligibility 

•	 National Resource Center on 

Homelessness and Mental Illness: 

http://www.nrchmi.samhsa.gov 

Integrating Behavioral 

Health Services With a 

Community System of 

Homelessness Services 

Across the continuum of rehabilitation services for people who are homeless, a variety of

community care providers may be engaged

with the client. Some of these services include 

mental health and substance abuse treatment,

housing and rehabilitation services specifically 

for people who are homeless, general healthcare programs, and other community social 

and rehabilitation services. Your program may

be a small part of the larger services continuum, or may be a major provider of care that

spans several of these domains. In either case,

it is important that programs have a common

goal of quality care for people experiencing

homelessness, a recognition that homelessness 

in the community cannot be addressed by 

simply providing shelter, and a commitment to

and a strategic plan for the coordination and

nonduplication of services. 

166 
 

 

Part 2, Chapter 1 

Additionally, there are distinct phases of care 

for persons who are homeless and are affected

by substance abuse or mental illness. These are 

described in Part 1, Chapter 1, and include 

engagement, intensive care, and ongoing rehabilitation (McQuistion, Felix, & Samuels,

2008). Two additional transition phases (from

engagement to intensive care and intensive 

care to ongoing rehabilitation) are critical

times during which clients may regress from 

their homelessness rehabilitation, experience a

relapse to their substance use or psychiatric

symptoms, or drop out of treatment; these

phases are therefore important to consider in

your community programming. 

In a few communities, the entire continuum of

care might be offered by one comprehensive 

program, but it is more likely that different

organizations work at different points on the

continuum. Be aware of services provided in

your community, the scope of the services in

an individual agency, and the extent to which 

outreach and treatment services for behavioral 

health are provided. This will allow you to

identify gaps in services and develop programs 

to address them. 

The phases of rehabilitation form a framework

that can guide your decisionmaking about

program development, implementation, management, and evaluation. The outline below 

lists the ways your agency can prepare for and

participate in providing services to clients who

are in each phase of rehabilitation from homelessness. 

Outreach and Engagement 

In this first phase of rehabilitation, counselors 

begin to build and leverage relationships to

offer the kinds of help needed by people with

substance use and mental disorders who face 

homelessness. As an administrator, you can:

•	 Establish collaborative relationships with

community organizations. 

•	 Form interdisciplinary teams from several 

organizations that are coordinated through 

a single entity. Teams can provide direct

access to services that meet client needs 

and help clients transition from this phase 

into intensive care. Outreach services that 

respond to community stakeholders’ needs

include taking hotline calls from individuals and neighborhood and civic association

representatives, in addition to forging

strong relationships with local police precincts and ERs. 

•	 Schedule staff members to be off site and 

available to potential clients. 

•	 Ensure that your staff has the training and

experience to perform outreach and engagement and to work with individuals 

and families experiencing crises related to

homelessness. This also entails being

aware of community resources for emergency and temporary housing, their restrictions and limitations on services, and

their admission requirements. 

•	 Provide funding for practical goods and 

resources that can be offered to prospective 

clients (e.g., specific needs of children who

live in families who are homeless, battered

and abused women and children, people 

who live on the street). 

•	 Develop tools to document outreach contacts. (See Part 2, Chapter 2, for a sample 

Homelessness Outreach Contact Form 

and a sample Daily Contact Log.) 

•	 Provide training for staff members to prepare them for the realities of outreach

work (e.g., working outside the office setting; working with individuals and families

who are experiencing immediate crises;

working with people who want resources 

but resist or only passively comply with

treatment services; tolerating clients who

are inconsistent in their contacts and appear one day, then disappear for several 

days). 

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Behavioral Health Services for People Who Are Homeless 

•	 Ensure that your staff is trained in the appropriate interventions for this phase of

homeless rehabilitation (such as rapport

building) and that staff members are able 

to rapidly develop case management plans 

for services. 

•	 Ensure that staff members can recognize

signs that a potential client is ready to

make a transition to the intensive care 

phase of homeless rehabilitation or the

contemplation stage of change for substance abuse or mental health treatment. 

•	 Provide supervision for outreach workers. 

•	 Provide a forum for discussion of policies 

and procedures related to conduct and 

safety on the street and in shelters; formalize policies and procedures (see Part 2,

Chapter 2, for samples). Policies should

require that staff members work in pairs,

carry cell phones, and be able to contact a

supervisor when needed. Policies and procedures should require teams to leave situations in which any one member feels 

unsafe and to choose next steps together. 

•	 Plan and structure critical incident debriefings. 

•	 Discuss steps necessary for quality assurance. 

Transition to Intensive Care 

This phase begins when the client agrees to

accept case management, entitlements, housing, treatment, health care, or other services—

or when there is a need for acute medical or 

mental health treatment. As an administrator, 

you can:

•	 Formalize policies and procedures for

recordkeeping for potential clients entering the system. 

•	 Provide for delivery of tangible benefits,

such as food, clothing, and transportation. 

•	 Enlist help from emergency shelters for

pretreatment beds to house clients while 

they wait for treatment slots. 

•	 Assign case management specialists to

provide flexible services, such as housing

negotiation, completion of financial

and/or health benefit applications, and assistance with using public transportation. 

•	 Provide intensive case management (ICM)

and critical time intervention (timelimited ICM) to potential clients as appropriate. These strategies help the agency 

keep track of clients, help clients stay connected to the agency, and provide access to

a variety of services and agencies. 

•	 Offer attractive support services for clients, 

such as employment, financial and health

benefits, and medical and mental health

services. 

•	 Offer peer-led services to encourage engagement in services and enhance empowerment and confidence. 

•	 Coordinate transition planning with local

agencies, such as jails, hospitals, and substance abuse and mental health treatment 

programs, to provide housing resources for

clients being discharged or released. 

•	 Develop protocols for transition planning. 

•	 Offer transportation to housing for clients

exiting jails, hospitals, or treatment programs. 

•	 Ensure that your staff is familiar with your

community’s housing resources, their requirements, and their limitations. 

Intensive Care 

Intensive care begins when a person engages 

in a clinic, shelter, outpatient, or residential 

treatment program, accepts ACT team services, or obtains transitional or permanent

supportive housing (McQuistion et al., 2008).

Treatment of substance use and mental disorders and medical conditions is the primary 

focus during this phase. You can:

•	 Develop MOAs and MOUs with collaborating housing resources in the community 

(e.g., programs providing transitional and 

168 
 

 

 

 

 

Part 2, Chapter 1 

permanent supportive housing) so clients 

do not fall through the cracks in transitioning between or working with two different community systems (housing and

behavioral health). 

•	 Provide thorough screening and assessment by behavioral health professionals 

that includes assessment of substance use 

and mental health as well as housing

needs, financial status, employment status,

and other areas of life functioning. 

•	 Fully accomplish active introduction to

ongoing and nonemergent general health

and wellness services, whether off site with 

active case management or on site through 

implementing models of behavioral health

and primary care integration. 

•	 Increase engagement and retention by reducing or eliminating waiting time; using

peer facilitators, mentors, and senior program participants to orient people to services right after they are assigned to a

treatment program; and providing educational sessions for the client’s family as appropriate. 

•	 Provide peer mentoring to strengthen

connections to recovery supports. 

•	 Develop methods to improve compliance 

with treatment of substance use, mental 

illness, and medical disorders and conditions. 

•	 Address, through your programming, the

needs of parents with children. Provide 

services or care for children in your agency 

or by referral. Offer treatment with a

family focus. Assess the safety of children

who do not accompany their parents to

treatment. 

•	 Ensure that the services you provide are 

trauma informed. Offer anger management and assertiveness training. Provide 

training to staff in nonconfrontational

methods of addressing conflict and in 

strengths-based approaches. Offer genderspecific treatment groups (see the planned 

TIP, Trauma-Informed Care in Behavioral 

Health Services [SAMHSA, planned h]). 

Be familiar with behavioral health treatment models for people who are homeless 

and how your community uses those

models. 

Behavioral health treatment models 

for people who are homeless 

You should be familiar with rehabilitation 

models for people who are homeless. Your

agency may want to partner with other agencies in your community; your staff members 

may want to be involved with clients from 

other programs. This section describes three 

approaches. Assertive community treatment

was first used for people with serious mental 

illness (SMI) at high risk of institutionalization and modified for people who are homeless. HCH is a model program designed to

engage people who are homeless into housing,

services, and substance abuse recovery. Modified therapeutic communities (MTCs) combine housing and treatment program models. 

ACT teams 

SAMHSA has designated this evidence-based

practice as appropriate for clients who have 

extensive histories of psychiatric hospitalization, are homeless, have co-occurring substance abuse or medical problems, and/or are 

involved in the criminal justice system. ACT

services are sometimes used in Housing First

programs, but ACT teams also function independently of housing programs and are often

part of a behavioral health organization. A 

team-based approach is used to offer substance abuse and mental health treatment,

housing, healthcare, medication, and employment services; help with family relations; and

recreational opportunities. People can refuse 

formal treatment without losing housing. Even

then, the team visits at least weekly to assess 

the person’s safety, well-being, and living conditions and to keep communication channels 

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Behavioral Health Services for People Who Are Homeless 

open between the client and the team. On visits, the team notes the person’s mental and 

physical state, follows up on outstanding issues 

from the last visit, and offers help with whatever the individual wishes to address. The 

team often helps with routine chores and conveys to the individual that he or she matters to

the team (Hackman & Dixon, 2006). 

Health Care for the Homeless 

HCH combines comprehensive services in a 

manner that is appealing to people who are 

homeless. Substance abuse treatment intake,

assessment, and engagement occur on a flexible 

walk-in basis to accommodate clients’ difficulty 

with keeping appointments. Participants who

meet the criteria for outpatient or intensive 

outpatient treatment are encouraged to engage 

in treatment at HCH. Those needing inpatient medical care, methadone maintenance, or

residential treatment are referred to other programs. People too ill to navigate the shelter

system are provided shelter and nursing services in a convalescent care program. 

Counselors assess for substance use, symptoms 

of mental illness, housing, criminal justice system involvement, social supports, job interests,

work history, and goals, then reframe this information to reflect client strengths and increase motivation to complete treatment and

pursue stable employment when possible.

Each counselor sees 15 to 20 clients. Each 

caseload is a mixture of people in various stages of treatment preparedness. Clients receive 

individual counseling once a week or as often

as determined by their recovery plans, including walk-in sessions. The group counseling

program is based on the stages of change. 

Modified therapeutic communities 

MTCs are specialized residential settings

staffed by workers who are trained to address 

both mental and substance use disorders. This 

model includes a supportive housing component in continuing care. 

Following the client’s decision to accept MTC 

services, a structured daily regimen is gradually 

introduced. Services emphasize personal responsibility and mutual support in addressing

life difficulties, peers as role models and

guides, and the peer community as the healing

agent. Staff and clients create action plans to

monitor short-term goals. These goals build as 

success accumulates, adapt to reflect relapses 

and return of symptoms of mental illness, and

reflect the unique needs and readiness for

change of the individual. 

At program entry, clients join a housing

preparation group and receive other initial services. Staff members build trust, increase motivation, and provide education on

homelessness, mental illness, and substance 

abuse through multiple contacts and a weekly 

orientation group. The group also strengthens 

peer affiliations and provides information on

program structure and activities. 

MTCs operate on token economies. Points are 

won for behaviors, such as medication compliance, abstinence, attendance at program activities, follow-through on referrals, completed

assignments, and activities of daily living.

Negative behaviors result in loss of points.

Points can be exchanged for phone cards, toiletries, and so forth. Peer facilitators act as role

models to encourage the involvement of people who are newly admitted, build hope, and

plan for the future. 

Teaching vocational and independent living

skills is a key part of an MTC program. Vocational activities begin shortly after entry, and

work experience begins in a peer work group.

Vocational exploration and work readiness assessments detail client work history, interests,

attitudes, and ability to find a job (e.g., applications, interviewing, interpersonal relationships). 

170 
 

 

 

 

 

Part 2, Chapter 1 

Basic vocational skills training in maintenance,

clerical, and inventory tasks are taught, with

weekly job assignments and peer group review. 

Interested individuals who show commitment 

to the program, personal progress, and ability 

to help others are recruited into peer counselor

training near the end of residential treatment.

They get didactic and practical experience as

role models, group facilitators, and counselors

and attend briefing and debriefing sessions

before and after each group and activity. The

supervisor or program director provides supervision each week and a written evaluation each 

month, and other staff members, assisted by 

senior trainees, run weekly peer counselor

training groups. Trainees are paid a stipend.

Those who successfully complete both peer 

counselor training and the MTC residential 

program can become counselors in the MTC 

or comparable programs. 

Transition to Ongoing 

Rehabilitation 

This transition is gradual and is a high-risk 

time for dropout and/or relapse. Much of the 

programming that behavioral health programs

can undertake at this phase relates to building

recovery skills, reducing relapse risks, and encouraging participants to increase their involvement in the community through 12-Step 

programs and other community support efforts. Transitional housing for individuals leaving intensive behavioral health treatment, as

described in Part 1, Chapter 1, may become a

primary support for the transition to ongoing

rehabilitation. Halfway and 3⁄4-way houses for

individuals graduating from intensive behavioral health treatment and Oxford Houses for 

people recovering from substance use disorders 

are examples of housing resources that can

benefit individuals making the transition to

ongoing homelessness rehabilitation. To make 

your program most effective at this stage, you 

can: 

•	 Facilitate staff efforts to plan for discharge

from substance abuse or mental health 

treatment for clients facing homelessness. 

•	 Plan for clients’ ongoing medical and rehabilitation needs, including continuing

care, relapse prevention training, support

services, transportation, and other recovery

supports (see the planned TIP, Recovery in 

Behavioral Health Services [SAMHSA, 

planned e]). 

•	 Include ICM and other evidence-based 

practices that support recovery. 

•	 Maintain agency contacts with the housing network, particularly transitional supportive and permanent supportive housing. 

•	 Facilitate connections in the community 

that could provide opportunities for clients 

to obtain paid or volunteer work. 

Ongoing Rehabilitation 

In this open-ended stage, the client selfidentifies as no longer homeless, sustains and

further incorporates changes made in intensive 

care, and works to avoid relapse (McQuistion

et al., 2008). Administrators can:

•	 Support staff members as they continue to

devote time to clients in ongoing rehabilitation and abstinence (e.g., by helping clients establish roles in the community). 

•	 Provide a means for clients to contact the 

agency in case of a relapse to substance 

use, a return of symptoms of mental illness, or a crisis in housing. 

•	 Provide ongoing support for clients, including regular follow-up meetings or

phone calls. 

Service approaches—model 

programs 

Permanent supportive housing 

Permanent supportive housing for persons 

with psychiatric disabilities offers individuals 

who are homeless, at risk of homelessness, or

precariously housed an opportunity to obtain 

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Behavioral Health Services for People Who Are Homeless 

and maintain a residence in the community.

The residence can be a single-occupancy

house or apartment (scattered-site housing) or

single-site housing, in which residents share 

apartments in a single building or cluster of

buildings. Permanent supportive housing offers people the opportunity to be integrated

within the larger community, to have a home

of their own, and to have choice in where and

how they live. 

SAMHSA’s Permanent Supportive Housing

Evidence-Based Practices (EBP) KIT (2010)

lists 12 elements of permanent supportive 

housing programs that form the core guiding

principles of these programs and differentiate 

them from other forms of housing assistance.

The 12 elements are: 

1.	 Tenants have a lease in their name; thus, 

they have full rights of tenancy under

landlord–tenant law, including control over

living space and protection against eviction. 

2.	 Leases do not have any provisions that

would not be found in leases held by 

someone who does not have a psychiatric

disability. 

3.	 Participation in services is voluntary, and

tenants cannot be evicted for rejecting services. 

4.	 House rules, if any, are similar to those 

found in housing for people without psychiatric disabilities and do not restrict visitors or otherwise interfere with life in the 

community. 

5.	 Housing is not time limited, and the lease 

is renewable at the tenant’s and owner’s 

option. 

6.	 Before moving into permanent supportive 

housing, tenants are asked about their

housing preferences and are offered the 

same range of choices as are available to

others at their income level in the same 

housing market. 

7.	 Housing is affordable; tenants pay no

more than 30 percent of their income toward rent and utilities, with the balance

available for discretionary spending. 

8.	 Housing is integrated. Tenants have the 

opportunity to interact with neighbors

who do not have psychiatric disabilities. 

9.	 Tenants have choices in the support services they receive.

10. As needs change over time, tenants can 

receive more intensive or less intensive 

support services without losing their

homes. 

11. Support services promote recovery and are 

designed to help tenants choose, get, and

keep housing.

12. The provision of housing and the provision of support services are distinct. 

The ultimate goal of permanent supportive 

housing is to reduce discrimination and social 

stigma experienced by people with psychiatric

disabilities; to offer choice in housing and deemphasize institutional and custodial care,

which invites withdrawal from family and the 

community; and, especially, to reduce relapse 

leading to the need for specialized intensive 

mental health treatment. Several types of

rental assistance can be provided through

permanent supportive housing, including:

•	 Project-based rental assistance: Housing

subsidies are tied to a specific housing

unit. 

•	 Sponsor-based rental assistance: The tenant leases a unit owned by a nonprofit

group that rents to people qualified for the 

program. 

•	 Tenant-based rental assistance: Qualified

tenants receive a voucher that can be applied to rent in a housing unit that agrees 

to accept the voucher for part of the rent. 

Oxford Houses 

The Oxford House movement began in 1975

in Silver Spring, MD, with the establishment 

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Part 2, Chapter 1 

of a house, in a residential neighborhood, for

persons in recovery from substance use disorders. The houses are democratically run by the 

residents and are drug free. There are now 

more than 1,200 houses throughout the United States. Each house operates under the 

guidelines of the Oxford House World Council and is guided in its operation by the Oxford 

House Manual. Some houses are exclusively for

men or for women; others accept both sexes. A

few houses operate exclusively for individuals 

with children who also reside in the house. 

Participation in 12-Step and other community 

change resources is strongly encouraged. 

Though most residents stay less than 2 years,

there is no fixed time for residence. Individuals 

can live in the house as long as they share in

the rent and share in the operation and

maintenance of the house. For more information on Oxford Houses, see Part 1, Chapter

1, of this TIP or the organization’s Web site 

(http://www.oxfordhouses.org). 

Building Linkages Among 

Services 

Individuals facing homelessness deal with

multiple stressors in their lives. In many communities, services to address these stressors 

have historically been segregated, making it

difficult for the client to access and use them. 

The lack of access to primary healthcare services can be a major difficulty. In recent years,

however, community health centers have become an integral component of healthcare delivery for individuals and families affected by 

homelessness. Some community health programs provide only primary healthcare services, but others have expanded to outreach,

behavioral health, health promotion, and other

activities. 

Federally Qualified Health 

Centers 

The “Federally Qualified Health Center”

(FQHC) designation is given by the Health 

Resources and Services Administration and 

the Centers for Medicare and Medicaid Services to nonprofit public or private clinics that

provide care to medically underserved areas or

populations. FQHCs provide a comprehensive 

range of primary healthcare, behavioral health, 

and supportive services to patients regardless 

of ability to pay. A key function of FQHCs is 

thus to provide care to people who are homeless in their communities. 

These centers are supported in part by grants 

from the Community Health Center program.

Some, in communities that have high rates of

homelessness, may receive Federal HCH Program grants; in fact, some FQHCs are supported solely by these grants. 

The HCH care delivery approach involves a

multidisciplinary integration of street outreach, primary care, mental health and substance abuse treatment, case management, and

client advocacy. Coordinated efforts between

FQHCs and other community health service 

providers and social service agencies characterize this approach to serving homeless populations. According to the National Academy for

State Health Policy, the ability of these coordinated efforts to improve the quality and efficiency of care is increasingly important, given

the emphasis in healthcare reform legislation

on consolidated, integrated care (Takach & 

Buxbaum, 2011). 

The National Association of Community 

Health Centers (NACHC) offers technical

assistance to all HCH health centers. For resource materials relevant to the provision of

care to people who are homeless, visit their

Web site (http://www.nachc.com/homelesshealthcare.cfm). 

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Behavioral Health Services for People Who Are Homeless 

It is critical that behavioral health programs 

providing services to people who are homeless 

coordinate their services with community 

healthcare and other primary healthcare providers. Clients facing homelessness may enter

the system through a variety of doors, and the 

locus of care may depend in part on primary

symptoms exhibited by the client. An integrated approach, however, remains essential to

quality care. 

Clients may enter the system in primary 

healthcare settings, State psychiatric hospitals 

or jails, community substance abuse treatment

facilities, or community mental health centers,

but should have access to care for primary 

health, substance abuse, and mental health 

services regardless of entry point. Depending

on the symptom presentation, clients may 

have one predominant need at the point of

entry to the system. Symptom severity may 

define how services are provided, but the important element of integration of care exists 

throughout the range of services available. 

Integrating Other Community 

Support Services 

Most individuals recovering from both homelessness and a mental and/or substance use 

disorder need a variety of supportive services,

especially in early recovery. Permanent housing

is not sufficient to address the urgent needs 

they experience. The supportive resources provided by a variety of community agencies are 

essential. As opposed to the typical experience 

in institutional settings, clients in permanent

supportive housing always have a choice in

which supportive services they will use. Additionally, the services offered need to be tailored

to the unique needs of the individual client.

Some people in recovery might need transportation, whereas others need case management

services to orchestrate their path through a

maze of social services. Still others may need

financial management, including a designated 

payee to help handle their income and expenses; others may benefit from peer mentoring.

Most will need a variety of supportive services.

Contrary to their past experiences, individuals

entering permanent supportive housing can

choose which services they will use. 

SAMHSA’s Permanent Supportive Housing

Evidence-Based Practices (EBP) KIT (2010)

lists several domains of relevant services, including:

•	 Services to support housing retention,

such as helping clients understand their 

rights and obligations as renters in the

program, crisis intervention, using peer

mentoring and support groups, and developing recreational and socialization skills. 

•	 Independent living skills, including communication skills, conflict management

skills, budgeting, personal hygiene, and

housekeeping. 

•	 Recovery-focused services, such as participating in recovery support groups, becoming an advocate for mental health and

substance abuse recovery, and being a peer

mentor to new clients entering permanent

supportive housing. 

•	 Community integration services designed

to help the individual become part of the 

larger community and thereby develop a

sense of belonging and connection to the 

neighborhood and the larger community 

through participation in community

events, such as recreational activities, spiritual programs, community educational activities, and community events. 

Other service domains include involvement in 

traditional community support programs,

which can include: 

•	 Mental health services. 

•	 Substance abuse treatment. 

•	 Health and medical services. 

•	 Vocational and employment services. 

•	 Family services. 

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Funding Community 

Homelessness Services 

Various community, State, and national resources provide funding for homelessness services. These funding sources may be private 

foundations, government entities, or community groups. Only rarely can health insurance

be a reliable funding source for homelessness 

services. Funding may be for “bricks and mortar,” for provisions such as food or clothing, or

for the targeting of specific needs, such as substance abuse treatment, mental health services,

primary health care, or case management. One 

place to start with program development is to

survey what resources for homelessness exist

in your community, what services those resources provide, and who offers the funding

for available services. Ideally, services should

arise from identified community needs 

(bottom-up planning); however, it is not uncommon that services arise from available 

funding (top-down planning) or a combination of both. 

Federal funding for homelessness services can

be divided into two major categories: direct

funding for housing and funding for services 

that support individuals who are homeless.

The primary source of direct funding for

housing is HUD. In fiscal year 2011, $1.63 

billion was available for Continuum of Care 

(CoC) grants. CoC programs are based on

community needs assessment and have a goal 

of helping individuals and families who are 

homeless quickly transition to self-sufficiency 

and permanent housing. In a CoC community,

a local or regional planning board coordinates

funding for housing and homelessness services 

for the geographic area. Local programs seeking funding apply jointly with other community programs in a single application to HUD.

The four primary components of CoC are: 

•	 Outreach, intake, and assessment. 

Part 2, Chapter 1 

•	 Emergency shelter to provide immediate 

and safe alternatives for people who are 

homeless. 

•	 Transitional housing with supportive services. 

•	 Permanent supportive housing. 

The four primary programs available to provide these services are: 

•	 Supportive Housing Program, now part of

the Continuum of Care program. 

•	 Shelter Plus Care Program, now part of

the Continuum of Care program. 

•	 Section 8 Moderate Rehabilitation Single

Room Occupancy Program. 

•	 Dwellings for Homeless Individuals 

(Section 8/SRO) Program. 

Other HUD-sponsored housing programs

include: 

•	 Base Realignment and Closure. 

•	 Housing Opportunities for Persons With 

AIDS Program. 

•	 Veterans Affairs Supportive Housing

Program. 

•	 Disaster Housing Assistance Program. 

•	 Housing Choice Voucher Program

(Section 8). 

•	 Public Housing Program. 

•	 Section 202 Supportive Housing for the 

Elderly Program. 

•	 Section 811 Supportive Housing for

Persons With Disabilities. 

Additionally, a variety of funding is available

for supportive services for individuals and

families who are homeless or at risk of homelessness. Some of these programs can also fund

housing services, but often only on a temporary or transitional basis. In addition to HUD 

funding for services, programs from HHS, VA,

the U.S. Department of Justice, and the U.S. 

Department of Labor contribute substantial 

funding to address homelessness. 

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Behavioral Health Services for People Who Are Homeless 

Projects for Assistance in Transition from 

Homelessness (PATH) is a SAMHSAsupported formula grant program to provide

homelessness services for people with serious

mental illness, including those with cooccurring substance use disorders. The program provides funding to all 50 States and the 

U.S. Territories and possessions through almost 600 local agencies. Services include 

community-based outreach, mental health and

substance abuse treatment, case management

and other support services, and limited housing options. Application for funding is made

through each State’s Single State Agency designated to manage PATH funding. The services provided in a particular State depend on

that State’s needs. For instance, in rural areas,

funding may be available for outreach in areas

where homelessness services have not traditionally been available. Some States have support programs for special populations with

SMI. Other States coordinate services with 

local community mental health centers to ensure that individuals who are homeless or at 

risk of homelessness receive comprehensive 

care for mental illness or CODs. PATH monies are also available for training local providers on effective strategies to assist people with

SMI who are homeless. 

Other programs available through HHS for

persons and families who are homeless include: 

•	 Health Care for the Homeless. This multidisciplinary, comprehensive program 

provides primary health care, substance 

abuse treatment, emergency care with referrals to hospitals for inpatient care services, and outreach services to help

difficult-to-reach people who are homeless 

establish eligibility for entitlement programs and housing. 

•	 Services in Supportive Housing (SSH) 

(SAMHSA). The SSH program helps

prevent and reduce chronic homelessness 

by funding services for individuals and

families experiencing chronic homelessness and living with a severe mental and/or

substance use disorder. Grants are awarded competitively for up to 5 years to community-based public or nonprofit entities.

Services supported include, but are not

limited to, outreach and engagement, intensive case management, mental health

and substance abuse treatment, and assistance with obtaining benefits. 

•	 Grants for the Benefit of Homeless Individuals (GBHI) (SAMHSA). GBHI is a

competitively awarded grant program that

helps communities expand and strengthen

their treatment services for people experiencing homelessness. Grants are awarded

for up to 5 years to community-based public or nonprofit entities. Funds may be 

used for substance abuse treatment, mental 

health services, wrap-around services, immediate entry into treatment, outreach

services, screening and diagnostic services,

staff training, case management, primary

health services, job training, educational 

services, and relevant housing services. 

VA provides a variety of programs to assist

veterans who are homeless. In cooperation

with HUD, VA provides permanent supportive housing and ongoing case management 

services for veterans who require those supports to live independently. HUD has also allocated more than 20,000 Housing Choice 

Section 8 vouchers to Public Housing Authorities throughout the country for eligible

veterans who are homeless. The Housing

Choice Section 8 vouchers program is particularly beneficial to female veterans, veterans 

recently returned from overseas, and veterans 

with disabilities. Housing is permanent and

accompanied by supportive services; the

voucher is portable, allowing users to move to

different locations or get better housing solutions as they become available. 

176 
 

Part 2, Chapter 1 

VA also funds community-based agencies to

provide transitional housing and supportive

services for veterans who are homeless 

through the Capital Grant Component program. For more information on this program

and the Homeless Providers Grant and Per 

Diem Programs, contact Jeff Quarles toll-free 

at 1-877-332-0334. 

Stand Down programs, located throughout 

the United States, are developed and operated

by veterans service organizations, local CoC 

programs, community groups, military personnel, and other interested citizens to provide 

shelter, meals, clothing, employment services,

and medical care for veterans who are homeless. Normally, Stand Down programs are time 

limited (1–3 days). VA funding is available for

up to $10,000 to conduct events each year. 

The Interagency Council on 

Homelessness and the HEARTH 

Act 

The United States Interagency Council on

Homelessness (USICH) is an independent

agency of the Federal executive branch and is

composed of 19 Cabinet Secretaries and agency heads. Its mission is to coordinate the Federal response to homelessness and to work 

with State and local governments and the private sector to end homelessness in the Nation. 

The blueprint for this monumental task is 

provided in USICH’s strategic plan, Opening 

Doors (http://www.usich.gov/opening_doors/).

The plan calls for heightened dedication to

solving the problem, with an emphasis on increasing economic security, improving health

and stability, and returning people experiencing homelessness to safe housing as soon as 

possible. The Council was established by the 

Stewart B. McKinney Homeless Assistance

Act of 1987 and was reauthorized by the 

Homeless Emergency Assistance and Rapid

Transition to Housing (HEARTH) Act of 

2009, which amends the McKinney-Vento

Act. 

Under the HEARTH Act, programs for

housing assistance were consolidated as follows: 

•	 The Shelter Plus Care Program, Supportive

Housing Program, and Section 8

Moderate Rehabilitation Single Room

Occupancy Program have been consolidated into the Continuum of Care Program.

The Act added 12 services to those eligible 

for funding: housing search mediation or

outreach to property owners; credit repair;

provision of security or utility deposits;

rental assistance for a final month at a location; assistance with moving costs;

and/or other activities that help individuals

who are homeless move immediately into

housing or would benefit individuals who

have moved into permanent housing in the 

past 6 months. 

•	 The Emergency Shelter Grant program 

has been modified and renamed the 

Emergency Solutions Grants (ESG) Program. The ESG Program is meant to fund

not only traditional shelter and outreach

activities, but also more prevention, rapid

rehousing, and emergency shelter activities. Family support services for youth who

are homeless, victim services, and mental 

health services now appear on the list of

eligible services that shelters or street outreach teams can provide. Homelessness 

prevention activities are also expanded to

include prevention and rehousing activities—such as short- or medium-term 

housing assistance, housing relocation or

stabilization services, housing searches,

mediation or outreach to property owners,

legal services, credit repair, security or utility deposits, utility payments, and assistance with moving costs—for people who

are homeless or at risk of homelessness. 

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Behavioral Health Services for People Who Are Homeless 

In addition, the HEARTH Act creates the 

“Collaborative Applicant.”This allows a single 

entity to submit one application for McKinney-Vento funds for all agencies in the community. Each geographic area has its own

Collaborative Applicant, which is not necessarily a legal entity. 

Changes in funding are likely to be made by 

future State and Federal legislation. Requirements, eligibility, levels of funding, and types 

of favored programs can change, as can the

community agencies with whom you collaborate to provide services. A skillful administrator is proactive, anticipating modifications in

policies and opportunities covered by the new 

laws. 

Chapter 2 of this section introduces you to the 

types of policies and procedures that behavioral health agencies have found helpful in working with clients who are homeless or at risk of

homelessness. The intent is to provide administrators with a starting point for handling issues of safety, transportation, medical 

emergencies, and the like, along with procedures for tracking your staff ’s contacts and actions with clients. 

178 
 

 

 

 IN THIS CHAPTER 

• Introduction 

• Organizational 

Approaches to 

Programming for 

Homelessness Services 

• Sample Policies and 

Procedures 

• Sample Forms 

Part 2, Chapter 2 

Part 2, Chapter 2
 

Introduction 

This chapter provides program descriptions and sample policies,

procedures, and forms that support development of programming

to meet the needs of people who are homeless. All documents are 

meant to serve as starting points; you must adapt them to suit the 

philosophy and procedures of your organization. 

Our thanks to Deborah Fisk, LCSW, Director, Connecticut Mental Health Center Outreach and Engagement Project in New Haven, CT, and Douglas J. Warn, LCSW, Director, Project Renewal 

Chemical Dependence Outpatient Clinic in New York, NY, for

providing some of the materials in this section. Additionally, a

number of programs described below offered program descriptions 

illustrating different approaches to programming for homelessness. 

Organizational Approaches to 

Programming for Homelessness 

Services 

Homelessness services may be provided by a variety of communitybased organizations: mental health clinics, substance abuse treatment programs, developmental disability service agencies, organizations specifically concerned with housing and homelessness, or as 

part of the community’s criminal justice system or social service organizations. Additionally, these programs may be part of a faithbased organization, part of a national organization (such as Volunteers of America or the Salvation Army), or an element of State or

local government. Few programs at the community level attempt to

meet all community housing needs. Some may focus primarily on

emergency homelessness needs, others on Housing First, and still 

others on individuals with substance use disorders or mental illness 

in remission. 

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Behavioral Health Services for People Who Are Homeless 

Following are descriptions of four programs 

that reflect the range of available homelessness 

services in various communities. Their organizational scope, target population, staff size,

funding, and responses to community needs 

differ, yet all four have their origins in an identified community need that was addressed by 

program development and implementation. 

Responsibility House 

Responsibility House in New Orleans, LA, 

began in 1994 as a halfway house for people 

recovering from substance use disorders. The 

programs of Responsibility House focus on

providing services to, and improving the lives 

of, the most underserved populations in the 

New Orleans area: indigent adults who have 

disabilities, such as substance use disorders, 

serious mental illness, and/or HIV/AIDS, and

people who are homeless. 

Contact person 

Mike Martyn, Executive Director: 504-367­

4426; mmartyn@rhousela.org 

Programs 

The Men’s Residential Treatment Program 

offers 3 to 6 months of treatment services in a 

modified therapeutic community setting for

people who have substance dependence. Clients begin working on the 12 Steps, connect

with sponsors, and perform community service 

while transitioning through four phases of

treatment: discovery, primary, work search, and

reentry. Funding is contracted through the

State with the Jefferson Parish Human Services Authority. 

Housing Opportunities for Persons With

AIDS (HOPWA) programming and services 

are available for adult men who have substance 

dependence and are HIV positive. Funding

comes from a U.S. Department of Housing

and Urban Development (HUD) HOPWA

grant to the City of New Orleans; Responsibility House is a subgrantee. Following primary treatment, those interested in living in a

drug- and alcohol-free, recovery-focused setting may apply for the Sober Living Program.

The program is designed for adult men who

have at least 2 months of demonstrated abstinence and are employed. 

Responsibility House also offers an Outpatient Treatment Program for men and women

who have a substance use disorder and/or a

co-occurring mental illness and who are at

least 18 years old. Group, individual, and family counseling are offered for recovery from 

substance use disorders. Funding is from the 

U.S. Probation Service, Access to Recovery,

private pay, and some insurance providers. 

In 2000, Responsibility House began offering

supportive housing to individuals and families 

who have disabilities and experience chronic

homelessness. The goals of this program are to

enable people who are homeless to maintain

permanent independent housing, to assist clients in improving their financial independence

and living skills, and to support clients in their

quest for self-sufficiency. 

Community collaboration 

In 2011, Responsibility House was presented

with an award for Outstanding Homeless Service Provider by UNITY of Greater New Orleans, the lead agency for the local Continuum 

of Care. Funding for the agency comes from 

HUD, the Jefferson Parish Community Development Block Grant, and several one-time 

grants from private foundations (Entergy, Orange County Foundation, and Greater New 

Orleans Foundation). 

Center for Urban Community 

Services 

The Center for Urban Community Services

(CUCS) of New York, NY, provides a wide 

range of services to help individuals and 

180 
 

 

 

Part 2, Chapter 2 

families who are homeless or were previously 

homeless (particularly those with behavioral or

other disabling conditions) live full and satisfying lives in the community. In 2011, CUCS

provided supportive housing services to 2,000

people and mental health services to 3,000

people; provided legal services, benefits, and/or

other financial counseling to 5,500 adults and

families at four sites, including one inside 

Rikers Island jail; helped 13,000 people gain

access to housing and/or case management

services, working under contract to city and 

State mental health authorities; and trained

more than 3,000 service providers from 300 

nonprofit organizations. 

Contact person 

Tony Hannigan, Executive Director: 212-801­

3300 

Programs 

Clients’ mental health and substance use issues 

are addressed in an integrated manner as appropriate to the program. Street outreach and

placement programs follow a strict Housing

First approach, aided by motivational interviewing to address specific aspects of mental 

illness or substance abuse. Transitional programs maintain the same tight focus on obtaining permanent housing but are able to

offer integrated psychopharmacology using

onsite psychiatric and medical treatment,

along with an array of evidence-based practices, including motivational interviewing, illness 

management and recovery, and co-occurring

disorders skills groups. Permanent supportive

housing programs use these same evidencebased practices to help tenants pursue a broad

range of personal goals and aspirations in addition to embedded supported employment.

Medical detoxification and residential rehabilitation are handled by partnering agencies.

CUCS case managers follow clients entering

such programs, helping inform treatment and

coordinate transition planning. 

Community collaboration 

CUCS is passionate about the welfare of all its 

clients, the quality of all its programs, and the 

skills and commitment of all its staff members. 

Recent highlights include the agency’s lead 

support role in the Manhattan Outreach Consortium, which has reduced the Manhattan

street homeless population by almost half by 

using an intensive Housing First model. The 

agency’s Project for Psychiatric Outreach to

the Homeless recently received an American

Psychiatric Association Silver Achievement

Award for providing services to thousands of

people who are currently homeless and people 

who had previously been homeless at 54 sites 

across the city. Another accomplishment is 

CUCS’s shift to a culture of evidence-based 

practice and continuous, data-driven quality 

improvement. Serious challenges remain,

however. Perhaps the most important is the

need to fully integrate primary medical care 

with mental health and substance abuse services. Even harder to solve is how to address 

the needs of New York City’s undocumented 

immigrants who are homeless, given restrictions imposed by most major funders. 

Open Arms Housing 

Open Arms Housing, Inc. (OAH) of Washington, DC, provides permanent housing with

ongoing supportive services for unaccompanied women who have lived on the streets or 

in shelters in Washington, DC. The organization is dedicated to providing permanent

housing for vulnerable women who have previously been overlooked by current housing

programs and services for the homeless. OAH

owns a building in Northwest Washington,

DC, that opened in 2009 to house 16 women

who have experienced a range of mental 

health issues, substance use disorders, and

medical conditions. 

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Behavioral Health Services for People Who Are Homeless 

Contact person 

Marilyn Kresky-Wolff, Executive Director:

202-525-3467 

Program 

The OAH model is unique in DC in that it 

operates under a Housing First approach,

which holds that all individuals are entitled to 

safe and decent housing and that access to this

housing should not be contingent on participation in services. Those services can come 

later, but housing is first. The OAH model is 

one of only a few similar programs across the 

country because:

•	 The OAH model rests on the premise that

stable, safe housing is necessary to promote the physical, mental, and emotional 

well-being of all persons, particularly 

women with a history of chronic homelessness. 

•	 OAH offers onsite supportive services that

are tailored to each individual’s needs and 

are designed to prevent a return to homelessness. 

•	 The building is designed to feature efficiency units with a full set of kitchen appliances and a private bathroom, and

community rooms with shared phones,

TVs, computers, and space for workshops,

meetings, and get-togethers. 

•	 Additionally, the building has three 

wheelchair-accessible units and a unit 

equipped for a deaf person; units like these 

are scarce. 

Onsite services provided by staff include:

•	 Outreach and engagement. 

•	 Orientation to community living and assistance in obtaining housing subsidies. 

•	 Financial management and help with activities of daily living. 

•	 Supportive counseling and crisis intervention. 

treatment teams, employment counseling,

day programs, volunteer opportunities,

self-help groups, medical treatment, home 

health care, and food and clothing resources. 

Community collaboration 

During the period from the founding of the 

organization until its opening in 2009, OAH

received: 

•	 Financial support from the DC Department of Housing and Community Development (DHCD) via a permanent loan

and a grant jointly from DHCD and the 

DC Department of Mental Health. 

•	 A Supportive Housing Program grant

from HUD via the DC Community Partnership for the Prevention of Homelessness. 

•	 Critical early support from private lenders

(e.g., acquisition loan from the OpenDoor

Housing Fund). 

•	 Predevelopment and construction funds 

from Cornerstone, Inc., construction loans 

from Local Initiatives Support Corporation and Enterprise Community Partners,

and a capacity-building grant from the 

Corporation for Supportive Housing. 

•	 Ongoing support through the DC Housing Authority’s Local Rent Supplement

Program. 

Open Arms has served 17 tenants. Fourteen of

the initial residents are still in the building.

One original resident moved out after reconnecting with family, and another moved to an

apartment. No Open Arms resident has returned to homelessness. 

Project Renewal 

Project Renewal in New York, NY, is designed

to help people who are homeless empower

themselves and leave the streets for a return to 

• Linkage to mental health treatment, alco- health, homes, and jobs. Since 1967, it has crehol and drug abuse counseling, assertive ated innovative strategies to address the barri182 
 

 

 

Part 2, Chapter 2 

ers that these men and women face. Services 

range from outreach to permanent housing

and span case management, substance abuse 

and mental health services, primary medical 

care, and vocational rehabilitation. 

Contact person 

Mitchell Netburn, President and CEO: 212­

620-0340 

Programs 

One innovative program of Project Renewal is 

In Homes Now (IHN), a Housing First model for chronically relapsing individuals who

have substance use disorders and are homeless. 

It is designed to meet the special needs of

people who have experienced long-term 

homelessness and have active substance use 

disorders. The program leases 110 apartments 

in the Bronx, Manhattan, and Brooklyn for

participants, and a multidisciplinary team provides intensive case management, medical and

mental health services, and occupational therapy, as well as socialization and recreational

activities. All services are delivered in either 

the program office or the client’s home. Staff 

members receive ongoing training in motivational interviewing and trauma-informed care.

The culture of the program is one of nonjudgmental acceptance, and all interactions are

centered on clients’ needs rather than program 

rules. The relationship that develops between

the staff and the clients becomes a stabilizing

force in the clients’ lives, allowing the staff to 

help guide clients toward a healthier lifestyle. 

Nearly all (97 percent) tenants have remained

stably housed over the past year. This success 

has led to the inclusion of harm-reduction 

beds in a key New York City–New York State 

supportive housing agreement. IHN operates 

from an office in Upper Manhattan that is

viewed as a key factor for success because the 

office models itself after a drop-in center. Tenants come for socialization, for recreation, to 

meet with staff, or just to relax in a supportive 

community environment. Another program 

success is the ability to work with clients with

co-occurring disorders and cognitive impairments. The team’s psychiatric nurse practitioners treat such clients (about 75 percent),

allowing integration of treatment for mental 

illness with other services. Occupational therapists help clients who have never lived independently master activities of daily living. 

Community collaboration 

Clients in In Homes Now are linked to community hospitals, methadone programs, and

outpatient clinics. About 25 percent of clients 

are veterans and receive services at the local 

VA medical center. Funding is received from 

HUD, the Substance Abuse and Mental 

Health Services Administration, and the New

York City Department of Health and Mental 

Hygiene. 

Sample Policies and 

Procedures 

As your organization increasingly provides

services to people who are homeless, the need

for policies and procedures to cover staff

members working off site, dealing with other

community agencies and partners, and responding to situations that are new to your

organization will become clear. The policies 

and procedures presented in this section may 

alert you to areas where your organization

needs additional guidelines. They refer to safety outside the office (for example, the “No Heroes Policy”), safety during outreach activities,

client transportation, and handling medical

and psychiatric emergencies in outreach settings. A sample memorandum of understanding (MOU) is also included at the end of this 

chapter. 

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Behavioral Health Services for People Who Are Homeless 

No Heroes Policy 

Policy 

[Name of program] recognizes the need to

address the safety of clinical and case management staff persons who deliver services to

clients outside of the organization setting and

to provide resources to facilitate safe practice. 

Procedures 

•	 A wide range of service activities are undertaken outside the office by clinical and

case management staff affiliated with the 

[name of program]. Community-based

work with clients includes, but is not limited to: 

–	 Services within other organizations

and agencies (e.g., Social Security, residential facilities, primary care clinics,

drop-in centers). 

–	 Services in public settings (e.g., grocery 

store, coin-operated laundry facility, 

library). 

–	 Offsite groups or community outings 

(e.g., theater, picnics). 

–	 Home visits. 

–	 Walks with clients. 

–	 Street-level outreach (e.g., city green,

under bridges). 

–	 Outreach to shelters, soup kitchens,

etc. 

–	 Crisis intervention to known and unknown individuals. 

–	 Transporting clients. 

–	 Medicating clients in the community. 

•	 The safety of any plan to provide service to

a client in the community must be carefully assessed before undertaking the planned

service. Base the number of workers and 

other resources needed to facilitate safety 

upon consideration of the following: 

–	 The extent to which staff members are 

familiar with the client, the client’s environment, and other people likely to

be present in that environment. 

–	 The extent to which staff persons are

familiar with the community or particular section of the community in

which the service will be provided. 

–	 The extent to which staff persons are

aware of client, environmental, or other

risk factors that might contribute to

unpredictability. 

–	 The time of day, season, and so forth

during which service is to be provided. 

–	 The nature of the service to be provided and the client’s likely response to

the service or task to be accomplished

(e.g., transporting or accompanying a 

client to a medical or dental procedure 

or an appointment that may elicit distress or other unpredictable response 

from the client—such as a court, probation, or Department of Child and

Family Services appointment). 

•	 Routine community-based contacts with 

clients who are assessed to present low risk 

can be accomplished by an individual staff

member according to the procedures outlined in this policy. 

•	 Under no circumstances will any staff

member enter any situation that is felt to

be unsafe: 

–	 Any questions regarding the safety of

an intervention or activity will be reviewed and cleared by the Director of

[name of program] or his/her designee 

prior to undertaking the activity or intervention in question. 

–	 Local police will be involved in all 

community visits that have been assessed as having significant potential

for violence. 

–	 When there is disagreement among

the staff regarding the safety of a particular situation, the planned activity

will be suspended until consultation

with the Director of [name of program] or his/her designee takes place. 

184 
 

 

Part 2, Chapter 2 

–	 The circumstances listed below will 

trigger particular attention to safety

concerns and will result in the abbreviation or suspension of direct clinical 

contact in the community, pending

consultation with the Director of 

[name of program] or his/her designee.

Such consultation will address concerns about the safety of the staff and

of the client and/or others in the client’s environment or network. If further intervention is indicated, develop

a plan to ensure the safety of involved

staff members, including consideration 

of the need for police escort during:

a. Outreach to a client who is suspected of being under the influence of

nonprescribed substances at the 

time of contact or whose environment includes other individuals who 

are using substances.

b. Outreach to a client who is suspected of or known to be carrying a

weapon at the time of contact or

whose environment includes individuals suspected of or known to be 

carrying weapons.

c. Outreach to a client who becomes 

volatile or threatening during contact or in a setting in which volatile

or threatening behavior is observed

or anticipated.

d. Outreach to a client who has a 

known history of physical violence. 

•	 All community visits for the purpose of

client contact require that workers bring

an activated beeper and cellular phone. 

•	 Established sign-out procedures will be 

used to facilitate awareness of staff whereabouts and attention to the safety of staff

persons working outside the office setting. 

•	 Sign-out information will include: 

–	 Name(s) of all staff members to be involved in outreach activity. 

–	 Destination. 

–	 Time of departure. 

–	 Anticipated time of return. 

–	 License plate number of vehicle being

used. 

–	 Cellular phone number. 

–	 Beeper number (if applicable). 

•	 If, in the course of providing community 

outreach, the staff begins to suspect or observe that the behavior of a client is exposing a child, elderly person, or individual

served by the Department of Mental Retardation to abuse or neglect—including

exposure to illicit activity or to circumstances that might imminently compromise the safety of these individuals—

reports must be filed with the appropriate 

protective services agency according to established procedures for such reporting. 

•	 All incidents that trigger safety concerns 

and/or require police/ambulance intervention will be reported to the Director of

[name of program] or his/her designee 

immediately following the incident. Also: 

–	 Following interventions triggering safety concerns and/or the assistance of the

police or an ambulance, staff will complete the Outreach Incident Report and

an emergency response form documenting the circumstances of the need

for emergency services. A review will be 

scheduled. 

–	 Team- and project-based reviews will 

be held as quickly as possible following

all such incidents to facilitate discussion 

of issues related to staff safety, client

treatment planning, and the interface 

between the project and the local police,

as well as other emergency personnel. 

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Behavioral Health Services for People Who Are Homeless 

Ensuring Safety During Street and 

Community Outreach 

Policy 

Street-level and community services will be 

provided through an interorganizational collaboration between [name of program] and

other service agencies. The following streetlevel and community outreach procedures will 

serve as addenda to those outlined in the “No 

Heroes Policy” and will inform the work of all 

outreach staff. They will be reviewed and revised yearly in collaboration with the involved

network service agencies. 

Procedures 

These procedures will guide the work of project staff members providing clinical or case

management services in outdoor public places,

such as street corners, the public green, under

highway bridges, and the like:

•	 The safety of all street outreach sites will 

be reviewed and approved by [name of

program] leaders prior to providing outreach to those sites. Review will include 

the following factors: 

–	 Street outreach locations cannot be 

isolated and desolate. Staff members 

must always be visible to the street and

be able to access other people (including the general public) for assistance in

a crisis situation. 

–	 The time of day is relevant to the safety of any specific street outreach site. 

–	 Differing numbers of staff members 

may be required to sustain safety at any 

particular outreach site. 

–	 Safety issues known to exist in the 

general area of any specific outreach

site may vary. 

•	 The safety of all approved outreach sites 

will be reviewed quarterly and as needed so 

that changes in the safety of specific sites 

are reflected in the day-to-day list of approved outreach sites. 

•	 Street-level outreach may be conducted

from 7:00 a.m. until 8:00 p.m. 

–	 Between 7:00 a.m. and 4:00 p.m., conduct street-level outreach with at least 

two staff members. 

–	 Between 4:00 p.m. and 8:00 p.m., conduct street-level outreach with at least 

three staff members; one stays in the

driver’s seat of the outreach vehicle. 

–	 Street outreach to individuals with 

whom the outreach staff has little or 

no familiarity will be guided by the 

following principles: 

a.	 Such individuals will not be invited 

into an organization vehicle for purposes of engaging in an interview or

for the provision of transportation. 

b.	 Efforts will be made to interview 

such individuals in community agencies or public buildings (e.g., the library, a train station) instead of on

public streets. 

The following procedures will guide the provision of clinical and case management services 

that take place inside community settings (e.g.,

local shelters, soup kitchens, train stations,

public libraries):

•	 All indoor sites will be established in collaboration between the [name of program]

leaders and the proposed community organization sites before using those sites for

outreach. The safety of each proposed

community outreach site depends upon

the following factors: 

–	 The community organization must

agree to have outreach staff members

visit their site. 

–	 A contact person must be identified

within each community organization

and must be available to outreach 

workers when they are on site to provide support. 

186 
 

 

 

 

Part 2, Chapter 2 

–	 The community organization must

agree to allow workers telephone access 

for emergencies. 

The following guidelines apply to outreach

and clinical/case management services provided in either outdoor locations or specified indoor community sites:

•	 At least one member of the outreach team 

will have an activated beeper and cellular

phone. 

•	 Street-level outreach activities may be 

conducted in [name of program] vehicles.

[Name of program] staff can be granted 

permission to drive the vehicles through a

process initiated by the Director of the 

[name of program]. Use of vehicles belonging to any one of the involved affiliated organizations will be guided by the 

policies and procedures established by that

organization. 

•	 Outreach activities will end if any outreach

team member indicates serious concerns 

about the safety of any particular activity. 

All outreach workers will receive yearly 

project-based training in clinical and community safety, and they will be eligible to participate in the Clinical Safety Training offered at

[name of program], regardless of organization

affiliation. 

Client Transport Policies and 

Procedures 

Policy 

The Director of [name of program] will establish procedures to guide staff decisionmaking

regarding the transport of clients to enhance 

both the safety of the staff members providing

transportation services and the safety of the 

clients they transport. This policy will serve as 

an addendum to the “No Heroes Policy.” 

Procedures 

•	 Organization vehicles may be driven only 

by staff persons who possess valid State 

drivers’ licenses. 

•	 Under no circumstances will a staff member use his/her personal vehicle to

transport a client. 

•	 Organization vehicles will be used only to

carry out work-related duties. Vehicles are 

available primarily to facilitate the care of

registered clients of [name of program].

However, it is recognized that the 

transport of a client’s nonregistered significant others is indicated at times and that 

the organization’s ability to provide transportation can also facilitate the process of

engaging nonregistered individuals who

might otherwise be reluctant to accept services. These circumstances will be viewed 

as exceptions and will be discussed and

approved by the relevant team leader, program leader, project director, or his/her 

designee. 

•	 The provision of transportation to clients

and their significant others will be regarded as a service, and the staff members who

transport these individuals will be expected

to maintain the same professional standards of practice that guide the provision of

all clinical services at [name of program].

Clients’ rights to safety and confidentiality 

will therefore be respected and protected

at all times. 

•	 Staff persons will carry an activated cellular phone when transporting clients. 

•	 Organization vehicles used for client

transport will be equipped with the following items for emergencies (e.g., accidental injuries, inclement weather): 

–	 An operable flashlight 

–	 Snow scraper 

–	 Personal protection gloves 

–	 First-aid kit 

–	 List of emergency phone numbers 

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Behavioral Health Services for People Who Are Homeless 

–	 Information regarding vehicle insurance coverage 

–	 Reflective safety triangles 

•	 Staff will make a general inspection of the 

organization vehicle before driving it to

make sure that there is adequate fuel and

that there are no objects within or outside 

the vehicle that might compromise the

safety of the driver or other vehicle occupants. 

•	 The driver of any organization vehicle will

maintain responsibility for ensuring that

all vehicle occupants honor relevant seatbelt laws, including laws governing the use 

of child safety seats when applicable. 

•	 The number of passengers transported in

an organization vehicle will not exceed the

vehicle’s stated capacity, and team-, program-, and project-identified staff-toclient ratios will be honored. 

•	 Clients who are symptomatically unstable 

and whose behavior may be impulsive 

and/or unpredictable will not be transported in an organization vehicle, including

clients suspected of being under the influence of any nonprescribed drug. Safety 

concerns that arise at any point during the

course of transporting a client will result in

termination of the transport. 

•	 Clients will not be left unattended by the

staff in an organization vehicle. 

•	 Clients needing hospitalization will generally be transported via ambulance. Any exceptions will be reviewed and approved by 

the appropriate team leader, program leader, project director, or his/her designee

and will be based on a thorough assessment of client needs and the availability of

the resources necessary to facilitate safe

transport. Factors that will preclude the 

transportation in a vehicle of a client needing hospitalization include, but are not

limited to: 

–	 The presence of medical needs better

addressed in an ambulance. 

–	 Client history of violence, impulsivity,

substance use, or other factors that 

might contribute to unpredictability 

during transport. 

–	 The lack of at least two clinicians or 

case managers available to assist in the 

transport of the client. 

Management of Psychiatric and 

Medical Emergencies 

Policy 

Procedures will be established to guide the 

handling of psychiatric or medical emergencies within the office or in the community that

require resources beyond the scope of [name 

of program] services. When a medical emergency occurs, basic life support, first aid, and

immediate emergency care will be given until 

the arrival of emergency medical service 

(EMS) personnel, who will provide any further emergency treatment and transport to the 

emergency department (ED). 

Purpose 

To facilitate the safety of clients served by the 

[name of program] and the safety of team or

project staff. 

Procedures 

Section A: Psychiatric/medical emergencies 

that occur within the office will be managed as 

follows: 

•	 Staff members involved in the management of a psychiatric or medical emergency will dial 911 to access emergency 

services or will use the panic button system 

available within the office. If possible, one 

staff member will announce a Code 3 on 

the overhead telephone paging system,

specify whether the code is medical, and

note the location of the code. 

•	 All available clinical staff persons will respond. 

188 
 

 

 

Part 2, Chapter 2 

•	 The first senior staff member on the scene 

will take charge of a psychiatric code. The 

first senior medically trained staff member

on the scene will take charge of a medical 

code. If the code bag and first-aid kits are

not present, the staff member will direct

another staff member to bring this equipment to the scene. If no medical personnel 

are available, the first person on the scene 

will be in charge of the code, direct basic

support and first-aid to the victim, and

designate someone to bring the code bag

and first-aid kit. 

•	 A staff member should gather relevant client data to provide to EMS and the ED.

When EMS arrives, care of the victim in a 

medical code will be handed off to them. 

In the event of a psychiatric code, the staff

member in charge of the code will manage 

the code collaboratively with EMS. 

•	 The staff member in charge of the code 

will gather interim assistance from other

staff working in the office at the time of

the emergency. If the incident is in the office, a program supervisor will also facilitate the management of other clients who

may be on site at the time of an emergency. These interventions will be guided by 

an appreciation of the importance of protecting all clients exposed to emergencies

and of the need to preserve the rights, dignity, and well-being of all involved clients. 

•	 The clinician and supervisor managing inhouse psychiatric or medical emergencies 

are responsible for the completion of documentation needed to facilitate transport

to an ED and will facilitate continuity of

care for the client by communicating relevant information to ED care providers. 

•	 After the care of the victim has been completely assumed by EMS, staff should: 

–	 Inform the client’s family or emergency contact persons. 

–	 Inform appropriate administrative staff 

persons. 

–	 Address and allay the anxiety of clients 

who witnessed the incident. 

–	 Meet to review the incident as soon as 

possible after it occurs. 

•	 The involved clinician will complete an 

incident report and an emergency response 

form documenting the circumstances of

the need for emergency services, and a review will be scheduled. 

•	 A note will be entered into the medical 

record reflecting the circumstances of the 

emergency and the outcome of planned

interventions. 

•	 Following a medical code, the [position of

person responsible] will direct a member

of the nursing department to check the

lock on the code bag. If the lock is broken,

the nursing staff member will call [name,

phone number] to check and replace contents. 

Section B: Psychiatric or medical emergencies 

that occur in the community will be handled

as follows: 

•	 Staff members involved in handling a psychiatric or medical emergency in the 

community will use their cell phones to

call the local police department directly or

to call 911 to access emergency services. A

call to 911 from a cell phone will access 

State Police, who will contact local police. 

•	 A program supervisor will be notified of

the emergency and will facilitate the deployment of additional staff resources as 

needed. 

•	 A first-aid kit is kept in each vehicle to

facilitate interim management of medical 

emergencies. No code bag is stored in vehicles. 

•	 Documentation needed to facilitate 

transport to an ED will be completed by 

the clinician most involved in the emergency situation. The involved clinician will 

also give relevant client information to ED 

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Behavioral Health Services for People Who Are Homeless 

care providers to facilitate continuity of 

care. 

•	 Procedures 3 through 9 as outlined in Section A of this policy will be followed. 

Sample Forms 

Recordkeeping is a necessary part of engaging

people who are homeless in services and tracking the course of these individuals’ contacts 

with service organizations. When possible,

records should be kept electronically and updated as new information becomes available. 

Sample forms presented in the following pages include: 

•	 Sample Memorandum of Understanding.

MOUs document tasks and roles of partnership organizations. 

•	 Sample Homelessness Outreach Contact 

Form. A sample of the type of form that 

can be used to document information 

gathered during early encounters between

a service provider and a potential client.

This sample form (along with the Sample 

Contact Log) is intended to be used during the outreach phase of homeless rehabilitation and illustrates the kinds of 

information you might want to record 

from outreach sessions. Although this

form includes information that is useful,

there is no expectation that it will be completed during the first several contacts 

with a potential client. Information gathering with people who have substance use 

disorders and are homeless is ongoing. 

•	 Sample Contact Log. A sample of the type 

of form that can be used to capture casefinding work during outreach and engagement activities. 

•	 Sample Case Management Discharge or

Transfer Note. A sample of the type of

form that is suited to record the circumstances of discharge or transfer. 

•	 Sample Interagency Referral Form. A sample of the type of form that is designed to

accompany an individual who is referred to

an outside agency. It provides the information the client has disclosed that is relevant to the referral. 

These documents are provided as a starting

point for your organization. Each must be

adapted to suit the particular philosophy and

procedures of your organization. 

190 
 

Part 2, Chapter 2 

Sample Memorandum of Understanding 

[Name of program] 

[Address] 

Dear [Name of partnering colleague]: 

This letter constitutes a memorandum of understanding between the [name of partnering organization], located at [address] and the [name of program] with its main office located at [address]. 

This understanding is solely for the purposes of clients associated with the [name of program]’s 

Section 8 supportive housing program for people with psychiatric disabilities that include a serious and persistent mental illness. This program intends to provide housing services to a maximum of [number] clients who will live at [address], subject to getting all zoning and commission

approvals. 

The [name of partnering organization] agrees to work collaboratively with the [name of program] to provide community-based psychiatric and case management services to the [number]

individuals who occupy the apartments noted above through the [name of program] based at

[address], provided that the clients meet the admission criteria for the [name of program]. Every 

effort will be made to ensure that the [name of program] is the sole source of referral for these 

[number] apartments. In the rare event that individuals not referred by the [name of program]

are accepted for apartments, it is the expectation that the [name of program] will refer these individuals to appropriate psychiatric and case management services, including those provided by 

[name of program] when appropriate. 

The [name of program] will be responsible for all management, upkeep, repairs, insurance, liability, and total operation of the building and program located at [address]. 

Please contact me at [telephone number; email address] if you have any questions. 

Sincerely, 

[Your name] 

Director of [name of program] 

CC: [relevant others] 

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Behavioral Health Services for People Who Are Homeless 

Sample Homelessness Outreach Contact Form 

Date: ______________ Name:_______________________________________________ 

Last First Middle 

DOB:______________ Age:______________SS#:__________________________ 

Gender: Male Female Veteran: Yes No Unknown 

Race/Ethnicity (voluntary): 

American Indian or Alaskan Native Native Hawaiian/Other Pacific Islander 

Asian or Pacific Islander White 

Black Other: ______________________ 

Hispanic/Latino Unknown 

Entitlements:
 

SS Disability: SSI: $____________ SSR: $____________
 

VA Pension: $_________ VA Service Connected: $_________ SAGA Cash: $ _________
 

SAGA Medical: Y N Title 19: Y N Medicare/Medicaid: Y N


A: Y N B: Y N D: Y N 

Employment: 

Job Title: __________________________________ Wage: __________________ 

Employer: __________________________________________________________ 

Education: High School Graduate: Y N GED: Y N Highest Grade: ______ 

College: Some Associate Bachelor’s Master’s 

Where has the person slept the past 2 weeks? How many nights in each place? 

Own apartment: # _____ Someone else’s apartment: #_____ Jail or prison: # ______
 

Shelter: # ______ Institution (hospital, nursing home): # _______ Outdoors: # _______
 

Public building: # _____ Abandoned building: # ______ Other: # ______
 

In your opinion, is the person served homeless? Yes No
 

Comments:
 

Length of time homeless this episode: 

Fewer than 2 days: ___ 2–30 days: ___ 31–90 days: ___ 91 days to 1 year: ___ 

More than 1 year: ___ Unknown: ___ 

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Part 2, Chapter 2 

Number of episodes homeless and length of time:________________________________ 

Brief Description: 

Eviction History: _______________________________________ 

Brief Description: 

Where is person staying a majority of the time?

Outdoors Jail or correctional facility

Short-term shelter Halfway house, residential treatment program

Long-term shelter Institution (psych, hospital, nursing home, etc.)

Own or another’s apartment, room, or house Unknown 

Hotel, SRO, boarding house Other:________________________________ 

Medical History: Does the person describe any significant medical problems? Yes No

Brief Description: 

Psychiatric History: Does the person describe any significant current psychiatric symptoms or

say he or she has received a psychiatric diagnosis in the past? Yes No 

Brief Description: 

Who was with the person at the time of contact?

1. Person was alone 4. Person was with spouse/partner & children 

2. Person was with children 5. Person was part of nonfamily group 

3. Person was with spouse/partner 6. Other: ____________________________ 

How was contact initiated? 

1. Outreach 3. Referral by mental 4. Self-referral 

2. Referral by shelter health agency or provider 5. Other_______________ 

How responsive was the person to contact?

1. Talked briefly; did not want to talk further 4. Interested in referral to non-PATH program

2. Would talk but not interested in services 5. Interested in outreach services 

3. Interested in basic services (food, clothing) 6. Other: _______________________ 

GOAL:__________________________________________________________________ 

Interviewer’s Name:_______________________________ Date:_________________ 

Duration of Contact: 5 min 10 min 15 min 30 min 45 min 60 min 61+ min 

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Behavioral Health Services for People Who Are Homeless 

Sample Contact Log
 

Counselor Name: Date: __Mon __Tue __Wed __Thur __Fri 

SECTION A: SCHEDULED OUTREACH RUNS 

Client Name # of 

Hours 

Client Name # of 

Hours 

SECTION B: CASE MANAGEMENT CLIENT CONTACTS (OPTIONAL) 

Client Name Contact 

Type* 

Contact 

Location† 

Amount 

of Time‡ 

Client Name Contact 

Type* 

Contact 

Location† 

Amount 

of Time‡ 

SECTION C: ALL NON-CASE-MANAGEMENT CONTACTS (REQUIRED) § 

Contact Name Contact 

Type* 

Contact 

Location† 

Amount 

of Time‡ 

Contact Name Contact 

Type* 

Contact 

Location† 

Amount 

of Time‡ 

* L=looking for/waiting with client; WC=with client; C=collateral; CI=crisis intervention (must do a critical incident report).

† O=office; CH=client home; C=community; OA=other agency.

‡ Hours and minutes in 5-minute intervals. 

§ Instructions for Section C: (1) Include all contact with non-case-managed clients. (2) Include clients

whose cases are managed by another outreach and engagement staff person. (3) Put case manager’s name 

in parentheses. (4) Do not include outreach contacts that occur during a scheduled outreach run (these go

in Section A). 

194 
 

 

 

 

 

 

 

 

 

 

________________________ ________ ______________________ ________ 

 

Part 2, Chapter 2 

Sample Case Management Discharge or Transfer Note 

Client Name ____________________________SS# _________________ DOB _____________________ 

Admission Date ________________ Case Manager _______________________ 

Discharge Date _________________ New Case Manager/Clinician _______________________ 

Transfer within O&E team Transfer to other provider agency_____________________ 


Discharge 


Reason for Discharge Dropped out/missing Incarcerated Moved away 

Tx continued elsewhere Facility Concurs Deceased 

No referral—services not needed No referral—client refused 

Housing Status Homeless Private residence w/supports 

Institution at Discharge 24-hr residential care 

Private residence w/o supports Unknown address 

Comment ______________________________________________________________ 

Name of Program/Facility _________________________________________________ 

Employment Status Not in labor force (disabled) Unemployed Unknown 

Supported/sheltered Employed F/T Employed P/T 

Summary of Services 

Why/how was client referred to O&E? (include referral source): 

Services Provided: 

Recommendations: 

Case Manager Date Supervisor Date 

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Behavioral Health Services for People Who Are Homeless 

Sample Interagency Referral Form 

Community-Based Clinical Services

Date Referring Team/
 

of Referral:__________ Person:_________________ Agency:____________________
 

Phone:________________	 Client’s name:_________________ MPI#: ____________________
 

Address:______________________________________________ CMHC#:__________________
 

Phone: ____________________________ DOB: _____________________
 

SSN: _____________________ Marital Status: _________ # of Children (if any):________ 


Race/Ethnicity: _______________ Emergency Contact: _____________ Relationship:___________
 

Phone: ________________________ Manages Own Finances? Yes No Conservator?______________
 

DSM-IV-TR Diagnoses:	 Axis I: 

Axis II: 

Axis III: 

Check all social/environmental factors that make it necessary to provide this level of services: 

___Social isolation ___Previous attempts to complete treatment 

___Presence of relapse trigger(s) ___History of multiple hospitalizations/ER con­

___Threatening spouse/significant other tacts within past 2 years 

___Homelessness ___History of multiple arrests/incarcerations 

___Unsafe living environment or victimization within past 2 years 

___Critical life event (or anniversary) ___Active substance abuse or dependence 

___Complicating medical condition(s) ___Failure to take prescribed medications 

___Denial of illness ___Inadequate financial support 

___Ineffective support system 

Describe current symptoms: 

Describe current case management needs: 

Nature of client’s involvement in treatment (including both substance abuse and mental health treatment): Describe attempts to engage client in treatment. What has worked and what hasn’t? 

196 
 

 

 

 

 

 

Part 2, Chapter 2 

Nature of client’s community adjustment: 

1.	 Describe current living circumstances and composition of household (include plans for housing if 

client is currently homeless and/or in transition): 

2.	 Client has history of placement in residential housing program: Yes No 

3.	 Describe current entitlement status (adapt choices to reflect specific entitlements in your area): 

___Basic Needs ___ADC ___SAGA Medical ___AD 

___SAGA Cash ___SSI ___Title XIX ___SSD 

___Medicare ___Other (please describe):___________________________ 

4.	 Describe available family/other support: 

5.	 Describe risk management issues (history of violence toward self or others): 

6.	 Describe nature of any past arrests/incarcerations, including current legal status (name and phone 

# of probation officer if applicable): 

7.	 Describe current medical problems, including name/phone of physician and/or medical clinic if 

applicable: 

8.	 Describe nature of current substance abuse: 

To be completed by intake clinician: Rationale for accepting or denying referral: 

197 
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Appendices 

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Appendices 

Fisk, D., Sells, D., & Rowe, M. (2007). Sober housing and motivational interviewing: The 

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Milby, J. B., Schumacher, J. E., Wallace, D., Freedman, M. J., & Vuchinich, R. E. (2005). To house

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Pearson, C. L., Locke, G., Montgomery, A. E., Buron, L., & McDonald, W. R. (2007). The 

applicability of Housing First models to homeless persons with serious mental illness. Final report. 

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Development and Research. 

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employment pathways for homeless job seekers in King County and Washington State: A report of the

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Housing. 

Robertson, P., & Myers, D. T. (2005). Digest of model programs for the homeless: Rural outreach and 

engagement and housing first. Glenside, PA: Pennsylvania Housing Choices. 

Rosenheck, R., & Mares, A. (2007). Implementation of supported employment for homeless 

veterans with psychiatric or addiction disorders: Two-year outcomes. Psychiatric Services, 58, 

325–333. 

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mentally ill. Administration and Policy in Mental Health and Mental Health Services Research, 

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integration. American Journal of Orthopsychiatry, 68, 490–496. 

Schanzer, B., Dominguez, B., Shrout, P. E., & Caton, C. L. (2007). Homelessness, health status,

and health care use. American Journal of Public Health, 97, 464–469. 

Schonebaum, A. D., Boyd, J. K., & Dudek, K. J. (2006). A comparison of competitive employment

outcomes for the clubhouse and PACT models. Psychiatric Services, 57, 1416–1420. 

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Alliance to End Homelessness. 

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Shaheen, G., & Rio, J. (2007). Recognizing work as a priority in preventing or ending

homelessness. Journal of Primary Prevention, 28, 341–358. 

Sosin, M. R., Bruni, M., & Reidy, M. (1995). Paths and impacts in the progressive independence 

model: A homelessness and substance abuse intervention in Chicago. Journal of Addictive 

Diseases, 14, 1–20. 

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systematic review. Journal of the Royal Society of Medicine, 97, 375–379. 

Stefancic, A., & Tsemberis, S. (2007). Housing first for long-term shelter dwellers with psychiatric

disabilities in a suburban county: A four-year study of housing access and retention. Journal of 

Primary Prevention, 28, 265–279. 

Stein, L. I., & Santos, A. B. (1998). Assertive community treatment of persons with severe mental 

illness. New York: W. W. Norton. 

Substance Abuse and Mental Health Services Administration. (n.d.). About PATH. Rockville,

MD: Substance Abuse and Mental Health Services Administration. Retrieved February 14,

2013, from: http://pathprogram.samhsa.gov/super/path/about.aspx 

Substance Abuse and Mental Health Services Administration. (2006). Transformation through 

partnerships: Systems change to end chronic homelessness (DVD). HHS Publication No. (SMA) 

06-4172. Rockville, MD: Substance Abuse and Mental Health Services Administration. 

Substance Abuse and Mental Health Services Administration. (2009). Supported employment 

evidence-based practices (EBP) KIT. HHS Publication No. (SMA) 08-4364. Rockville, MD:

Center for Mental Health Services, Substance Abuse and Mental Health Services 

Administration, U.S. Department of Health and Human Services. 

Substance Abuse and Mental Health Services Administration. (2010). Permanent supportive 

housing evidence-based practices (EBP) KIT. HHS Publication No. (SMA) 10-4510. Rockville,

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in people with substance use disorders. Treatment Improvement Protocol (TIP) Series 53. HHS

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Substance Abuse and Mental Health Services Administration. (2011b). Leading change: A Plan for 

SAMHSA’s Roles and Actions 2011-2014. HHS Publication No. (SMA) 11-4629. Rockville,

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Substance Abuse and Mental Health Services Administration. (2011c). Managing chronic pain in 

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Substance Abuse and Mental Health Services Administration. (2013). Addressing the specific 

behavioral health needs of men. Treatment Improvement Protocol (TIP) Series 56. HHS

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Substance Abuse and Mental Health Services Administration. (planned a). Behavioral health 

services for American Indians and Alaska Natives. Treatment Improvement Protocol (TIP)

Series. Rockville, MD: Substance Abuse and Mental Health Services Administration. 

Substance Abuse and Mental Health Services Administration. (planned b). Building health, 

wellness, and quality of life for sustained recovery. Treatment Improvement Protocol (TIP)

Series. Rockville, MD: Substance Abuse and Mental Health Services Administration. 

Substance Abuse and Mental Health Services Administration. (planned c). Improving cultural 

competence. Treatment Improvement Protocol (TIP) Series. Rockville, MD: Substance Abuse 

and Mental Health Services Administration. 

Substance Abuse and Mental Health Services Administration. (planned d). Managing anxiety 

symptoms in behavioral health services. Treatment Improvement Protocol (TIP) Series.

Rockville, MD: Substance Abuse and Mental Health Services Administration. 

Substance Abuse and Mental Health Services Administration. (planned e). Recovery in behavioral 

health services. Treatment Improvement Protocol (TIP) Series. Rockville, MD: Substance 

Abuse and Mental Health Services Administration. 

Substance Abuse and Mental Health Services Administration. (planned f). Reintegration-related 

behavioral health issues in veterans and military families. Treatment Improvement Protocol 

(TIP) Series. Rockville, MD: Substance Abuse and Mental Health Services Administration. 

Substance Abuse and Mental Health Services Administration. (planned g). Systems-level 

implementation of screening, brief intervention, and referral to treatment. Technical Assistance 

Publication (TAP) Series. Rockville, MD: Substance Abuse and Mental Health Services 

Administration. 

Substance Abuse and Mental Health Services Administration. (planned h). Trauma-informed care 

in behavioral health services. Treatment Improvement Protocol (TIP) Series. Rockville, MD:

Substance Abuse and Mental Health Services Administration. 

Substance Abuse and Mental Health Services Administration. (planned i). Using telephone- and 

Web-based technologies in behavioral health settings. Treatment Improvement Protocol (TIP)

Series. Rockville, MD: Substance Abuse and Mental Health Services Administration. 

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recovery. Columbus, OH: Ohio Department of Mental Health. 

Tsemberis, S., Gulcur, L., & Nakae, M. (2004). Housing first, consumer choice, and harm

reduction for homeless individuals with a dual diagnosis. American Journal of Public Health, 

94, 651–656. 

U.S. Department of Housing and Urban Development. (2001). Supportive housing program desk 

guide: Community planning and development. Washington, DC: U.S. Department of Housing 

and Urban Development. 

U.S. Department of Housing and Urban Development. (2007a). The annual homeless assessment 

report to Congress. Washington, DC: U.S. Department of Housing and Urban Development. 

U.S. Department of Housing and Urban Development Office. (2007b). The applicability of 

Housing First models to homeless persons with serious mental illness. Office of Policy 

Development and Research, U.S. Department of Housing and Urban Development. 

U.S. Department of Housing and Urban Development. (2008). Supportive housing program desk 

guide. Washington, DC: Office of Community Planning and Development, U.S. Department

of Housing and Urban Development. 

U.S. Department of Housing and Urban Development. (2010). 2009 annual homeless assessment 

report (AHAR) to Congress. Washington, DC: U.S. Department of Housing and Urban 

Development. 

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Retrieved on February 20, 2013, from http://portal.hud.gov/hudportal/HUD?src=/topics/ 

housing_choice_voucher_program_section_8 

U.S. Department of Housing and Urban Development, Office of Community Planning and

Development. (2010). The 2009 annual homeless assessment report. Washington, DC: U.S. 

Department of Housing and Urban Development, Office of Community Planning and

Development. 

U.S. Department of Housing and Urban Development. (2011). The 2010 annual homeless 

assessment report to Congress. Washington, DC: U.S. Department of Housing and Urban 

Development. 

U.S. Department of Housing and Urban Development & U.S. Department of Veterans Affairs.

(2010). Veteran homelessness: A supplemental report to the 2009 annual homeless assessment report 

to Congress. Washington, DC: U.S. Department of Housing and Urban Development & U.S.

Department of Veterans Affairs. 

U.S. Interagency Council on Homelessness. (2011). Projects for the assistance in transition from 

homelessness (PATH). Washington, DC: United States Interagency Council on Homelessness. 

211 
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. 

Appendices 

Appendix B—Advisory Meeting 

Panel 

H. Westley Clark, M.D., J.D., M.P.H., 

CAS, FASAM

Director 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Mady Chalk, Ph.D.

Director 

Division of Services Improvement

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Christina Currier 

Public Health Analyst

Practice Improvement Branch

Division of Services Improvement

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Michael T. Flaherty, Ph.D.

Northeast Addiction Technology Transfer

Center 

Institute for Research, Education and

Training in Addictions

Pittsburgh, PA 

Kevin Hennessy, Ph.D.

Science to Service Coordinator 

Office of Policy, Planning and Budget

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Constance M. Pechura, Ph.D.

Senior Program Officer

Robert Wood Johnson Foundation 

Princeton, New Jersey 

Richard A. Rawson, Ph.D.

Pacific Southwest Addiction Technology

Transfer Center 

Los Angeles, CA 

Jack B. Stein, Ph.D.

Acting Deputy Director

Division of Epidemiology, Services and

Prevention Research 

National Institute on Drug Abuse

National Institutes of Health 

Bethesda, MD 

Richard T. Suchinsky, M.D.

Associate Chief for Addictive Disorders 

Mental Health and Behavioral Sciences 

Service 

U.S. Department of Veteran Affairs

Washington, DC 

213 
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Behavioral Health Services for People Who Are Homeless 

Karl D. White, Ed.D.

Public Health Analyst

Practice Improvement Branch

Division of Services Improvement

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Mark Willenbring, M.D.

Director 

Division of Treatment and Recovery

Research 

National Institute on Alcohol Abuse and 

Alcoholism 

National Institutes of Health 

Bethesda, MD 

214 
 

 

 

 

 

 

 

 

 

Appendices 

Appendix C—Stakeholders
 

Meeting Participants
 

Michael Ahmadi 

Public Health Analyst

Office of Communications 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Lynnette Araki, M.P.H.

Senior Health Program Analyst

Health Resources and Services 

Administration 

Rockville, MD 

Moe Armstrong, M.B.A., M.A.

Director of Consumer and Family Affairs

Vinfen Corporation

Cambridge, MA 

Joseph H. Autry III, M.D.

Senior Medical Associate & Interagency 

Coordinator 

Department of Veterans Affairs

Washington, DC 

Christina Currier 

Contracting Officer’s Representative

Knowledge Application Program

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Pete Dougherty

Director 

Homeless Veterans Program (075D)

Department of Veterans Affairs

Washington, DC 

Janice Elliott 

Managing Director

Corporation for Supportive Housing

New Haven, CT 

Anne Fletcher, M.S.W., M.P.A.

Social Science Analyst

Office of the Assistant Secretary for

Planning and Evaluation

Department of Health and Human Services

Washington, DC 

Joanne Gampel, M.A.

Social Science Analyst

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Peggy Halpern

Program Analyst

Office of the Assistant Secretary for

Planning and Evaluation

U.S. Department of Health and Human

Services 

Washington, DC 

215 
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Behavioral Health Services for People Who Are Homeless 

Anne M. Herron, M.S.W.

Director 

Division of State and Community 

Assistance 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Cynthia High

Special Needs Assistance Program Specialist

U.S. Department of Housing and Urban 

Development

Washington, DC 

Jean Hochron 

Director 

Office of Minority and Special Populations

Bureau of Primary Health Care

Health Resources and Services 

Administration 

Rockville, MD 

Clarese V. Holden, Ph.D.

Public Health Advisor 

Division of State Programs

Center for Substance Abuse Prevention 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Mary Ellen Hombs

Deputy Executive Director

U.S. Interagency Council on Homelessness

Washington, DC 

Richard Kopanda, M.A.

Deputy Director

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Andrea Kopstein, Ph.D.

Practice Improvement Branch Chief

Division of Services Improvement

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Charlene LeFauve, Ph.D.

Co-Occurring and Homeless Activities

Branch Chief 

Division of State and Community 

Assistance 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Charlene Lewis, Ph.D.

Public Health Analyst

Office of the Administrator 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

John Lozier 

Executive Director 

National Health Care for the Homeless 

Council 

Nashville, TN 

Webb Lyons

Assistant to the President 

National Alliance to End Homelessness 

Washington, DC 

Philip Mangano

Executive Director 

U.S. Interagency Council on Homelessness

Washington, DC 

216 
 

 

 

 

 

 

 

 

 

Appendices 

Hunter L. McQuistion, M.D. (Chair)

Director 

Division of Outpatient and Community 

Psychiatry

Department of Psychiatry and Behavioral 

Health 

The St. Luke’s and Roosevelt Hospitals

Associate Clinical Professor of Psychiatry

Columbia University College of Physicians 

and Surgeons

New York, NY 

Cheri Nolan 

Senior Advisor to the Administrator 

Office of the Administrator 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Cathy Nugent

Public Health Advisor 

Division of Services Improvement

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Arne Owens, M.S.

Senior Advisor to the Administrator 

Office of the Administrator 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Lawrence D. Rickards, Ph.D.

Chief 

Homeless Programs Branch

Center for Mental Health Services 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Lora Routt 

Director 

State Assistance Division Office of Special 

Needs Assistance Programs

U.S. Department of Housing and Urban 

Development

Washington, DC 

Ruth Samardick 

Director 

Homeless Assistance Programs

Department of Labor

Washington, DC 

Jack Stein, M.S.W., Ph.D.

Director 

Division of Services Improvement

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Mark Weber 

Director 

Office of Communications 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, MD 

Harry Wilson 

Associate Commissioner 

Family and Youth Services Bureau

Administration for Children and Families 

U.S. Department of Health and Human

Services 

Washington, DC 

217 
 218
 

 

Appendices 

Appendix D—Field Reviewers
 

Kanzoni Asabigi

Deputy Director

Substance Abuse Prevention, Treatment and

Recovery 

Department of Health and Wellness 

Promotion 

Detroit, MI 

Kim M. Ball 

Clinical Supervision

Montgomery County Department of Health

and Human Services 

Silver Spring, MD 

Jessica Bass, CAC III, LCSW

Team Leader 

Community Housing & Multi Cultural 

Services 

Arapahoe House, Inc.

Lakewood, CO 

Hardy G. Bennett

Manager III 

Montgomery County Department of Health

and Human Services 

Rockville, MD 

Kathleen L. Estlund 

Star II Program Administrator 

Gateway Community Services, Inc.

Jacksonville, FL 

Claude Grazia 

Supervising Clinician

Substance Abuse Treatment Unit 

Connecticut Mental Health Center 

New Haven, CT 

Betty Kavanagh, LCSW-G 

Behavioral Health Officer 

Health Care for the Homeless, Inc.

Baltimore, MD 

Stefan Kertesz, M.D.

Assistant Professor 

Division of Preventive Medicine 

University of Alabama at Birmingham

Birmingham, AL 

Donna LaPaglia, Psy.D.

Associate Professor of Psychiatry 

Director of Substance Abuse Treatment 

Unit 

Yale University School of Medicine 

New Haven, CT 

ShunDell McGlothen 

Case Manager/Staff Advocate 

LAMP, Inc.

Los Angeles, CA 

John Mitchell 

Littleton, CO 

219 
 

 

 

Behavioral Health Services for People Who Are Homeless 

Else Pedersen-Wasson, M.B.A., LAC

Executive Director 

Bridge House Corporation

New Orleans, LA 

Calvin R. Trent 

General Manager

Special Populations Health Services 

Detroit Bureau of Substance Abuse 

Prevention, Treatment and Recovery 

Detroit, MI 

Sam Tsemberis 

Executive Director 

Pathways to Housing, Inc.

New York, NY 

Nancy R. VanDeMark, M.S.W.

Wheat Ridge, CO 

Carol Wilkins 

Director of Policy & Research

Corporation for Supportive Housing

Oakland, CA 

Darrell Woods 

Los Angeles, CA 

Renee Wyatt

Money Management Coordinator

LAMP, Inc.

Los Angeles, CA 

Cynthia Zubritsky, Ph.D.

Senior Research Faculty

University of Pennsylvania Department of

Psychiatry

Philadelphia, PA 

220 
 

 

Appendices 

Appendix E—Acknowledgments 

Numerous people contributed to the development of this Treatment Improvement Protocol 

(TIP), including the TIP Consensus Panel (see p. v), the Knowledge Application Program 

(KAP) Advisory Meeting Panel (Appendix B), the Stakeholders Meeting Participants (Appendix

C), and the Field Reviewers (Appendix D). 

This publication was produced under KAP, a Joint Venture of The CDM Group, Inc. (CDM),

and JBS International, Inc. ( JBS), for the Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. 

CDM KAP personnel included Rose M. Urban, M.S.W., J.D., LCSW, LSAC, Executive Project

Co-Director; Jessica Culotta, M.A., Managing Project Co-Director and former Managing Editor; Susan Kimner, former Managing Project Co-Director; Claudia Blackburn, Psy.D., Expert

Content Director; Bruce Carruth, Ph.D., former Expert Content Director; Jennifer Frey, Ph.D.,

former Expert Content Director; Marilyn Kresky-Wolff, M.P.H., LCSW-C, former Administrative Content Director; Sheldon Weinberg, Ph.D., Senior Researcher/Applied Psychologist;

Jonathan Max Gilbert, Ph.D., Writer/Editor; Leslie Kelley, former Writer/Editor; Angela

Fiastro, Junior Editor; Virgie Paul, Librarian; and Maggie Nelson, former Project Coordinator. 

221 

 

 

 

 

 

 

Index 

Index 

A 

AA (Alcoholics Anonymous), 100, 102–104,


108, 112, 137


ACT (assertive community treatment), 20, 39–


40, 140, 142–148, 143, 154, 169


Addiction Technology Transfer Center 


Network, 164


Administrators, information for


behavioral health program administrators,


xi, 4, 5. See also programming


health service providers and 


administrators generally, xi, 4


Agencies providing preventive services, 9
 

Alcoholics Anonymous (AA), 100, 102–104,


108, 112, 137


American Psychiatric Association, 181


Appointments, missed or late, 104
 

Assertive community treatment (ACT), 20,


39–40, 140, 142–148, 143, 154, 169


Assignments for clients between sessions, 106
 

B 

Base Realignment and Closure program, HUD,

175
 

Behavioral health, defined, xii


Behavioral health program administrators,


information for, xi, 4, 5. See also 

programming

Behavioral health counselors/service providers,

17–25 

attitudinal competencies and selfassessment, 18–23 

clinical interventions, involvement in, 32–


33
 

CODs (co-occurring disorders), working


with clients with, 107
 

community housing options and, 46–48


competencies for working with clients 


who are homeless, 18–20, 54


in critical stages of recovery model, 26, 27
 

cultural competence of, 45–46


information for, xi, 3–5


knowledge competencies, 18


parole officers, preparing clients for


conversations with, 71
 

preventive services and, 8–9


rewards of working with clients who are 


homeless, 17–18


self-care for, 23–25, 107
 

skill competencies, 18–19


summarizing for clients, 69
 

vignettes as training tools for. See 


vignettes


BI (brief intervention), 35
 

Boston Consortium Model of Trauma-


Informed Substance Abuse Treatment for
 

Women, 44


Bottom-up planning, 48, 157, 158–161, 158,


175
 

Brief intervention (BI), 35
 

Brief strategic family therapy (BSFT), 111
 

Brief treatment (BT), 36
 

223 
 

 

 

 

 

 

 

C 

Behavioral Health Services for People Who Are Homeless 

Case management, 37–38, 168–169, 173


CBSG (Curriculum-Based Support Group)


Program, 42, 138
 

Center for Mental Health Services (CMHS),


16, 141
 

Center for Substance Abuse Treatment
 

(CSAT), 18, 24


Center for Urban Community service (CUCS),

New York City, 180–181

Change model of recovery, 25, 25–26 

CHC (Community Health Center) program,


173
 

Children. See families and children 

Chronic homelessness, 7, 14, 15, 157. See also
 

Francis vignette, pages 72-83; Juan vignette,


pages 57-72


Clinical interventions, 32–44


case management, 37–38, 168–169, 173


early intervention and stabilization, 35


EBPs (evidence-based practices), 6, 40,


39–44
 

initial screening and evaluation, 34–35


outreach and engagement, 29–30, 33


relapse prevention and recovery 


management, 39


retention and continuity of care, 38–39


SBIRT (screening, brief intervention, and


referral to treatment), 35–36, 36, 135


treatment and prevention planning, 37


Clinical preventive services, 8


Clinical Supervision and Professional 


Development of the Substance Abuse Counselor


(TIP 52), 24, 56


Clinical supervisors, information for, xi


Clinician-Based Cognitive Psychoeducational 


Intervention, 45


Clubhouse model of transitional employment,

43
 

CMHCs (community mental health centers),


139, 140, 142, 143, 144, 145


CMHS (Center for Mental Health Services), 


16, 141
 

Co-occurring disorders (CODs), 7, 16, 35, 44,


50, 101, 144, 161, 176
 

CoC (Continuum of Care) programs, 159, 162,


175, 177


Cognitive–behavioral interventions, 39, 41


Cognitive impairment, 13, 79


Collaborative Applicants, 178


Collaborative partnerships, 162–166, 165
 

Community Health Center (CHC) program,


173
 

Community housing services, 46–54


Community mental health centers (CMHCs),


139, 140, 142, 143, 144, 145


Community services


agencies providing preventive services, 9
 

continuum of care through interaction


with community resources, 162, 163
 

environmental factors in, 12–13


funding, 175–178


homelessness programs, 7


integration of programming with


community services, 166–173

responses to homelessness, 14–16

Consensus panel recommendations on

preventive services, 10


Contact log, 190, 194


Contingency management, 40, 41
 

Continuity of care, maintaining, 38–39


Continuum of Care (CoC) programs, 159, 162,


175, 177


Continuum of care through interaction with 


community resources, 162, 163
 

Coping Cat Program, 138
 

Corporation for Supportive Housing (CSH),


153
 

Cost-effectiveness of supportive housing, 153
 

Counselors. See behavioral health counselors
 

Critical time intervention (CTI), 39, 40


CSAT (Center for Substance Abuse 


Treatment), 18, 23


CSH (Corporation for Supportive Housing),


153
 

CTI (critical time intervention), 39, 40


CUCS (Center for Urban Community service),


New York City, 180–181

Cultural competence, 45–46 

224 
 

 

 

 

 

 

 

 

 

 

 

Index 

Curriculum-Based Support Group (CBSG)


Program, 42, 138
 

D 

Damp housing, 51, 52
 

DARE To Be You (DTBY), 45


DCHV (Domiciliary Care for Homeless 


Veterans), 42


DESC (Downtown Emergency Service 


Center), 165–166


Disaster Housing Assistance Program, 175


Discharge/transfer form, 190, 195


Disruptive clients, 87
 

Documentation. See recordkeeping


Domiciliary Care for Homeless Veterans 


(DCHV), 52


Downtown Emergency Service Center


(DESC), 165–166


Drop-In Centers, 52


Dry housing, 51, 52
 

DTBY (DARE To Be You), 45
 

E 

Early intervention and stabilization, 35. See also
 

Mikki vignette, pages 129-139


EBPs (evidence-based practices), 6, 40, 39–44,
 

138
 

EDs (emergency departments), 84, 85–87, 159


Education and training, 10, 13


Emergencies, management policy and


procedures for, 188–190


Emergency departments (EDs), 84, 85–87, 159


Emergency shelters, 46, 50–51, 132, 157, 177


Emergency Solutions Grants (ESG) Program,


177
 

Employment


Clubhouse model of transitional 


employment, 43
 

education and training, 10, 13


environmental factors in homelessness,


12–13
 

incidence of homelessness and, 21–22


income stability, importance of, 10


in rural areas, 53-54


stress coping mechanisms, 139
 

supportive employment, 40, 41–42, 43
 

Engagement. See outreach and engagement


Enhancing Motivation for Change in Substance 


Abuse Treatment (TIP 35), 26, 41


Environmental factors in homelessness, 12–13


Episodic homelessness, 15, 156–157
 

ESG (Emergency Solutions Grants) Program,


177
 

Evaluation and screening, 34–36, 135
 

Evidence-based practices (EBPs), 6, 40, 39–44,
 

138
 

F 

Faith-based organizations, 179


Familias Unidas, 44


Families and children. See also See also Mikki
 

vignette, pages 129–139; Troy vignette, pages

100–113 

BSFT (brief strategic family therapy),

111
 

EBPs (evidence-based practices) for 

children, 138
 

housing for, 9, 131, 132


impact of homelessness on children, 22,


138
 

military families, SAMHSA Strategic


Initiative on, 6


preventive services to reduce 


intergenerational risk, 44


rates of homelessness, 21–22


social and family support issues, 10, 13


stress coping mechanisms, 139
 

Federally Qualified Health Centers (FQHCs),

73, 81, 173
 

Focus of clients, maintaining, 89, 94
 

Forms, 190–197


FQHCs (Federally Qualified Health Centers),


73, 81, 173
 

Francis, 56, 72–83


counselor skills and objectives, 71


dialog with behavioral health counselor,


72–83
 

potential reactions of behavioral health 


counselors to, 20


setting, 73
 

225 
 

 

 

 

 

 

 

 

Behavioral Health Services for People Who Are Homeless 

summary of situation, 15, 73–74, 82–83 

Funding resources, 6, 175–178 

G 

GBHI (Grants for the Benefit of Homeless 

Individuals), SAMHSA, 176

Gender-related problems and gender-specific 

treatment, 46, 169

Grants for the Benefit of Homeless Individuals 

(GBHI), SAMHSA, 176 

H 

Halfway houses, 50, 180

HCH (Health Care for the Homeless), 160,

170, 173

HCHV (Health Care for Homeless Veterans),

51–52 

Healthcare facilities providing preventive

services, 9 

Health Care for Homeless Veterans (HCHV),

51–52 

Health Care for the Homeless (HCH), 160,

170, 173

Health service providers and administrators 

generally, information for, xi, 4

HEARTH (Homeless Emergency Assistance 

and Rapid Transition to Housing) Act of

2009, 11, 177–178

HHS (U.S. Department of Health and Human

Services), 161, 166, 170

HIV/AIDS, 13, 34, 42, 44, 180

Homeless Emergency Assistance and Rapid

Transition to Housing (HEARTH) Act of

2009, 11, 177–178

Homelessness 

behavioral health services and, 17–25. See 

also behavioral health counselors/

service providers

characteristics of persons who are

homeless, 6–7, 11–12

chronic and multiple incidences of

homelessness, 7

clinical interventions, 32–44. See also 

clinical interventions 

community responses to, 15–17. See also 

community services

complex and multifactoral nature of, 10

cultural competence and, 45–46

defining, 11–12

environmental factors, 12–13

individual factors, 13–14

mental illness and, 6, 7, 12–13, 22. See 

also mental illness; serious mental 

illness 

myths and realities about, 21–23

number of homeless individuals, 12

preventive services, 8–9. See also 

preventive services

programming for, 151–197. See also 

programming

recovery from, 26–32. See also recovery 

risk of, 22

in rural areas, 53–54

specific client needs, addressing, 44–46

street skills, ingenuity, and

resourcefulness, 22–23

substance abuse and, 6, 7, 22, 152. See 

also substance abuse
 

types of, 14, 14–15, 156–157
 

vignettes, 55–148 


Web sites, 166


HOPWA (Housing Opportunities for Persons 

With AIDS) program, 175, 180

Housing

community housing services, 46–54

costs as environmental factor in 

homelessness, 12–13

families and children, 9, 131, 132 

for families in crisis, 131 

as first step in treating homelessness, 21,

59, 132, 149–151 

halfway houses, 50, 180

importance of, 7, 9

IOP (intensive outpatient) treatment,

114, 121

mental disorders, persons with, 49–50, 52 

as prevention, 9

PSH (permanent supportive housing), 16,

47, 48, 56, 136, 171–172 

226 
 

 

 

 

 

 

 

 

 

Index 

in rural areas, 53–54


Section 8 Housing, 103, 175, 176, 191


SRO (single room occupancy), 15, 45, 47,
 

84–85, 88, 95, 136, 142, 175


for people who abuse substances, 49–53,


52
 

supportive, 40, 41, 153, 171–172
 

temporary, 47


3⁄4-way houses, 50, 171


transitional supportive, 15, 47, 51, 131,


132
 

for veterans, 52–53


Web sites, 166


Housing First programs, 20, 59, 132, 153–155,
 

169, 179, 181, 182


Housing Opportunities for Persons With


AIDS (HOPWA) program, 175, 180


HUD. See U.S. Department of Housing and


Urban Development
 

I
 

ICM (intensive case management), 168, 171


IHN (In Homes Now), 183


Illness self-management, 39


In Homes Now (IHN), 183


Inappropriate behavior, 87, 92


Incarceration and homelessness, 7, 14, 44, 71,


140
 

Income stability, 10


Indicated prevention services, 8


Individual placement and support, VA, 40


Initial screening and evaluation, 32–35, 132
 

Integrated approach to homelessness services


collaborative partnerships, 162–166, 163,


165
 

community services, integration of


programming with, 166–173


continuum of care through interaction


with community resources, 162, 163
 

primary health care services, linkages 


with, 173–174


SAMHSA advocacy of, 3


sample forms, 191, 194–197
 

Intensive care, 30–31, 168–169. See also
 

Roxanne vignette, pages 83-100; Troy vignette,


pages 100-113


Intensive case management (ICM), 168, 171


Intensive outpatient (IOP) treatment, 114, 121


Interagency referral form, 191, 194–197


Intergenerational problems, family services 


addressing, 44-45


Interorganizational partnerships, 162–166, 163,


165
 

Intraorganization assessment, 164


IOP (intensive outpatient) treatment, 114, 121
 

J 

Jobs. See employment


Joint sessions, 91
 

Juan, 57–72


counselor skills and objectives, 58


dialog with behavioral health counselor,


58–62
 

setting, 57


summary of situation, 57, 72
 

L 

Language issues, 46


Lesbian, gay, bisexual, and transgendered


(LGBT) community, 46


Life-threatening conditions and situations, 6–7


Lions Quest Skills for Adolescence program,


42
 

Lists used to keep clients focused, 94
 

Literature review, xi, 4, 5


Local agencies providing preventive services, 9
 

M 

Maintaining continuity of care, 38–39

Managing Depressive Symptoms in Substance 


Abuse Clients During Early Recovery (TIP 


48), 134


Manhattan Outreach Consortium, 181


McKinney-Vento Act, 11, 177, 178


Medicaid, 73, 81, 154, 173
 

Medical issues
 

FQHCs (Federally Qualified Health


Centers), 73, 81, 173
 

227 
 

 

 

 

 

 

 

 

Behavioral Health Services for People Who Are Homeless 

life-threatening conditions in people who

are homeless, incidence of, 6–7

management of psychiatric and medical 

emergencies, policy and procedures,

188–190 

percentage of people who are homeless 


with, 13


refusal of services, follow-up care in cases 


of, 77
 

specific client needs, 44


Medicare, 80, 173
 

Memoranda of understanding (MOUs) or 


agreement (MOAs), 160, 163, 183, 190
 

Mental illness. See also Mikki vignette, pages 


129-139; Roxanne vignette, pages 83-100;


Sammy vignette, pages 139-148; serious 


mental illness
 

CODs (co-occurring disorders), 13, 40,


41, 44, 107, 161, 176


critical stages in recovery model and, 25,


26–29
 

homelessness and, 6, 7, 12–13, 23


housing as prevention, 9


housing for persons with, 49


institutional supports, loss of, 12


management of psychiatric and medical 


emergencies policy and procedures,


188–190
 

SAMHSA Strategic Initiative for 


preventing, 6


MI (motivational interviewing), 39, 41


Mikki, 14, 56, 129–139


counselor skills and objectives, 130–131


dialog with behavioral health counselor,


131–138
 

potential reactions of behavioral health


counselors to, 21


preventive services for, 38


setting, 130


summary of situation, 129–130, 139


Military families, SAMHSA Strategic


Initiative on, 6


Modified therapeutic communities (MTCs),


169, 170
 

Modified therapeutic community for persons 


with co-occurring disorders, 44


Motivational interviewing (MI), 39, 41


MOUs (memoranda of understanding) or 


MOAs (memoranda of agreement), 160,


163, 183, 190


MTCs (modified therapeutic communities),


169, 170


Multiple incidences of homelessness, 7
 

N 

Narcotics Anonymous (NA), 114, 119, 125,


127, 129


National Alliance on Mental Illness (NAMI),


140, 141, 144, 144, 145, 147


National Alliance to End Homelessness, 54,


166
 

National Association of Community Health


Centers (NACHC), 173


National Center for Trauma-Informed Care 


(NCTIC), SAMHSA, 134
 

National Center on Family Homelessness 


(NCFH), 22


National Health Care for the Homeless 


Council, 157, 166


National Institute on Drug Abuse (NIDA), 35


National Registry of Evidence-Based Programs 


and Practices (NREPP), SAMHSA, 42, 43,


44, 45, 139, 166
 

National Resource Center on Homelessness 


and Mental Illness, 166


National Survey of Homeless Assistance 


Providers and Clients, 12, 21


NCFH (National Center on Family 


Homelessness), 22


NCTIC (National Center for Trauma-


Informed Care), SAMHSA, 134
 

Network for the Improvement of Addiction


Treatment, 164


NIDA (National Institute on Drug Abuse), 35


No Heroes policy and procedures, 184–185

Nongovernmental organizations, 10, 158, 159,
 

160, 165
 

228 
 

 

 

 

 

 

 

 

 

 

 

Index 

NREPP (National Registry of Evidence-Based

Programs and Practices), SAMHSA, 40, 41,

42, 43, 134, 161 

O 

OAH (Open Arms Housing, Inc.), 181–182

Ongoing rehabilitation, 31–32, 171. See also 

René vignette, pages 113–129 

Open Arms Housing, Inc. (OAH), 181–182

Opening Doors, USICH, 177

Organizational approaches to programming,

179–183 

Outreach and engagement, 74, 75. See also 

Francis vignette, pages 72-83; Juan vignette,

pages 57-72

as clinical intervention, 29–30, 33

community housing services, 51

integration of programming with

community services, 167–168

sample forms, 190, 192–193

Overwhelmed clients, 103 

Oxford Houses, 32, 50–51, 52, 156, 171, 172– 

173 

P 

Parole officers, preparing clients for

conversations with, 71 

Partnerships, collaborative or

interorganizational, 162–166, 163, 165

PATH (Projects for Assistance in Transition

from Homelessness) Program, SAMHSA,

16–17, 53, 139–140, 141, 143, 146, 148, 176

Permanent supportive housing (PSH), 16, 47, 

48, 56, 136, 171–172 

Permanent Supportive Housing Evidence-Based

Practices (EBP) KIT, 172, 174

Planning treatment and prevention, 37

Policies and procedures, 183, 186–190

Posttraumatic stress disorder (PTSD), 7, 13, 83,

87 

Preventive services, 8–10

agencies providing, 10 

case management methods, 38

family-based, 44–45

relapse prevention, 39, 116 

suicide prevention, 42

treatment and prevention planning, 37

types of, 8 

Primary healthcare services, linkages with, 173–

174 

Programming, 151–197

adaptation of existing programs, 155–162

bottom-up, 48, 157, 158–159, 158, 161– 

162 

collaborative partnerships, 162–166, 163,

165 

community services, integration with,

166–173 

continuum of care through interaction

with community resources, 162, 163 

cost-effectiveness of, 153 

development of, 152–153

forms, 190–197

funding community services, 175–178

importance of, 151–152

Internet resources for, 166

organizational approaches to, 175–178

policies and procedures, 183, 186–190

primary healthcare services, linkages with,

173–174 

specific needs of homeless, addressing,

155–156 

top-down, 157, 159, 160–162

Progress, helping clients appreciate, 117 

Project Renewal, New York City, 182–183

Projects for Assistance in Transition from 

Homelessness (PATH) Program,

SAMHSA, 16–17, 53, 139–140, 141, 143, 

146, 148, 176

Providers 

behavioral health service providers. See 

behavioral health counselors/service 

providers

health service providers generally,

information for, xi, 4

PSH (permanent supportive housing), 16, 47, 

48, 56, 136, 171–172 

PTSD (posttraumatic stress disorder), 7, 13, 83,

87 

Public awareness and support, 6 

229 
 

 

 

 

 

 

 

 

 

 

 

Behavioral Health Services for People Who Are Homeless 

Public Housing Program, HUD, 176


Publicly disruptive clients, 87
 

R 

Recordkeeping

MOUs or MOAs (memoranda of


understanding or agreement), 160, 163,


183, 190


sample forms, 190–197

Recovery, 25–32

critical stages of recovery model, 24, 25–

29, 27, 28


defined, xii


planned TIPs addressing, 29, 39, 116,


171
 

rehabilitation model, 25, 29–32, 167–171


relapse prevention and recovery 


management, 39


SAMHSA Strategic Initiative on, 6


stages of change model, 25, 25–26
 

transition periods, 168, 169, 171


Referrals
 

interagency referral form, 190, 196–197


RT (referral to treatment), 36
 

transfer/discharge form, 190, 195


Refusal of services, follow-up care in cases of,

77
 

Rehabilitation model of recovery, 25, 29–32, 

167–171
 

Relapse prevention, 37–38, 116
 

René, 54, 113–129


counselor skills and objectives, 114


dialog with behavioral health counselor,


113–129
 

setting, 114


summary of situation, 113–114, 129


Responsibility House, 180


Retention of clients in treatment, 38–39


Role-playing, 122
 

Roxanne, 15, 56, 83–100


counselor skills and objectives, 84


dialog with behavioral health counselor,


83–100
 

potential reactions of behavioral health


counselors to, 21, 83
 

setting, 84


summary of situation, 83–84, 96–97


RT (referral to treatment), 36
 

Rural areas, 53–54
 

S 

Safe housing. See housing

Safety policies and procedures, 183–187

SAMHSA. See Substance Abuse and Mental 

Health Services Administration 

Sammy, 56, 139–148


counselor skills and objectives, 140


dialog with behavioral health counselor,


141–148
 

setting, 136


summary of situation, 139–140, 148


Sample forms, 190–197


Sample policies and procedures, 183, 186–190


Say It Straight program, 42


SBIRT (screening, brief intervention, and


referral to treatment), 35, 36, 135


Screening and evaluation, 34–36, 135
 

Screening, brief intervention, and referral to


treatment (SBIRT), 35, 36, 135
 

Section 8 Housing, 103, 175, 176, 191


Section 202 Supportive Housing for the 


Elderly Program, HUD, 175


Section 811 Supportive Housing for Persons 


with Disabilities, HUD, 175


Seeking Safety program, 44


Selective prevention services, 8


Services in Supportive Housing (SSH),


SAMHSA, 175


Serious mental illness (SMI). See also Sammy 


vignette, pages 139-148


ACT programs aimed at, 169–170


co-occurrence with homelessness, 6


institutional supports, loss of, 13


PATH (Projects for Assistance in


Transition from Homelessness)


Program, SAMHSA, 16–17, 53, 139–


140, 141, 143, 146, 148, 176


Sexually transmitted diseases, 13


Shelters, 46, 53, 132, 157, 177
 

230 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Index 

Single room occupancy (SRO) housing, 15, 47,


50, 84, 85, 88, 136, 142, 175


SIs (Strategic Initiatives), SAMHSA, 6


SMI. See serious mental illness 

Sober living houses, 50, 52
 

Social and family support issues, 10, 13


Social Security Administration, 16, 137, 150
 

Social Security Disability Insurance (SSDI),


141, 145, 154


Specific client needs, addressing, 44, 155


SRO (single room occupancy) housing, 15, 47,


50, 84, 85, 88, 136, 142, 175


SSDI (Social Security Disability Insurance),


141, 145, 154


SSH (Services in Supportive Housing),


SAMHSA, 176


SSI (Supplemental Security Income), 141, 154
 

Stabilization, 36


Stand-Down programs, 52, 177


State agencies providing preventive services, 9
 

Stewart B. McKinney Homeless Assistance 


Amendments Act of 1990, 141, 177
 

Strategic Initiatives (SIs), SAMHSA, 6


Street and community outreach safety policy 

and procedures, 186–187

Strengthening Families Program, 45


Stress coping mechanisms, 139
 

Substance abuse. See also Juan vignette, page 57­

70; René vignette, pages 113-129; Roxanne 


vignette, pages 83-100; Troy vignette, pages


100-113
 

CODs (co-occurring disorders), 7, 16, 35,


44, 50, 101, 144, 161, 176


critical stages in recovery model and, 25,


26–29
 

defined, xii


homelessness and, 6, 7, 22, 152


housing as prevention, 9


housing services for people who abuse 


substances, 49–51, 52
 

institutional supports, loss of, 13


SAMHSA Strategic Initiative for 


preventing, 6


Substance Abuse and Mental Health Services 


Administration (SAMHSA)
 

Building your program: permanent


supportive housing, 172


as funding resource, 6, 176


Homelessness Resource Center, 48


NCTIC (National Center for Trauma-


Informed Care), 134
 

NREPP (National Registry of Evidence-


Based Programs and Practices), 40, 41,


42, 43, 134, 161
 

PATH (Projects for Assistance in


Transition from Homelessness)


Program, 16–17, 53, 139–140, 141,


143, 146, 148, 176


PSH (permanent supportive housing),


support for, 48, 172


SBIRT (screening, brief intervention, and


referral to treatment) endorsed by, 35,


135
 

Web sites, 166


Suicide prevention, 42


Summarizing for clients, 69
 

Supplemental Security Income (SSI), 141, 154
 

Supportive employment, 40, 41–42, 43
 

Supportive housing, 38, 39, 149, 169–170. See 


also permanent supportive housing;


transitional supportive housing
 

T 

Temporary housing, 47


3⁄4-way houses, 50, 171


TIPs. See Treatment Improvement Protocols

Top-down planning, 157, 159, 160–162


Training and education, 10, 13


Transfer/discharge form, 190, 195


Transition periods in treatment process, 168,


171
 

Transitional homelessness, 14, 16. See also René 


vignette, pages 113-129


Transitional supportive housing, 15, 47, 51,
 

131, 132


Transportation of clients, policy and procedures 


for, 187–188


Trauma. See also Roxanne vignette, page 83-100


frequency in homeless persons, 7, 13


planned TIP addressing, 169
 

231 
 

 

 

Behavioral Health Services for People Who Are Homeless 

PTSD (posttraumatic stress disorder), 7,


13, 84, 87


SAMHSA Strategic Initiative on, 6


specific client needs, 44


Trauma-informed care, 90, 134, 169
 

Trauma Recovery and Empowerment Model 


(TREM), 44


Treatment and prevention planning, 37


Treatment Improvement Protocols (TIPs)


Clinical Supervision and Professional 


Development of the Substance Abuse


Counselor (TIP 52), 24, 56


cultural competence, planned TIP


addressing, 46


defined, vii


Enhancing Motivation for Change in 


Substance Abuse Treatment (TIP 35),
 

26, 41


Managing Depressive Symptoms in 


Substance Abuse Clients During Early


Recovery (TIP 48), 134


recovery, planned TIPs addressing, 29,


39, 122, 171


trauma, planned TIP addressing, 169


TREM (Trauma Recovery and Empowerment


Model), 44


Troy, 56, 100–113


counselor skills and objectives, 100–101


dialog with behavioral health counselor, 100–


113
 

preventive services for, 38


setting, 100


summary of situation, 100, 113


12-Step programs, 32, 50, 171, 173


Types of homelessness, 14, 14–15, 157
 

U 

Universal prevention services, 8


U.S. Department of Health and Human


Services (HHS), 161, 166, 170


U.S. Department of Housing and Urban 


Development (HUD)


CoC (Continuum of Care) programs,


159, 162, 175, 177


definition of homelessness, 11
 

as funding resource, 6, 159, 169–170, 171


Housing First and, 150


on number of individuals who are 


homeless, 11


PSH (permanent supportive housing),


support for, 47


Section 8 Housing, 103, 175, 176, 191


veterans, Supported Housing Program 


for, 52


Web site, 166


U.S. Department of Veterans Affairs (VA)


as funding resource, 6, 176–177


housing services and programs, 52


individual placement and support, 42


Web sites, 166


U.S. Interagency Council on Homelessness 


(USICH), 15, 177
 

V
 

VA. See U.S. Department of Veterans Affairs


Veterans
 

community housing services for, 52


HUD programs, 176


individual factors contributing to


homelessness of, 13


military families, SAMHSA Strategic


Initiative on, 6


Veterans Affairs Supportive Housing Program,


176
 

Vignettes, 55–148. See also Francis; Juan;


Mikki; René; Roxanne; Sammy; Troy


decision trees, 56


how-to notes, 56


master clinician notes, 56


potential reactions of behavioral health


counselors and, 21, 23


preventive services in, 36


purpose of, 5


skills introduced in, 55
 

W 

Welcome Home, 140


Wellness self-management, 39


Wet housing, 51, 52
 

Work. See employment
 

232 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CSAT TIPs and Publications Based on TIPs 

What Is a TIP? 

Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that

brings together clinicians, researchers, program managers, policymakers, and other Federal and nonFederal experts to reach consensus on state-of-the-art treatment practices. TIPs are developed under

CSAT’s Knowledge Application Program to improve the treatment capabilities of the Nation’s alcohol 

and drug abuse treatment service system. 

What Is a Quick Guide? 

A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized

booklet. Each Quick Guide is divided into sections to help readers quickly locate relevant material. Some

contain glossaries of terms or lists of resources. Page numbers from the original TIP are referenced so providers can refer back to the source document for more information. 

What Are KAP Keys? 

Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening instruments, checklists, and summaries of treatment phases. Printed on coated paper, each KAP Keys set is 

fastened together with a key ring and can be kept within a treatment provider’s reach and consulted frequently.The Keys allow you, the busy clinician or program administrator, to locate information easily and

to use this information to enhance treatment services. 

Ordering Information 

Publications may be ordered for free at http://store.samhsa.gov. To order over the phone, please call

1-877-SAMHSA-7 (1-877-726-4727) (English and Español). Most publications can also be downloaded 

at http://kap.samhsa.gov. 

TIP 1	 State Methadone Treatment Guidelines— TIP 9 Assessment and Treatment of Patients With 

Replaced by TIP 43 Coexisting Mental Illness and Alcohol and

TIP 2 Pregnant, Substance-Using Women—Replaced Other Drug Abuse—Replaced by TIP 42 

by TIP 51 TIP 10 Assessment and Treatment of CocaineTIP 3 Screening and Assessment of Alcohol- and Abusing Methadone-Maintained Patients— 

Other Drug-Abusing Adolescents—Replaced Replaced by TIP 43 

by TIP 31	 TIP 11 Simple Screening Instruments for Outreach

TIP 4	 Guidelines for the Treatment of Alcohol- and for Alcohol and Other Drug Abuse and

Other Drug-Abusing Adolescents—Replaced Infectious Diseases—Replaced by TIP 53 

by TIP 32	 TIP 12 Combining Substance Abuse Treatment With

TIP 5	 Improving Treatment for Drug-Exposed Intermediate Sanctions for Adults in the 

Infants—BKD110 Criminal Justice System—Replaced by TIP 44 

TIP TIP 13 6 Screening for Infectious Diseases Among Role and Current Status of Patient Placement 

Criteria in the Treatment of Substance Use Substance Abusers—Archived
 

Disorders—BKD161
 TIP 7	 Screening and Assessment for Alcohol and Quick Guide for Clinicians QGCT13 Other Drug Abuse Among Adults in the Quick Guide for Administrators QGAT13 Criminal Justice System—Replaced by TIP 44 KAP Keys for Clinicians KAPT13 

TIP 8 Intensive Outpatient Treatment for Alcohol

and Other Drug Abuse—Replaced by TIPs 46 TIP 14 Developing State Outcomes Monitoring

and 47 Systems for Alcohol and Other Drug Abuse

Treatment—BKD162 

233 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Behavioral Health Services for People Who Are Homeless 

TIP 15	 Treatment for HIV-Infected Alcohol and 

Other Drug Abusers—Replaced by TIP 37 

TIP 16	 Alcohol and Other Drug Screening of

Hospitalized Trauma Patients—(SMA) 12­

3686 

Quick Guide for Clinicians QGCT16

KAP Keys for Clinicians KAPT16 

TIP 17	 Planning for Alcohol and Other Drug Abuse

Treatment for Adults in the Criminal Justice 

System—Replaced by TIP 44 

TIP 18	 The Tuberculosis Epidemic: Legal and Ethical 

Issues for Alcohol and Other Drug Abuse 

Treatment Providers—Archived 

TIP 19	 Detoxification From Alcohol and Other 

Drugs—Replaced by TIP 45 

TIP 20	 Matching Treatment to Patient Needs in

Opioid Substitution Therapy—Replaced by 

TIP 43 

TIP 21	 Combining Alcohol and Other Drug Abuse

Treatment With Diversion for Juveniles in the 

Justice System—(SMA) 12-4073

Quick Guide for Clinicians and

Administrators QGCA21 

TIP 22 LAAM in the Treatment of Opiate 

Addiction—Replaced by TIP 43 

TIP 23 Treatment Drug Courts: Integrating

Substance Abuse Treatment With Legal Case 

Processing—(SMA) 12-3917

Quick Guide for Administrators QGAT23 

TIP 24 A Guide to Substance Abuse Services for 

Primary Care Clinicians—(SMA) 08-4075

Concise Desk Reference Guide BKD123 

Quick Guide for Clinicians QGCT24

KAP Keys for Clinicians KAPT24 

TIP 25	 Substance Abuse Treatment and Domestic 

Violence—(SMA) 12-4076

Linking Substance Abuse Treatment and

Domestic Violence Services: A Guide for 

Treatment Providers MS668 

Linking Substance Abuse Treatment and

Domestic Violence Services: A Guide for 

Administrators MS667 

Quick Guide for Clinicians QGCT25

KAP Keys for Clinicians (SMA) 12-3584 

TIP 26	 Substance Abuse Among Older Adults— 

(SMA) 12-3918

Substance Abuse Among Older Adults: A

Guide for Treatment Providers MS669 

Substance Abuse Among Older Adults: A

Guide for Social Service Providers MS670 

Substance Abuse Among Older Adults:

Physician’s Guide MS671 

Quick Guide for Clinicians QGCT26

KAP Keys for Clinicians KAPT26 

TIP 27	 Comprehensive Case Management for

Substance Abuse Treatment—(SMA) 12­

4215 

Case Management for Substance Abuse

Treatment: A Guide for Treatment Providers 

MS673 

Case Management for Substance Abuse 

Treatment: A Guide for Administrators 

MS672 

Quick Guide for Clinicians QGCT27

Quick Guide for Administrators QGAT27 

TIP 28 Naltrexone and Alcoholism Treatment— 

Replaced by TIP 49 

TIP 29	 Substance Use Disorder Treatment for People 

With Physical and Cognitive Disabilities— 

(SMA) 12-4078

Quick Guide for Clinicians QGCT29

Quick Guide for Administrators (SMA)

08-3592 

KAP Keys for Clinicians KAPT29 

TIP 30	 Continuity of Offender Treatment for

Substance Use Disorders From Institution to 

Community—(SMA) 12-3920

Quick Guide for Clinicians QGCT30

KAP Keys for Clinicians KAPT30 

TIP 31	 Screening and Assessing Adolescents for

Substance Use Disorders—(SMA) 12-4079

See companion products for TIP 32. 

TIP 32	 Treatment of Adolescents With Substance 

Use Disorders—(SMA) 12-4080

Quick Guide for Clinicians QGCT312

KAP Keys for Clinicians KAPT312 

TIP 33	 Treatment for Stimulant Use Disorders— 

(SMA) 09-4209

Quick Guide for Clinicians QGCT33

KAP Keys for Clinicians KAPT33 

TIP 34	 Brief Interventions and Brief Therapies for

Substance Abuse—(SMA) 12-3952

Quick Guide for Clinicians QGCT34

KAP Keys for Clinicians KAPT34 

234 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TIP 35	 Enhancing Motivation for Change in 


Substance Abuse Treatment—(SMA) 12­

4212
 

Quick Guide for Clinicians (SMA) 12-4097


KAP Keys for Clinicians (SMA) 12-4091
 

TIP 36	 Substance Abuse Treatment for Persons With
 

Child Abuse and Neglect Issues—(SMA) 12­

3923
 

Quick Guide for Clinicians QGCT36


KAP Keys for Clinicians KAPT36


Helping Yourself Heal: A Recovering Woman’s


Guide to Coping With Childhood Abuse 


Issues (SMA) 08-4132


Available in Spanish: PHD981S


Helping Yourself Heal: A Recovering Man’s


Guide to Coping With the Effects of


Childhood Abuse (SMA) 08-4134


Available in Spanish: PHD1059S
 

TIP 37	 Substance Abuse Treatment for Persons With
 

HIV/AIDS—(SMA) 12-4137


Quick Guide for Clinicians MS678


KAP Keys for Clinicians KAPT37


Drugs, Alcohol, and HIV/AIDS: A Consumer 


Guide (SMA) 08-4127


Available in Spanish: PHD1134


Drugs, Alcohol, and HIV/AIDS: A Consumer 


Guide for African Americans (SMA) 07-4248
 

TIP 38	 Integrating Substance Abuse Treatment and


Vocational Services—(SMA) 12-4216


Quick Guide for Clinicians QGCT38


Quick Guide for Administrators QGAT38


KAP Keys for Clinicians KAPT38
 

TIP 39	 Substance Abuse Treatment and Family


Therapy—(SMA) 12-4219


Quick Guide for Clinicians QGCT39


Quick Guide for Administrators QGAT39
 

TIP 40	 Clinical Guidelines for the Use of
 

Buprenorphine in the Treatment of Opioid


Addiction—(SMA) 07-3939


Quick Guide for Physicians QGPT40


KAP Keys for Physicians KAPT40
 

TIP 41	 Substance Abuse Treatment: Group


Therapy—(SMA) 12-3991


Quick Guide for Clinicians (SMA) 12-4024
 

TIP 42	 Substance Abuse Treatment for Persons With
 

Co-Occurring Disorders—(SMA) 12-3992


Quick Guide for Clinicians (SMA) 07-4034


Quick Guide for Administrators (SMA) 12­

4035
 

KAP Keys for Clinicians (SMA) 08-4036
 

TIP 43	 Medication-Assisted Treatment for Opioid


Addiction in Opioid Treatment Programs—
 

(SMA) 12-4214


Quick Guide for Clinicians QGCT43


KAP Keys for Clinicians (SMA) 07-4108
 

TIP 44	 Substance Abuse Treatment for Adults in the 


Criminal Justice System—(SMA) 12-4056


Quick Guide for Clinicians QGCT44


KAP Keys for Clinicians (SMA) 07-4150
 

TIP 45	 Detoxification and Substance Abuse
 

Treatment—(SMA) 12-4131


Quick Guide for Clinicians(SMA) 06-4225


Quick Guide for Administrators (SMA) 06­

4226
 

KAP Keys for Clinicians (SMA) 06-4224
 

TIP 46	 Substance Abuse: Administrative Issues in
 

Outpatient Treatment—(SMA) 12-4157


Quick Guide for Administrators (SMA) 07­

4232
 

TIP 47	 Substance Abuse: Clinical Issues in
 

Outpatient Treatment—(SMA) 12-4182


Quick Guide for Clinicians (SMA) 07-4233


KAP Keys for Clinicians (SMA) 07-4251
 

TIP 48	 Managing Depressive Symptoms in Substance


Abuse Clients During Early Recovery—
 

(SMA) 12-4353
 

TIP 49	 Incorporating Alcohol Pharmacotherapies


Into Medical Practice—(SMA) 12-4380


Quick Guide for Counselors (SMA) 10-4542


Quick Guide for Physicians (SMA) 10-4543


KAP Keys for Clinicians (SMA) 10-4544
 

TIP 50	 Addressing Suicidal Thoughts and Behaviors


in Substance Abuse Treatment—(SMA) 09­

4381
 

TIP 51	 Substance Abuse Treatment: Addressing the


Specific Needs of Women—(SMA) 09-4426
 

TIP 52	 Clinical Supervision and Professional 


Development of the Substance Abuse 


Counselor—(SMA) 09-4435
 

TIP 53	 Addressing Viral Hepatitis in People With


Substance Use Disorders—(SMA) 11-4656
 

TIP 54	 Managing Chronic Pain in Adults With or in


Recovery From Substance Use Disorders—
 

(SMA) 12-4671
 

TIP 55 Behavioral Health Services for People Who


Are Homeless—(SMA) 13-4734
 

TIP 56 Addressing the Specific Behavioral Health


Needs of Men—(SMA) 13-4736
 

235 
HHS publication no. (SmA) 13-4734 

First printed 2013

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and mental Health Services Administration 

center for Substance Abuse Treatment