Breaking Down Substantial Barriers:
Recognizing trauma and stigma in housing instability and substance use
By Nina Ovian
Housing is a basic human need, and research across a wide range of disciplines shows that without it, we face dire physical and emotional consequences. While most people can agree on this understanding, our social systems still fail to come together to accept housing as a basic human right, and resist confronting the realities of those living day-to-day without it.
Being deprived of housing on a prolonged basis is a severe and dangerous trauma, which one cannot process or recover from until well after housing is established. The difference between understanding housing as just a need or as a full human right can be a product of the stigma surrounding homelessness and behavioral health. This stigma creates a treacherous pathway rife with barriers to permanent housing, and, if a person is also using substances, it can become practically impossible to complete. Policy must be rooted in the lives and needs of people currently experiencing homelessness, and many of the restrictions that target people who use substances seem to ignore the practical reality of housing insecurity.
People who use substances have higher rates of homelessness than those who do not, and among people who experience homelessness, those who use substances are more likely to remain homeless. This isn’t due to a moral or individual failing, but a stigma created by policies and lack of resources available to certain people deemed “not deserving” of help.
Shelters are often not welcoming or warm environments; they are severely underfunded and over capacity. The staff are often overworked, underpaid, and not provided the proper emotional support for a job of that nature. There is very little privacy or security, and most of the people coming through are facing some sort of behavioral health crisis, be it mental health, substance use, or both, often with little to no behavioral health support. While people can and are connected to both physical and behavioral health care services upon entering a shelter, these can only provide a stopgap measure until the person can be removed from the ongoing trauma of homelessness. A human needs to be out of survival mode before they can truly focus on recovery, because the prolonged toxic stress of homelessness is an ongoing trauma.
While many shelters may still let someone in while intoxicated, they will go through an individual’s belongings and confiscate any substances in order to hinder further consumption while in the shelter. Many people avoid going into the shelter system because entering could mean experiencing withdrawal, something that may not be safe to do in that environment, without medical supervision or any semblance of privacy. While there may be a shelter bed available, with these conditions it might not be realistically safer than sleeping on the streets for someone who is substance dependent. This highlights a failure not of the individual, but of the systems created to serve homeless populations without accounting for the realities of homelessness.
The day-to-day reality of being without basic needs like food, water, or housing is in and of itself a threat to one’s behavioral health; the results of homelessness can have long-lasting and negative consequences for the mind. Sleep deprivation, lack of regular access to things like bathrooms and clean water, and a societal stigma that leads to social isolation are things that would degrade anyone’s mental health, even if they had no preexisting conditions. The experience of homelessness will also exacerbate any preexisting behavioral health challenges, as the focus shifts to survival rather than addressing those specific challenges. A person who is dependent on substances is not likely to address that dependency until after they have had a meal and a safe place to sleep.
It is reasonable that people find ways to cope with the conditions surrounding homelessness, and obtaining drugs or alcohol can be more accessible than most forms of mental health care. Even those linked to care who may also be candidates for psychiatric medication may struggle if they face frequent thefts and are unlikely to be able to hold onto prescriptions and possessions long-term, a common reality for many people living on the streets. This causes them to be more likely to rely on street drugs as they can more easily get what they need at the moment, and not have to hold onto monthly supplies. During this time, dependencies on drugs and alcohol are likely to arise.
It must be understood that the road to and within recovery is long and complicated, and cannot be sped up by enforcing shallow or unrealistic requirements for acceptance into a housing program. Even something as simple as deciding you want to change your substance use habits could take months for someone who has obtained housing. It is not as simple as giving someone housing, but also giving them the time to trust that it won’t be taken away again.
While there can be more leniency and discretion in shelters when it comes to active substance use, this decreases substantially when it comes to more long-term solutions to housing. Due to policies attached to many funding sources, most long-term housing programs across the country have initial requirements for sobriety or substance use, as well as policies allowing eviction and program termination for substance use. While some programs argue there is a differentiation between substance “use” and substance “abuse,” the delineation is still determined by the housing program and not the person in recovery.
Policy is not neutral; it can be both influenced by stigma and responsible for the creation of stigma. A policy barring people who use substances from entering into long-term housing programs makes the statement that they are not deserving of receiving this fundamental support. When the war on drugs expanded into social services, it created the narrative that people who use substances were responsible for their current situation, and that only through abstinence from those substances could they become worthy of these basic human necessities once again.
There are exceptions to abstinence-based models of housing popping up and growing interest across the country, such as programs that utilize a housing first or harm reduction model, acknowledging and accepting the realities of substance use and homelessness. “Housing first” is exactly what it sounds like, providing the housing first, and setting the stage for the rest to follow. The emphasis on no- or low-barrier entry into housing affirms the humanity and reality of those struggling with housing insecurity. Policies and programs that fit within this model take on the important work of destigmatizing homelessness, an important step in being able to acknowledge the trauma of housing insecurity, and hopefully moving towards ending homelessness entirely.