Abstract
Homeless veterans are likely to experience Post Traumatic Stress Disorder (PTSD). Homelessness itself is traumatic, and PTSD may exacerbate homelessness risk for veterans. Often, PTSD goes untreated in this subpopulation of veterans. Our study examined trauma-focused treatment (TFT) and non-TFT initiation and completion in a sample of housed and homeless veterans being served by a PTSD clinical team in Washington, DC. Findings included a high percentage of veterans who experienced homelessness in the sample and lower treatment completion rates among homeless veterans compared to housed veterans. This difference was no longer significant when comparing only those veterans who engaged in treatment, reinforcing the critical role of treatment engagement in successful treatment completion across populations.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Abt Associates. (2021). FY 2019 SSVF Annual Report. Retrieved from https://www.va.gov/homeless/ssvf/docs/SSVF_Annual_Report_FY19.pdf
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (Revised (5th ed.). American Psychiatric Association.
Blackstock, O. J., Haskell, S. G., Brandt, C. A., & Desai, R. A. (2012). Gender and the use of Veterans Health Administration homeless services programs among Iraq/Afghanistan veterans. Medical Care, 50(4), 347–352. https://doi.org/10.1097/MLR.0b013e318245a738
Blanchard, E. B., Jones-Alexander, J., Buckley, T. C., & Forneris, C. A. (1996). Psychometric properties of the PTSD Checklist (PCL). Behaviour Research and Therapy, 34, 669–673. https://doi.org/10.1016/0005-7967(96)00033-2
Bovin, M. J., Marx, B. P., Weathers, F. W., Gallagher, M. W., Rodriguez, P., Schnurr, P. P., & Keane, T. M. (2016). Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5) in veterans. Psychological Assessment, 28(11), 1379–1391. https://doi.org/10.1037/pas0000254
Boyd, J. E., Hayward, H., Bassett, E. D., & Hoff, R. (2016). Internalized stigma of mental illness and depressive and psychotic symptoms in homeless veterans over 6 months. Psychiatry Research, 240, 253–259. https://doi.org/10.1016/j.psychres.2016.04.035
Cahill, S. P., Rothbaum, B. O., Resick, P. A., & Follette, V. M. (2009). Cognitive-behavioral therapy for adults. In E. B. Foa, T. M. Keane, M. J. Friedman, & J. A. Cohen (Eds.), Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (pp. 139–222). The Guilford Press.
Carlson, E. B., Garvert, D. W., Macia, K. S., Ruzek, J. I., & Burling, T. A. (2013). Traumatic stressor exposure and post-traumatic symptoms in homeless veterans. Military Medicine, 178(9), 970–973. https://doi.org/10.7205/MILMED-D-13-00080
Chard, K. M., Schumm, J. A., Owens, G. P., & Cottingham, S. M. (2010). A comparison of OEF and OIF veterans and Vietnam veterans receiving cognitive processing therapy. Journal of Traumatic Stress, 23, 25–32.
Chinman, M., George, P., Dougherty, R. H., Daniels, A. S., Ghose, S. S., Swift, A., & Delphin-Rittmon, M. E. (2014). Peer support services for individuals with serious mental illnesses: Assessing the evidence. Psychiatric Services, 65(4), 429–441. https://doi.org/10.1176/appi.ps.201300244
Cook, J. M., Schnurr, P. P., Simola, V., Thompson, R., Hoff, R., & Harpaz-Rotem, I. (2019). Adoption of VA residential programs of two evidence-based psychotherapies for PTSD: Effect on patient outcomes. Psychiatric Services, 70(7), 553–560. https://doi.org/10.1176/appi.ps.201800338
Cox, K. B., Malte, C. A., & Saxon, A. J. (2017). Characteristics and service utilization of homeless veterans entering VA substance use treatment. Psychological Services, 14(2), 208–213. https://doi.org/10.1037/ser0000133
Crone, B., Metraux, S., & Sbrocco, T. (2022). Health service access among homeless veterans: Health access challenges faced by homeless African American veterans. Journal of Racial and Ethnic Health Disparities, 9, 1828–1844. https://doi.org/10.1007/s40615-021-01119-z
DeViva, J. C., McCarthy, E., Southwick, S. M., Tsai, J., & Pietrzak, R. H. (2021). The impact of sleep quality on the incidence of PTSD: Results from a 7-Year, Nationally Representative, Prospective Cohort of U.S. Military Veterans. Journal of Anxiety Disorders, 81, 102413. https://doi.org/10.1016/j.janxdis.2021.102413
Ding, K., Slate, M., & Yang, J. (2018). History of co-occurring disorders and current mental health status among homeless veterans. BMC Public Health, 18(1), 751. https://doi.org/10.1186/s12889-018-5700-6
Dinnen, S., Kane, V., & Cook, J. M. (2014). Trauma-informed care: A paradigm shift needed for services with homeless veterans. Professional Case Management, 19(4), 161–172. https://doi.org/10.1097/NCM.0000000000000038
Donoho, C. J., Bonanno, G. A., Porter, B., Kearney, L., & Powell, T. M. (2017). A decade of war: Prospective trajectories of post-traumatic stress disorder symptoms among deployed US military personnel and the influence of combat exposure. American Journal of Epidemiology, 186, 1310–1318.
Edens, E., Kasprow, W., Tsai, J., & Rosenheck, R. (2011). Association of substance use and VA service-connected disability benefits with risk of homelessness among veterans. American Journal on Addictions, 20(5), 412–419.
Elbogen, E., Sullivan, C., Wolfe, J., Wagner, H., & Beckham, J. (2013). Homelessness and money mismanagement in Iraq and Afghanistan veterans. American Journal of Public Health, 103(2), S248–S254.
Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39(2), 175–191. https://doi.org/10.3758/bf03193146
Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (Eds.). (2009). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (2nd ed.). The Guilford Press.
Gabrielian, S., Yuan, A. H., Andersen, R. M., Rubenstein, L. V., & Gelberg, L. (2014). VA health service utilization for homeless and low-income Veterans: A spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles. Medical Care, 52(5), 454–461. https://doi.org/10.1097/MLR.0000000000000112
Garcia, H. A., Kelley, L. P., Rentz, T. O., & Lee, S. (2011). Pretreatment predictors of dropout from cognitive behavioral therapy for PTSD in Iraq and Afghanistan war veterans. Psychological Services, 8(1), 1–11. https://doi.org/10.1037/a0022705
Gates, M. A., Holowka, D. W., Vasterling, J. J., Keane, T. M., Marx, B. P., & Rosen, R. C. (2012). Posttraumatic stress disorder in veterans military personnel: Epidemiology, screening, and case recognition. Psychological Services, 9(4), 361–382. https://doi.org/10.1037/a0027649
Goodman, L. A., Saxe, L., & Harvey, M. (1991). Homelessness as psychological trauma: Broadening perspectives. American Psychologist, 46(11), 1219–1225. https://doi.org/10.1037/0003-066X.46.11.1219
Gros, D. F., Yoder, M., Tuerk, P. W., Lozano, B. E., & Acierno, R. (2011). Exposure therapy for PTSD delivered to veterans via telehealth: Predictors of treatment completion and outcome and comparison to treatment delivered in person. Behavior Therapy, 42(2), 276–283. https://doi.org/10.1016/j.beth.2010.07.005
Hamilton, A. B., Poza, I., & Washington, D. L. (2011). Homelessness and trauma go hand-in-hand: Pathways to homelessness among women veterans. Women’s Health Issues, 21(4), S203–S209. https://doi.org/10.1016/j.whi.2011.04.005
Harris, T., Winetrobe, H., Rhoades, H., Castro, C. A., & Wenzel, S. (2018). Moving beyond housing: Service implications for veterans entering permanent supportive housing. Journal of Clinical Social Work, 46, 130–144. https://doi.org/10.1007/s10615-018-0648-7
Henry, M., Watt, R., Mahathey, A., et al. (2020). The 2019 Annual Homeless Assessment Report (AHAR) to Congress: Part One. The U.S. Department of Housing and Urban Development’s Office of Community Development and Planning.
Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13–22. https://doi.org/10.1056/NEJMoa040603
Hopper, E. K., Bassuk, E. L., & Oliver, L. (2010). Shelter from the storm: Trauma-informed care in homelessness services settings. Open Health Services and Policy Journal, 3(2), 80–100. https://doi.org/10.2174/1874924001003020080
Ijadi-Maghsoodi, R., Feller, S., Ryan, G. W., Altman, L., Washington, D. L., Kataoka, S., & Gelberg, L. (2021). A sector wheel approach to understanding the needs and barriers to services among homeless-experienced veteran families. Journal of the American Board of Family Medicine: JABFM, 34(2), 309–319. https://doi.org/10.3122/jabfm.2021.02.200331
Kenny, D. J., & Yoder, L. H. (2019). A picture of the older homeless female veteran: A qualitative, case study analysis. Archives of Psychiatric Nursing, 33(4), 400–406. https://doi.org/10.1016/j.apnu.2019.05.005
Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. Journal of Traumatic Stress, 26(5), 537–547. https://doi.org/10.1002/jts.21848
Kip, K. E., D’Aoust, R. F., Hernandez, D. F., Girling, S. A., Cuttino, B., Long, M. K., Rojas, P., Wittenberg, T., Abhayakumar, A., & Rosenzweig, L. (2016). Evaluation of brief treatment of symptoms of psychological trauma among veterans residing in a homeless shelter by use of Accelerated Resolution Therapy. Nursing Outlook, 64(5), 411–423. https://doi.org/10.1016/j.outlook.2016.04.006
Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1990). Trauma and the Vietnam war generation: Report of findings from the National Vietnam Veterans Readjustment Study. Brunner/Mazel.
Lehavot, K., Katon, J. G., Chen, J. A., Fortney, J. C., & Simpson, T. L. (2018). Post-traumatic stress disorder by gender and veteran status. American Journal of Preventive Medicine, 54(1), e1–e9. https://doi.org/10.1016/j.amepre.2017.09.008
LePage, J. P., Bradshaw, L. D., Cipher, D. J., Crawford, A. M., & Hoosyhar, D. (2014). The effects of homelessness on Veterans’ health care service use: An evaluation of independence from comorbidities. Public Health, 128(11), 985–992. https://doi.org/10.1016/j.puhe.2014.07.004
Livingston, W. S., Brignone, E., Fargo, J. D., Gundlapalli, A. V., Maguen, S., & Blais, R. K. (2019). VHA-enrolled homeless veterans are at increased risk for eating disorder diagnoses. Military Medicine, 184(1–2), e71–e75. https://doi.org/10.1093/milmed/usy175
Lu, M. W., Duckart, J. P., O’Malley, J. P., & Dobscha, S. K. (2011). Correlates of utilization of PTSD specialty treatment among recently diagnosed veterans at the VA. Psychiatric Services, 62(8), 943–949. https://doi.org/10.1176/ps.62.8.pss6208_0943
Maguen, S., Cohen, B., Cohen, G., Madden, E., Bertenthal, D., & Seal, K. (2012). Eating disorders and psychiatric comorbidity among Iraq and Afghanistan veterans. Women’s Health Issues, 22(4), e403–e406. https://doi.org/10.1016/j.whi.2012.04.005
Malte, C. A., Cox, K., & Saxon, A. J. (2017). Providing intensive addiction/housing case management to homeless veterans enrolled in addictions treatment: A randomized controlled trial. Psychology of Addictive Behaviors, 31(3), 231–241. https://doi.org/10.1037/adb0000273
McGuire, J. (2007). Closing a front door to homelessness among veterans. The Journal of Primary Prevention, 28(3), 389–400. https://doi.org/10.1007/s10935-007-0091-y
Metraux, S., Clegg, L. X., Daigh, J. D., Culhane, D. P., & Kane, V. (2013). Risk factors for becoming homeless among a cohort of veterans who served in the era of the Iraq and Afghanistan conflicts. American Journal of Public Health, 103(2), S255–S261. https://doi.org/10.2105/AJPH.2013.301432
Min, S. Y., Whitecraft, J., Rothbard, A. B., & Salzer, M. S. (2007). Peer support for persons with co-occurring disorders and community tenure: A survival analysis. Psychiatric Rehabilitation Journal, 30, 207–213. https://doi.org/10.2975/30.3.2007.207.213
O’Toole, T. (2018). Primary care for homeless veterans. In J. Tsai (Ed.), Homelessness among US Veterans: Critical perspectives (pp. 61–76). Oxford University Press.
O’Connell, M. J., Kasprow, W., & Rosenheck, R. A. (2008). Rates and risk factors for homelessness after successful housing in a sample of formerly homeless veterans. Psychiatric Services, 59(3), 268–275. https://doi.org/10.1176/ps.2008.59.3.268
O’Toole, T. P., Conde-Martel, A., Gibbon, J. L., Hanusa, B. H., & Fine, M. J. (2003). Health care of homeless veterans. Journal of General Internal Medicine, 18(11), 929–933. https://doi.org/10.1046/j.1525-1497.2003.21209.x
Perl, L. (2015). Veterans and Homelessness. Congressional Research Service. Retrieved from https://digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?article=2485&context=key_workplace
Perron, B. E., Alexander-Eitzman, B., Gillespie, D. F., & Pollio, D. (2008). Modeling the mental health effects of victimization among homeless persons. Social Science & Medicine (1982), 67(9), 1475–1479. https://doi.org/10.1016/j.socscimed.2008.07.012
Pompili, M., Sher, L., Serafini, G., Forte, A., Innamorati, M., Dominici, G., Lester, D., Amore, M., & Girardi, P. (2013). Posttraumatic stress disorder and suicide risk among veterans: A literature review. The Journal of Nervous and Mental Disease, 201(9), 802–812. https://doi.org/10.1097/NMD.0b013e3182a21458
Raad, J. H., Tarlov, E., Kho, A. N., & French, D. D. (2020). Health care utilization among homeless veterans in Chicago. Military Medicine, 185(3–4), e335–e339. https://doi.org/10.1093/milmed/usz264
Rauch, S. A., Favorite, T., Giardino, N., Porcari, C., Defever, E., & Liberzon, I. (2010). Relationship between anxiety, depression, and health satisfaction among veterans with PTSD. Journal of Affective Disorders, 121(1–2), 165–168. https://doi.org/10.1016/j.jad.2009.05.026
Resnik, L., Ekerholm, S., Johnson, E. E., Ellison, M. L., & O’Toole, T. P. (2017). Which homeless veterans benefit from a peer mentor and how? Journal of Clinical Psychology, 73(9), 1027–1047. https://doi.org/10.1002/jclp.22407
Rosenheck, R. A., & Fontana, A. (1994). A model of homelessness among male veterans of the Vietnam War generation. American Journal of Psychiatry, 151(3), 421–427.
Schinka, J. A., Bossarte, R. M., Curtiss, G., Lapcevic, W. A., & Casey, R. J. (2016). Increased mortality among older veterans admitted to VA homelessness programs. Psychiatric Services (Washington, D. C.), 67(4), 465–468. https://doi.org/10.1176/appi.ps.201500095
Sestito, S. F., Rodriguez, K. L., Saba, S. K., Conley, J. W., Mitchell, M. A., & Gordon, A. J. (2017). Homeless veterans’ experiences with substance use, recovery, and treatment through photo elicitation. Substance Abuse, 38(4), 422–431. https://doi.org/10.1080/08897077.2017.1356422
Smith, T., & True, G. (2014). Warring identities: Identity conflict and the mental distress of American veterans of the wars in Iraq and Afghanistan. Society and Mental Health, 4(2), 147–161.
Speed, K. J., Crean, H. J., Bishop, T. J., Hoff, R., & Pigeon, R. W. (2020). Sleep disturbances in returning veterans that are homeless and combat-exposed. Sleep, 43(supplemental 1), 308. https://doi.org/10.1093/sleep/zsaa056.806
Steenkamp, M. M., & Litz, B. T. (2013). Psychotherapy for military-related posttraumatic stress disorder: Review of the evidence. Clinical Psychology Review, 33(1), 45–53. https://doi.org/10.1016/j.cpr.2012.10.002
Szafranski, D. D., Gros, D. F., Menefee, D. S., Wanner, J. L., & Norton, P. J. (2014). Predictors of length of stay among OEF/OIF/OND veteran inpatient PTSD treatment noncompleters. Psychiatry, 77(3), 263–274. https://doi.org/10.1521/psyc.2014.77.3.263
Tsai, J., Doran, K. M., & Rosenheck, R. A. (2013). When health insurance is not a factor: National comparison of homeless and non homeless US veterans who use Veterans Affairs Emergency Departments. American Journal of Public Health, 103(2), S225–S231. https://doi.org/10.2105/AJPH.2013.301307
Tsai, J., Pietrzak, R. H., & Szymkowiak, D. (2021). The problem of veteran homelessness: An update for the new decade. American Journal of Preventive Medicine, 60(6), 774–780. https://doi.org/10.1016/j.amepre.2020.12.012
Tsai, J., & Rosenheck, R. A. (2015). Risk factors for homelessness among US veterans. Epidemiologic Reviews, 37, 177–195. https://doi.org/10.1093/epirev/mxu004
Tsai, J., Rosenheck, R. A., Decker, S. E., Desai, R. A., & Harpaz-Rotem, I. (2012). Trauma experience among homeless female veterans: Correlates and impact on housing, clinical, and psychosocial outcomes. Journal of Traumatic Stress, 25(6), 624–632. https://doi.org/10.1002/jts.21750
Tsai, J., Schick, V., Hernandez, B., & Pietrzak, R. H. (2020). Is homelessness a traumatic event? Results from the 2019–2020 National Health and Resilience in Veterans Study. Depression and Anxiety, 37(11), 1137–1145. https://doi.org/10.1002/da.23098
Tuerk, P. W., Wangelin, B., Rauch, S. A., Dismuke, C. E., Yoder, M., Myrick, H., Eftekhari, A., & Acierno, R. (2013). Health service utilization before and after evidence-based treatment for PTSD. Psychological Services, 10(4), 401–409. https://doi.org/10.1037/a0030549
U.S. Department of Veterans Affairs and U.S. Department of Defense. (2017). VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. Retrieved from https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal012418.pdf
U.S. Department of Housing and Urban Development. (2020). HUD 2020 Continuum of Care Homeless Assistance Programs Homeless Populations and Subpopulations. Retrieved from https://files.hudexchange.info/reports/published/CoC_PopSub_NatlTerrDC_2020.pdf
Van Voorhees, E. E., Resnik, L., Johnson, E., & O’Toole, T. (2019). Posttraumatic stress disorder and interpersonal process in homeless veterans participating in a peer mentoring intervention: Associations with program benefit. Psychological Services, 16(3), 463–474. https://doi.org/10.1037/ser0000231
van Vugt, M. D., Kroon, H., Delespaul, P. A., & Mulder, C. L. (2012). Consumer-providers in assertive community treatment programs: Associations with client outcomes. Psychiatric Services, 63, 477–481.
Washington, D. L., Yano, E. M., McGuire, J., Hines, V., Lee, M., & Gelberg, L. (2010). Risk factors for homelessness among women veterans. Journal of Health Care for the Poor and Underserved, 21(1), 82–91. https://doi.org/10.1353/hpu.0.0237
Weber, M., Schumacher, S., Hannig, W., Barth, J., Lotzin, A., Schäfer, I., Ehring, T., & Kleim, B. (2021). Long-term outcomes of psychological treatment for posttraumatic stress disorder: A systematic review and meta-analysis. Psychological Medicine, 51(9), 1420–1430. https://doi.org/10.1017/S003329172100163X
Williams, J. K., & Hall, J. A. (2009). Stress and traumatic stress: How do past events influence current traumatic stress among mothers experiencing homelessness? Social Work Research, 33(4), 199–207.
Author information
Authors and Affiliations
Corresponding author
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Disclaimer
The opinions and assertions expressed herein are those of the author(s) and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense. References to non-Federal entities or products do not constitute or imply a Department of Defense or Uniformed Services University of the Health Sciences endorsement.
Rights and permissions
About this article
Cite this article
Crone, B., Arenson, M., Cortell, R. et al. Comparing Trauma Treatment Outcomes Between Homeless and Housed Veterans in a VA PTSD Clinical Program. Community Ment Health J 59, 797–807 (2023). https://doi.org/10.1007/s10597-022-01061-2
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10597-022-01061-2