When Helen entered a homeless shelter in Chicago, staff members described her as "depressed, refusing to change her clothes, and flat." Helen said that she'd been homeless for the last three years. She also said that she'd been hearing strange voices in her head since age 8 and had been diagnosed as a substance abuser. Yet she'd never received mental health treatment and was still drinking alcohol.

A referral to a local service, the Thresholds Mobile Assessment Unit, changed Helen's life. She got a bed at Thresholds Safe Haven, a program housed in a local YMCA. She started seeing a psychiatrist at a mental health clinic located there. Helen also stopped drinking alcohol and got training in skills for living independently. Eventually she moved into her own studio apartment.

Helen's story opens "Blueprint for Change: Ending Chronic Homelessness for Persons with Serious Mental Illnesses and Co-Occurring Substance Use Disorders." This 2003 report from the Substance Abuse and Mental Health Services Administration estimates that nearly 630,000 Americans are homeless on any given night. About half of homeless adults have histories of alcohol abuse or dependence. One-third have abused drugs, and nearly a quarter of them have experienced serious mental illness.

In Minnesota, a November 2006 statewide survey of homelessness published by the Amherst H. Wilder Foundation revealed that more than half of the people had a serious mental illness, 34 percent considered themselves alcoholic or dependent on drugs, and 45 percent reported at least one chronic health problem (such as asthma, lung problems, high pressure).

As part of this study, researchers asked 3,700 homeless people to name the main problems that they faced in getting a job. Lack of transportation and housing topped this list, followed directly by physical and mental health problems. Health issues were even bigger barriers to employment than a criminal record, lack of education, or lack of work experience.

Even homeless people who are willing to admit their addiction and get treatment face obstacles to recovery. For one, they usually lack health insurance. In addition, treatment centers in many states have long waiting lists. And without stable housing, even people who complete treatment can end up back on the streets or in jail.

One solution is helping homeless people access a variety of services under one roof. This happens at places like People Serving People (PSP) in downtown Minneapolis. Founded in 1982 as a shelter for homeless and chemically dependent men, PSP now works with families and children as well. It has the capacity to house 350 people and serve 1,000 meals daily. PSP also offers a medical clinic, a childcare center, and an employment assistance program.

People Serving People insists that residents be free of alcohol and other drugs. "The bottom line is that while they're staying here at the shelter, people cannot be under the influence or have chemicals in their possession," says Dan Goodermont, PSP's community integrated services manager. If people choose to violate this policy, he adds, then "they're choosing not to be housed here."

For homeless people who are willing to get help for addiction, however, PSP offers immediate assistance. This includes a referral to the Hennepin County Health Care for the Homeless Medical Clinic, where psychologists and psychiatrists are onsite. From these professionals, homeless people can get referrals to more services. "And if you're looking for addiction treatment and you're in Minnesota, then you're in the right place," says Goodermont.

As Helen's story indicates, there's room for optimism about the twin problems of homelessness and addiction. Demonstration programs indicate that homeless people--even those thought to be unreachable--can gain sobriety, get jobs, and learn to live independently. Moreover, the costs of social services for homeless people are off set by savings in prison programs and public hospital expenses.

"Clearly, the time has come to end homelessness among people with serious mental illness and/or co-occurring substance use disorders," note the authors of "Blueprint for Change." "We know what works. Now we must put what we know to work."

--Published July 9, 2007