Cuyahoga CSAT
Comprehensive
Substance Abuse Treatment

Helping homeless women with substance-use disorders achieve recovery, housing, health, and income. A SAMHSA-funded collaborative project in Cuyahoga County, Ohio, U.S.A.

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What the project does.

Project partners.

Project milestones.

Who the project serves.
Project participants are drawn from the homeless women who utilize the Community Women’s Shelter operated by Mental Health Services for Homeless Persons, Inc. (MHS). With the capacity to serve at least 135 women and children per night, the Community Women’s Shelter is the largest of five shelters for homeless women in Cuyahoga County. The average number of women using the shelter each night during February and March 2004 was 124.

Participants are shelter clients who have substance dependence disorders (American Psychiatric Association [APA], 1994). Many experience co-occurring mood, anxiety, or personality disorders, but would not meet the SAMHSA National Survey criteria (SAMHSA, 2003, pp. 100-101) for having a serious mental illness. Those who have a co-occurring severe mental illness and substance-use disorder would not participate in this project, but are invited to participate in a separate project operated by MHS.

A client of the Community Women's Shelter speaks with the Honorable Claude Allen, Deputy Secretary of the U.S. Department of Health and Human Services. Mr. Allen visited the Shelter in October 2004 to launch the Cuyahoga CSAT project.

Click here to read about his visit.
Note: Clients depicted here have provided written authorization for this use.

Number.
There are an estimated 22,326 individuals in Cuyahoga County who are homeless at some time during the year (Coalition on Homelessness and Housing in Ohio (COHHIO), 1999). Of those, COHHIO estimates that 8,484 (38%) have a chronic substance use disorder. The Cleveland and Cuyahoga County Office of Homeless Services (2003, p. 17) estimates the number of chronically homeless individuals in Cuyahoga County to be 3,800.

The number of homeless women in Cuyahoga County on a given night is estimated to be 1,601 (COHHIO, 2002). This count includes both single women, and women with children. It was estimated that 38% (608) have a chronic substance use disorder, 24% have a severe mental illness, and 13% have a co-occurring severe mental illness and substance use disorders.

An actual count conducted on a single night in 2003 found 530 homeless women. Each year, the Cleveland and Cuyahoga County Office of Homeless Services (OHS) conducts a comprehensive analysis of local needs for homeless assistance services, including a analysis of the homeless population of Cuyahoga County, Ohio. OHS is the administrative entity that oversees Federal, State, and local funding of the county’s homeless assistance services. In its most recent analysis (Cleveland and Cuyahoga County Office of Homeless Services, 2003, pp. 15-19), OHS conducted a point-in-time count of individuals who were homeless in Cuyahoga County on June 25, 2003, for a 24-hour period of time. The count was based on a survey of all homeless assistance providers in the county. OHS determined that 2,354 individuals were homeless that night, including 330 single women, 200 women with children, and 370 children. Of all homeless individuals, there were 916 (39%) who had chronic substance-use disorders, 324 (14%) who were seriously mentally ill, and 142 (6%) who had been victims of domestic violence.

Homelessness.
Duration of homelessness among these women varies considerably. Of the 427 women who used the Community Women’s Shelter during March and April 2004, half (212 women) spent seven or fewer days at the shelter. However, 92 women (22%) spent four weeks or more at the shelter, and they speak about lengthy and repeated episodes of homelessness, due in part to the difficulty of obtaining treatment while homeless. Being homeless requires spending a good part of each day traveling (on foot, usually) from one meal site to another and then securing a shelter bed or a safe place to sleep at night. These demands do not leave much time to make scheduled appointments during traditional Monday through Friday 9 to 5 working hours, especially since most offices where treatment can be obtained are not located near meal sites or shelters.

Age.
The average age of women using the Community Women’s Shelter is 39 years, although those who have stayed at the shelter the longest have an average age of 45 years. Homeless persons in Cuyahoga County are disproportionately young, compared to the population of Cuyahoga County at large. While those younger than 45 years of age comprise 62% of the total population of Cuyahoga County residents, and 68% of Cleveland residents (U.S. Census Bureau, 2001), they make up 81% of the county’s homeless individuals (Coalition on Homelessness and Housing in Ohio [COHHIO], 2002).

Race.
African Americans comprise 72% of the women who use the Community Women’s Shelter. This is consistent with characteristics of the general population of all homeless persons in Cuyahoga County, who are disproportionately African-American compared to the population of Cuyahoga County at large (see Table 1 below). African-Americans comprise 27% of all Cuyahoga County residents, and 51% of Cleveland residents (U.S. Census Bureau, 2001-b), but 78% of the county’s homeless individuals (COHHIO, 2002). This is a disproportionately large percentage even when compared with the homeless population of Ohio’s ten largest urban counties, in which an average of 66% of homeless individuals are African American (COHHIO, 2002). It emphasizes the need of project providers to be aware of the differential effects of psychiatric interventions and psychotropic medications with individuals of racial minorities, diagnostic issues related to race, and vernacular language use among those of diverse races and ethnicities (Center for Mental Health Services, 2001; U.S. Department of Health and Human Services, 2001.)

Table 1

Percent of Women’s Shelter Clients and Residents of the Service Area Who Identify Themselves as Being of Selected Races, or Latino Ethnicity.

Race or Ethnicity

Community Women’s Shelter Clients

Residents of …

Cleveland, Ohio¹

Cuyahoga County, Ohio ²

African American

72

51

27

Asian

<1

1

2

Latino

1

7

3

Native American

<1

<1

<1

White

27

42

67

¹ U.S. Census Bureau. (2001-b); ² U.S. Census Bureau. (2001)

Ethnicity.
Nationally, the proportion of individuals of Hispanic or Latino ethnicity among those who experience homelessness (11%)(Burt et al., 2001, p. 225) is less than their proportion among the general population (12.5%)(U.S. Census Bureau, 2000). Locally, the proportion of individuals of Hispanic or Latino ethnicity who are clients of Mental Health Services for Homeless Persons, Inc. during 2003 (1%) is less than their proportion among the general population of Cleveland (7%)(U.S. Census Bureau, 2001-b) or Cuyahoga County (3%)(U.S. Census Bureau, 2001). Hispanic community leaders have told us that Hispanic families are more likely to take in a homeless family member than families of most other cultures. They also note that Hispanic families are particularly likely to take in a female family member who becomes homeless. Moreover, they have reported that Hispanic households, especially compared with white households, are more “fluid” or “permeable,” in that family members enter or leave households easily and frequently (Leo Serrano, Executive Director of The Spanish American Committee, personal communication, 5 November 2003). As a result, taking in a homeless family member is easily accomplished. Providers of the proposed project would be sensitive to these issues. Staff members with Spanish language skills would be among the providers of the proposed project, or would be easily accessible to project staff members. Providers would also have access to 24/7 translation services.

Ohio has the ninth-largest Muslim population of all the states, and there are several areas within Cleveland that have significant populations of Muslims. MHS has Muslim staff members, and can competently provide assessment and intervention services to homeless women who are followers of Islam.

Mental and substance use disorders.
Mental disorders are common and varied. About one-third of the women to be served by the proposed project have mood, anxiety, and/or personality disorders that are not disabling, but do affect functional capacities and efforts to achieve recovery from substance use disorders.

Truama Issues.
Violent victimizations among homeless women are common, have complex and varied consequences, and require special consideration in program design and staff training. In studies of homeless mothers from shelters in Massachusetts, almost 88% reported being assaulted at least once in their lives (Bassuk et al., 1996), and 67% reported being physically assaulted as a child (Weinreb et al., 1999). Locally, more than 75% of the homeless women of the Community Women’s Shelter reported being physically assaulted at some time in their lives, most often from a male sexual partner. Many reported childhood histories of physical abuse. Nearly half reported being assaulted during the most recent 12-month period. Of those who had been assaulted, nearly all sustained injuries that required medical treatment. Many of the women spoke of becoming homeless after an assault that ended a relationship with a man whose income had been essential to the maintenance of housing.

Post-traumatic stress is a significant diagnostic issue among homeless women, and the reluctance to discuss rape and other violent assaults hinders diagnostic clarity. Vigilance, anxiety, mood disturbances, and suicidal conduct can be manifestations of post-traumatic stress that is undiagnosed because of incomplete or contradictory information. Even when trauma issues have been competently assessed, identified, and understood, services that are insensitive to the effects of trauma, or unresponsive to specific trauma-related needs may hinder the woman’s achievement of recovery, health maintenance, and housing.

Languages spoken.
Spanish is the non-English language most frequently spoken by homeless women who use shelter services. However, clients who speak only Spanish are rare among homeless women, in part because many are bilingual, but also because of factors discussed in the section on ethnicity. However, there are occasions when clients speak only a Slavik or Asian language. To serve these clients, MHS maintains a contract with a provider of 24/7 language translation services.

Sexual orientation.
Homeless individuals who are not heterosexual are particularly vulnerable to abuse and assault. Current shelter policies prohibit discrimination based on sexual orientation. However, the management of services to transgendered individuals has been an issue that has challenged the leaders, staff members, and clients of the Community Women’s Shelter. On several occasions, transgendered individuals have requested shelter services. Women of the shelter made it clear that they did not welcome these individuals, and some felt threatened by them. MHS was able to offer the transgendered individuals services at its emergency shelter for homeless men, but some clients of that shelter also did not welcome these individuals. Consultations with agency leadership, and discussions with shelter clients and staff members resulted in the achievement of resolutions that had consensual support and that respected the rights of all clients.

Physical Health.
An additional concern when serving homeless women is their compromised physical health. Nationally, single homeless women report having more physical disabilities and chronic physical problems than single homeless men (Burt et al., 2001, p. 84). Homeless women also report a much higher incidence of acute infectious conditions. Among clients of the Community Women’s Shelter, diabetes is the most common physical health problem, although various cancers and trauma wounds are also common. Linkages to primary health care services must be an integral part of case management services for these clients.

Values.
Surveys and focus groups conducted with shelter clients provided information about their beliefs, norms, and values. A recurring theme was the women’s desire to be respected by staff and counselors. Most indicated that social service staff they have encountered do not make efforts to know them as individuals. Clearly, individualized relationships and solutions are highly valued. They believe that their drug use, mental and physical health problems and other issues are a result of their homelessness, not the cause; therefore, obtaining permanent housing is perceived by them to be their most important need.