Homeless Veterans

“War is about combat, combat is about fighting, fighting is about killing and killing is a traumatic personal experience for those who fight.”

Col. Timothy Hanifen, USMC Iraq 2003

A couple of eye opening videos.

Define the culture: why is it a culture?

Most homeless veterans begin to establish values and beliefs that begin long before they come home from combat. Combat is the beginning of the journey towards the dawn of entering a new culture. Soldiers return home from combat and enter into a state of suffering and despair, which is known as being a veteran. No longer synchronized with their previous culture, or feeling like true civilians, these individuals enter into the culture of veterans. Many roam the streets homeless. The culture of veterans is millions strong, with nearly 150,000 of then homeless at any given time. The homeless veterans make up their own culture as they have their own language, symbols, places their gather, and a shared experience most regular civilians don’t completely grasp. According to The National Coalition of Homeless “The U.S. Department of Veterans Affairs estimates that 131,000 veterans are homeless on any given night”. It is estimated that nearly one third of homeless men have at one point put on a service uniform and served the very country they live in the streets in. In terms of providing health care, veterans as a culture exhibit unique challenges to the health care system. According to Hobbs, veteran culture includes health dissimilarities and inconsistencies related to post-traumatic stress syndrome, depression, mental disorders, and substance abuse, which all must be understood in context in order to insure the best possible care for this culture.

Source: http://www.nationalhomeless.org/factsheets/

Values/Norms:

Veterans, whether homeless or not, have been close to the edge during combat. Given this, they tend to hold value to things others may take for granted. For example, spending a lot of time over seas in the jungle or desert without common items like water or electricity an individual tend to value it much more than before. They also value how special their country is and the right to freedom, and grasp what life without these liberties would bring.

Beliefs/Attitudes:

Many suffer depression, strong patriotism; highly regard other veterans, Loss of self-efficacy. Highly regard armed forces and other veterans. Many feel “wronged” by their country for lack of better veteran support systems.

Traditions:

Veterans Day. Honor other veterans. Mutual respect and admiration for other military personnel. Strong association with American flag.

Sense of Self/Space:

Feeling of being alone or abandoned by their country. Feelings of separation from the country they left behind versus the one they came back to. Loss of hope and low self-esteem.

Communication Style/Language:

Communicate often through anger and hate for being left out in the cold. Mental disorders often affect communication. Often polite and respect figures of authority

Dress/Appearance:

Military uniforms are a common dress of homeless veterans, which shows their pride in their country and the service they did. However, many dress just like anyone else and it may not be noticeable that they are a homeless vet.

Food/Feeding Habits:

Homeless vets typically are limited to what is served in shelters or from specialized homeless programs from the V.A.

Relationships/Social Organization:

After coming home from serving in the military, homeless veterans struggle socially. For example, many became accustomed to a sense of brotherhood with his fellow servicemen, and they find that they now struggle forming close friendships. This can result in them feeling emotionally and physically isolated.

Mental Process/Learning:

Many homeless vets suffer with mental disabilities, especially PTSD, and substance abuse.

Work Habits/Practices:

Many homeless vets fail to hold down jobs because of substance abuse taking over their lives, resulting in their inability to maintain a stable life. Many lack making long-term goals, which can also affect their ability to keep jobs. Also, not having an address prevents their ability to get a job, and not having a job prevents their ability to pay for a home. Its a “catch 22”.

Demographics and Statistics:


“Conservative estimates count about 131,000 homeless veterans in the United States, most of them from the Vietnam War era. The VA has pinpointed 3,717 homeless veterans of Iraq and Afghanistan, but the nationwide total could be as many as twice that — about 7,400, he said.”

“The VA estimates about 10 percent of all homeless veterans are women, making the estimated number of homeless Iraq-Afghanistan female veterans about 740.”

Homeless U.S. veterans

Estimated homeless veterans: 131,000
Estimated homeless female veterans: 13,100
Estimated post-9/11 veterans: 7,400
Estimated number of female post-9/11 veterans: 740
12 percent of homeless veterans younger than 34 are women
Jobless rate for post-9/11 veterans: 11.3 percent

Sources: Department of Veterans Affairs, Bureau of Labor Statistics

http://www.cnn.com/2009/LIVING/09/25/homeless.veterans/

The majority of homeless veterans are single, from urban areas, and have a mental illness and abuse alcohol and/or drugs. Approximately 56% of homeless veterans are African American or Hispanic. 23% of the homeless population are veterans

Listed below are veteran-specific highlights from the USICH (U.S. Interagency Council on the Homeless)

23% of the homeless population are veterans
33% of the male homeless population are veterans
47% served Vietnam-era
17% served post-Vietnam
15% served pre-Vietnam
67% served three or more years
33% were stationed in war zone
25% have used VA homeless services
85% completed high school/GED, compared to 56% of non-veterans
89% received an honorable discharge
79% reside in central cities
16% reside in suburban areas
5% reside in rural areas
76% experience alcohol, drug or mental health problems
46% are white males, compared to 34% of non-veterans
46% are age 45 or older, compared to 20% non-veterans

Service needs cited include:

45% need help finding a job
37% need help finding housing

The Department of Veteran’s Affairs has specialized homeless programs for assistance. In 2009, these programs served more that 92,000 veterans. However, that still leaves over 100,000 veterans who are seeking assistance.

Healthcare Environment:

Health risks/high risk behaviors common to this culture-
Lack of resources such as money and a home lead these individuals to have a poor diet, and poor hygiene. These individuals often get a lack of sleep, utilize and abuse drugs and alcohol, have high prevalence of depression, and post traumatic stress disorder.

Cultural taboos and Important Considerations:
Being a homeless person makes an individual very vulnerable to judgment and ridicule. It may be taboo for a homeless veteran to tell those of authority that they are homeless because they feel that they will be judged, and if they were to inform health care providers their lifestyle they may be victim to lack of compassion from the providers (Marnocha & Nickasch, 2008). It is important as a health care professional to have a nonjudgmental attitude toward these individuals and show compassion by asking open ended questions. Show your support by asking for their side of the story.

Lack of Resources:
They are more exposed to a life of unclean behavior, a lot of these individuals may be substance abusers, mental illness, lack of family and social support in their lives, lack of transportation, lack of access to mail/telephone. It is also important to take note of the experience that health care providers may have with homeless patients. A nurse could be taking care of a homeless individual and have no idea.

Stereotyping:
Many people may generalize that all homeless people are lazy and got to their circumstances by their own poor choices. They are often seen as crazy and only want to use other’s money to buy drugs or alcohol.
Consider the hardships that these individuals have gone through-they are emotionally complicated from their abusive relationships, constant ridiculing by those better off than they are. As a health care provider it would be good for us to talk to these individuals and allow them time to explain themselves. Someone of the homeless veterans culture may find talking to others about their lifestyle to be heavy and difficult, so we cannot expect a stranger to open up about their lives and their feelings. It is our job as the patient advocate to ask the right open-ended questions to understand that individual.

Lack of Support in the Clinical Setting:
Many nurses have their own preconceived ideas about homeless clients and these ideas will indirectly affect their quality of care. The less the nurse or health care worker believed that the homeless client deserved quality care, the less likely they were to invest much compassion in to the nurse-to-client relationship (Balogh & Zrini, 2004). The lack of support and understanding from nurses in the clinical setting is one of the many junctures that a homeless veteran has to endure.

Top 5 things a Nurse of Health Care Provider Should Know About Homeless Veterans:

1. Common issues of homeless veterans:
These include depression, post traumatic stress disorder, failure to thrive, malnutrition, health neglect, and social isolation.

2. Some resources and organizations to help homeless veterans:

Volunteers of America’s Homeless Veterans Reintegration program for employment assistance.
http://www.nchv.org/hvrp_article.cfm?id=62.

VA’s Health Care for Homeless Veterans Program (HCHV)
operates at 133 sites, where extensive outreach, physical and psychiatric health exams, treatment, referrals and ongoing case management are provided to homeless veterans with mental health problems, including substance abuse. This program assesses more than 40,000 veterans annually.

http://www.military.com/benefits/veteran-benefits/homeless-veterans-programs

Readjustment Counseling Service’s Vet Centers provide outreach, psychological counseling, supportive social services and referrals to other VA and community programs. Every Vet Center has a homeless veteran coordinator assigned to make sure services for homeless veterans are tailored to local needs. Annually, the program’s 207 Vet Centers see approximately 130,000 veterans and provide more than 1,000,000 visits to veterans and family members. More than 10,000 homeless veterans are served by the program each year.

http://www.military.com/benefits/veteran-benefits/homeless-veterans-programs

VA’s Supported Housing Program allows VA personnel to help homeless veterans secure long-term transitional or permanent housing. They also offer ongoing case management services to help the veterans remain in housing they can afford. VA staff work with private landlords, public housing authorities and nonprofit organizations to find housing arrangements. Veteran service organizations have been instrumental in helping VA establish these housing alternatives nationwide. VA staff at 22 supported housing program sites helped more than 1,400 homeless veterans find transitional or permanent housing in the community.

http://www.military.com/benefits/veteran-benefits/homeless-veterans-programs

3. Common Reasons for Homelessness:
Many reasons for homelessness poverty, death of family/spouse, domestic violence. It is important to remember that no one chooses to be homeless and that there is always more to their story.

4. Stereotypes for the Homeless
Understand that there are more contributing factors than the individual’s choices for how they came to be homeless. Many people assume that all homeless people are lazy, drug abusers and alcoholics who don’t deserve to be treated with respect.

5. Individual’s Definition of Health
This is imperative for taking care of any patients, but specific to homeless veterans it is important to remember that many homeless individuals simply strive to survive. Their view of health may simply be the lack of a deadly disease that prevents them from going about their daily routine.

What are the biggest differences between homeless veterans and non-veteran homeless in the US?

While they are often put into the same stereotypes, homeless veterans significantly differ from the non-veteran homeless population in the United States. Compared to the non-veteran homeless population, homeless veterans are more likely to report a chronic medical condition and there is a higher incidence of post traumatic stress syndrome and hepatitis/cirrhosis. Veterans were also significantly more likely to report going to a shelter based clinic or stress outreach team for usual care while non-veterans were more likely to report going to a community clinic or the emergency department. Homeless veterans were more likely to have health insurance when compared to non-veteran, with most of this difference due to the VA.

In regards to income, the most frequently identified source from homeless vets is odd jobs. Homeless vets identified that they are more likely to make money by selling plasma or by steady employment.

As stated above, homeless vets have a higher incidence of post traumatic stress syndrome as well as other mental comorbidities than non-vet homeless but they are less likely to report it.

Source:

O’Toole, T.P., Conde-Martel, A., Gibbon, J.L., Hanusa, B.H., Fine, M.J. (2003). Health Care of Homeless Veterans: Why Are Some Individuals Falling Through the Safety Net?. Journal of General Internal Medicine, 18, 929-933

What  are the biggest differences between the homeless veteran culture and the U.S. culture?


Put yourself in this scenario for a moment. You are driving in downtown Spokane and as you pull up to a stop light you see a man holding a sign at the side of the road. His sign reads:

Homeless Vet

Will Work For Food

Anything Helps

Thank You and God Bless

Do you avoid making eye contact with him? Do you pretend like he does not exist? Do you assume that because he is homeless that he must be an alcoholic or a drug user?  Do you offer to help by giving him food or some spare change? Do you believe that he is a vet, or just saying that to get money?

We all say that we support our troops, but why does it seem that the support disappears the second that they get home? Is saying thank-you when they return from a deployment  where the gratitude ends?  More and more veterans from the current war in Iraq/Afghanistan as well as veterans that served in the past  are finding themselves with no other option but to turn to the streets.

This is where one of the most propellant difference between the two cultures is evident. The definition of supporting our troops is completely different depending on which culture you ask. Much of the U.S. culture looks at homeless veteran population as if they deserve to be in the position that they are in and that they made the conscious decisions to get there. Most do not think about the fact that the veterans may have endured injuries in combat that make it impossible for them to work, or that the horrific events that they saw protecting each and every citizen of the United States may have been what driven them depression and for some substance abuse.

An average American looks at supporting our troops as sending a letter to a soldier overseas, going to the airport to welcome a group home from a tour in Iraq, or even simply shaking a person’s hand when they are in their uniform. It is of course a positive thing to thank the people who risk everything they have including their life for you but is that where is ends?

Many homeless veterans find themselves frustrated and ultimately feeling hopeless because they are living on the streets and dealing with medical conditions often as a direct result of fighting for our country. They do not expect to be millionaires, they just want to be given assistance  in return for their sacrifice. Homeless vets see supporting our troops as being there for the good and the bad. They see supporting our troops as something that should not end at the airport terminal when they return from a tour.

The link below takes you to an interview of a homeless veteran. It shows his living conditions as well as his frustration that is directed at his country for not being there when he needs them the most.

When I Came Home – Theatrical Trailer | Movies & TV | SPIKE.com

Are there any perceived discrimination problems against homeless veterans?

There are many perceived discrimination problems against the homeless veteran culture as a whole. It is often assumed that every homeless person is an alcoholic or drug user and these habits are what led them to be living on the streets. Putting people into this group because of the culture that they belong to is not conducive to being able to give the best care possible as a nurse. Discrimination against this population does exist in everyday life but it is part of our profession to put that aside and see the person that is on the inside.

From defending our country and fighting for freedom, to lost and feelings of hopelessness in the very streets they fought to keep safe.

References

http://www.nationalhomeless.org/factsheets/

http://www.nchv.org/background.cfm

http://www.cnn.com/2009/LIVING/09/25/homeless.veterans/

http://www.bc.edu/schools/cas/sociology/meta-elements/pdf/ChoThesis.pdf

Hobbs, K. (2008). Reflections on the cultures of veterans. AAOHN Journal 2008; 56(8), 337-341.

Garcia-Rea, Elizabeth & LePage, James P. (2008). Reliability and validity of World Health Organization Quality of Life-100 in homeless substance dependent veteran population. Journal of Rehabilitation Research & Development, 45(4), 619-626. Retrieved fron CINAHL March 23, 2010 with Full Text database.

Marnocha, Suzanne K. & Nickasch, Bonnie. (2008). Healthcare experiences of the homeless. Healthcare experiences of the homeless. Journal of the American Academy of Nurse Practitioners 21 (2009) 39–46.  doi:10.1111/j.1745-7599.2008.00371.x

Copeland, Laurel A, Kilbourne, Amy M.,McCarthy, John F., Miller, Alexander L., Welsh, Deborah E., & Zeber, John E. (2009). American Journal of Public Health, 99(5). Retrieved from CINAHL March 25, 2010 with Full Text database.

O’Toole, T.P., Conde-Martel, A., Gibbon, J.L., Hanusa, B.H., Fine, M.J. (2003). Health Care of Homeless Veterans: Why Are Some Individuals Falling Through the Safety Net?. Journal of General Internal Medicine, 18, 929-933

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