Addressing the psychosocial impact of posttraumatic stress disorder (PTSD) and housing insecurity remain top priorities within the U.S. Department of Veterans Affairs (VA). Indeed, the VA has made substantial gains in addressing these factors. For example, from 2010 to 2016, rates of veteran homelessness reduced by 47% (Department of Housing and Urban Development & VA, 2021). Moreover, the VA has widely disseminated a number of effective, evidence-based treatments for PTSD, including cognitive processing and prolonged exposure therapies (Karlin et al., 2010).
It is equally important to note that PTSD and housing insecurity rarely occur in isolation of one another. For example, many veterans endorse experiences of trauma (e.g., childhood abuse) which precede their experiences of homelessness (Hamilton et al., 2011). Moreover, repeated, chronic traumatization (e.g., exposure to combat or physical/sexual assault) is also commonplace among veterans at risk for or experiencing homelessness (Brignone et al., 2016; Macia et al., 2020).
Conversely, PTSD can also impact functioning across various domains. For example, PTSD is associated with decreased psychosocial functioning, inclusive of domains such as financial and occupational difficulties (Pietrzak et al., 2010). Such financial and occupational stress can, in turn, exacerbate risk for homelessness (e.g., difficulties paying rent). Therefore, there is likely a relationship between PTSD and homelessness requiring a nuanced, bidirectional conceptualization.
In understanding this relationship, it is important that providers and policymakers alike be cognizant that social, contextual and demographic factors likely also play a role. For example, veterans who identify as a race other than white have far greater risk for housing instability relative to those who identify as white (Montgomery et al., 2020). Other sociodemographic factors have been similarly noted as increasing risk for homelessness (e.g., identifying as transgender; Brown & Jones, 2016). In addition to sociodemographic factors, contextual factors (e.g., rurality, disability, access to care) are likely factors that impact rehabilitation and recovery among this population (Holliday et al., 2021).
Despite this, a comprehensive understanding of the relationship between sociodemographic and contextual factors upon the relationship between PTSD and housing insecurity requires further elucidation. Indeed, research specific to homeless veteran populations remains more limited due to methodological difficulties, including identifying and consenting homeless veterans, especially specific to those outside VA medical settings. Nonetheless, given that homelessness remains a top research priority, we anticipate the continued proliferation of this evidence base.
As such, taken in aggregate, extant research remains limited in its ability to comprehensively inform the conceptualization of the bidirectional relationship between PTSD and homelessness from an intersectional lens. However, given the aforementioned publications, we implore providers and policymakers to be aware that several factors may impact the relationship between PTSD and housing insecurity. In particular, sociodemographic and contextual factors may be key moderators in need of both clinical assessment and further inquiry. In doing so, we can ensure that this population of veterans is best understood in terms of risk and needs for care.
About the Authors
Ryan Holliday, PhD, is a clinical research psychologist at the Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention and assistant professor at the University of Colorado Anschutz Medical Campus. His clinical and research interests focus upon understanding the intersection of trauma, psychosocial stressors (such as homelessness and justice involvement), and mental health. He is further interested in translating these findings into evidence-based practice.
Shawn Liu, LCSW, is a community engagement coordinator with the U.S. Department of Veterans Affairs, Veterans Health Administration, Homeless Programs Office where he is responsible for the development of strategic communications and partnerships to enhance efforts to prevent and end homelessness among veterans and their families.
References
Brignone, E., Gundlapalli, A. V., Blais, R. K., Carter, M. E., Suo, Y., Samore, M. H., Kimerling, R., & Fargo, J. D. (2016). Differential risk for homelessness among US male and female Veterans with a positive screen for military sexual trauma. JAMA Psychiatry, 73(6), 582-589.
Brown, G. R., & Jones, K. T. (2016). Mental health and medical health disparities in 5135 transgender Veterans receiving healthcare in the Veterans Health Administration: A case-control study. LGBT Health, 3(2), 122-131.
Department of Housing and Urban Development & Department Veterans Affairs. (2021). Secretaries of HUD, VA Joint Statement on Ending Veteran Homelessness. Retrieved from https://www.hud.gov/press/press_releases_media_advisories/HUD_No_21_059.
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(4S), S203-S209.
Holliday, R., Liu, S., Brenner, L. A., Monteith, L. L., Cappelletti, M. M., Blosnich, J. R., Browstow, D. R., Gelberg, L., Hooshyar, D., Koget, J., McInnes, D. K., Montgomery, A. E., O’Brien, R., Rosenheck, R. A., Strickland, S., Workman, G. M., & Tsai, J. (2021). A consensus statement by the Veterans Affairs Suicide Prevention Among Veterans Experiencing Homelessness workgroup. Medical Care, 59(Suppl 2), S103-S105.
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Macia, K. S., Moschetto, J. M., Wickham, R. E., Brown, L. M., & Waelde, L. C. (2020). Cumulative trauma exposure and chronic homelessness among Veterans: The roles of responses to intrusions and emotion regulation. Journal of Traumatic Stress, 33(6), 1017-1028.
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