Why Are So Many Veterans Homeless?

I met my first homeless vets on the streets of Los Angeles in 1971. I’d just returned from Vietnam where I’d served as a psychiatric social worker in the Army. No more Captain’s bars for me. I had wild hair, a bushy mustache, and an attitude, so I fit right in.

Initially I’d been asked to find out why veterans were not using the VA Center for their healthcare, but my interactions with these vets, all of us lost in one way or another, changed the course for me. Those were dark times, shadowed by what we’d seen and done in the war. Some vets brought all that horror home, re-living it episode by episode, riding that long escalator down into despair and chronic homelessness.

It wasn’t until 1980 that PTSD, Post-Traumatic Stress Syndrome, made it into the DSM manual. By then, of course, I’d been seeing and documenting its effects while trying to deal with them for over nine years. To this day our National Veterans Foundation (NVF) Outreach van still serves Vietnam veterans in communities of homeless under bridges, in abandoned lots, alongside riverbanks, any place we find them. Now we’re seeing more and more vets who served in Iraq and Afghanistan. These vets often have PTSD, but many have also had a TBI or traumatic brain injury. As you probably know, TBIs are so prevalent they’re called the signature wound of these two long-running wars.

Not only do we need to focus on getting our vets the correct diagnoses and then the right treatment, we have to look at the larger picture, at all the elements that come together to build a life. Education is one of them; others are medical care, gainful employment, and meaningful social contact.

The VA is by now familiar with PTSD, its symptoms and its effects. However, because the symptoms of PTSD and TBI are similar and often overlap, PTSD can be the initial incorrect or incomplete diagnosis where TBI is present. Both these conditions can manifest as depression, anxiety, sleeplessness, irritability, aggression, and increasing social isolation. But TBI can also include memory loss, migraines, seizures, problems with language, and trouble making what might seem like simple decisions. Vets with brain injury need different treatment.

Homelessness and brain injury

What’s this got to do with homelessness? Just this: the VA’s first large-scale study of homeless veterans, released in 2012, found that over half of the newly homeless diagnosed with mental disorders had received that diagnosis before homelessness. The VA’s Inspector General (IG) said, “Presence of mental disorders (substance-related disorders and/or mental illness) is the strongest predictor of becoming homeless after discharge from active duty.”

That’s from the horse’s mouth. Strongest predictor. It gets worse. Here’s the IG later in the same report: “…about half of the newly homeless occurred after 3 years discharged from active duty.” So what we’re looking at is vets returning home, trying to transition back into civilian life—jobs, school, families—while they’re dealing with the effects of PTSD and/or TBI. Say they give it three years. And then, for many, the wheels come off.

It looks to me like homelessness is the last stop on this PTSD/TBI train ride, not the first.

The NVF employs veterans as peer counselors on our crisis hotline. Three of our best counselors have had extensive combat experience: one has two combat tours in Iraq; the second, four combat tours in Iraq; and the third (who’s returned to military duty), four combat tours — two in Iraq and two in Afghanistan. A total of ten tours, all of them “outside the wire.” The first two counselors were diagnosed with PTSD and TBI; the third counselor’s PTSD was expressed in aggression. All of them found that when they came home, they couldn’t turn off the hypervigilance that had served them so well in the combat zone. The result: a quick-to-rise edginess, a dislike of crowds, sleeplessness, difficulty controlling emotion when they perceived a threat. Another side to the hypervigilance is the havoc it plays with the body, in a constant state of heightened alertness.

I think a key factor in their successful transition back into civilian life was employment. See what I mean? A problem this size has many parts. Not only do we need to focus on getting our vets the correct diagnoses and then the right treatment, we have to look at the larger picture, at all the elements that come together to build a life. Education is one of them; others are medical care, gainful employment, and meaningful social contact. The VA now has a special section targeting homeless vets that is staffed by previously homeless vets. That’s the model the NVF has used for decades because it works: vet to vet.

Brain injuries require integrated care

The injured brain takes time to adjust to the effects of the injury. And as for diagnosis and treatment, no one size fits all. Each traumatic brain injury is unique in itself, not to mention that no human is a copy of another. What’s needed is patience, and coordinated care. Maybe a better word is integrated care. There are many agencies for the homeless and community-based organizations for vets, all trying to re-invent the same wheel. Wouldn’t it make more sense to coordinate these efforts to make better use of our financial and human resources? The VA is a place to start and they’re trying, but their size and the overwhelming number of vets waiting for care makes me think we’d better start working on this from the ground up. A solution from the top down is likely to be further in our future.

Homelessness is what’s in store for far too many of these veterans if we wait. It doesn’t make sense to squander all the talent that resides in these men and women. We need them as contributing members of our society. Allowing them to slip into homelessness or worse because we didn’t provide the care they need to heal from PTSD and TBI is just not an option.