Addressing Mental Health Amongst First Responders: Sometimes Superheroes Need Saving, Too

Hidden Anguish

First responders play a vital and commendable role in society as they display exceptional bravery to save the lives of others, often at the risk of their own. Many first responders encounter unimaginable tragedy and horror on a daily basis, and then are expected to go home and attend to their loved ones. However, separating work from personal life may not be so easy for these individuals as the impact that traumatic events can have on one’s mental health is often left unacknowledged. Frequent exposure to death and tragedy undoubtedly affects one’s psychological state of well-being, including post-traumatic stress disorder (PTSD), substance abuse, depression and especially suicidal ideations. However, along with the societal expectation of first responders to be brave and strong, comes the suppression of such mental health problems and lack of proper psychiatric treatment.[1] 

Risk factors & Causes 

In comparison to the general population, first responders such as law enforcement officers (LEO), emergency medical technicians (EMT), and firefighters are at a greater risk of suicide ideation and suicide. Stanley et. al. (2016) conducted a systematic review of 63 quantitative studies examining the suicidal thoughts, behaviors, and fatalities of first responders, and found them to be at a significantly higher risk than general population samples.[2] Bond & Anestis (2021) conducted a study which showed that 23-25% of LEOs and 46.8% of firefighters experience suicidal ideations, and 10.4% of EMTs report severe lifetime suicidal ideation.[3] Frequent and severe traumatic experiences also lead to a higher risk of PTSD. Approximately 32% of LEOs, 22% of EMTs and 32% of firefighters experience PTSD. In comparison to the general civilian population, out of whom only 7-12% experience PTSD, these rates are concerningly high. There are also various risk factors amongst first responders that can contribute to their increased risk of developing PTSD, including:[4]

• Family history of psychiatric disorders

• Childhood trauma (abuse/adversity)

• Intelligence level

• Education

• Early conduct problems

Proper sleep hygiene (due to long and demanding shift schedules) also plays a role in the increased rates of disorders such as PTSD, depression, and anxiety. A longitudinal study conducted by Feldman et al. (2021) included 135 emergency medical service providers and recorded changes in symptoms of various psychological disorders over the course of 3 months. Their findings revealed that the increase in symptoms of PTSD, depression, and anxiety were all correlated with a poor sleep pattern and lower social support.[5] Erratic sleep patterns are especially problematic given that they compromise inflammatory and physiological stress responses.[6]

Acute stress disorder (ASD) is another common psychiatric disorder among first responders who experience frequent and high-impact stressors. A few pertinent symptoms of this disorder include:[7]

• Hyperarousal

• Negative mood

• Anger/irritability

• Dissociation

• Avoidance

• Numbing

• Nightmares

• Intrusive thoughts

ASD is developed once an acute stress response leads to more serious impairments after exposure to a traumatic stress with documented biological or psychological sequelae. Within 3 days of the traumatic event, multiple symptoms within five diagnostic categories will appear. ASD is signified by persistent symptoms well beyond the time frame of an acute stress reaction, which is more common and normal for anyone who experiences a traumatic event. While first responders who are acutely impacted by a trauma may develop ASD, developing ASD puts them at a greater risk for subsequently developing PTSD.[8]

The Three-Step Theory 

Not only do first responders experience greater rates of suicidal ideations, but they are also more likely to actually perform suicidal attempts.[9] Ideation-to-action is outlined by the Three-Step Theory (3ST), which states that there are three subcategories of capability that can shift an individual from suicidal thoughts to actual suicidal actions. These subcategories include:[10]

1. Practical - Broader knowledge of lethal weapons/drugs, and potentially even better access to them. The means of suicidal means are more readily obtainable. 

2. Dispositional - Innate tolerance to death and pain. 

3. Acquired - Learned desensitization and tolerance to death and pain. Having encountered numerous tragic events has built a sense of fearlessness in many first responders.

Suffering in Silence

Since a large majority of first responder suicides go unreported by mainstream media, there is an ongoing lack of knowledge/awareness of the general public to the degree that it occurs.  In addition, barriers exist that prevent first responders from accessing the proper psychiatric care they need when experiencing depression or suicidal ideations. Such barriers include shame and stigma surrounding mental health issues within their professions, as the concept of bravery and courage is heavily instilled upon them during training and work. Moreover, first responders and their families often fail to have open discussions about mental health, which unfortunately fuels the lack of awareness on the issue of first responder suicide.[11] 

Even when a first responder recognizes they are in crisis, several factors often prevent them from seeking adequate help: lack of knowledge on where/how to seek help, fear of confidentiality breach, belief that they cannot show weakness, lack of access and availability to therapy, family burden, pride and denial.[12] Destigmatizing mental health issues and spreading awareness is the first crucial step to ensuring that first responders are able to comfortably and willingly ask for help.[13] First responders should also be informed about mental health disorders and how to facilitate help-seeking.[14]

First responders are often expected to prevent their traumatic experiences from interfering with their professional and personal lives. The culture of first responders may prevent them from seeking actual mental health interventions, due to stigma and self-image. However, doing so often leads to unhealthy coping mechanisms such as substance abuse and high-risk behavior as an outlet for their stressors. Some also practice avoidance, leading to absenteeism in work and home, causing tension with their personal relationships. Conflict may even arise between colleagues, as high-stress environments and internal stressors combine together to create overall tension in the workplace. Therefore, psychoeducation to reduce stigma and subcultural barriers could help encourage first responders to seek treatment. This would eventually remediate their own psychological health and mend other impacted professional and personal relationships in their lives.[15] 

Building Resilience 

High resilience has been shown to be associated with lower symptomology of PTSD, depression, and alcohol abuse in active first responders. Therefore, resilience screening can help to protect the long-term mental health of first responders. High resilience indicates the ability to better tolerate problems, illness, failure, pressure, and feelings of pain.

These adaptive qualities of resilience can be developed in first responders via targeted interventions, including cognitive behavioral therapy (CBT) and mindfulness training programs. These two methods have been proven effective in increasing adaptive resilience amongst health professionals, factory workers, civil servants, and even breast-cancer patients. Employing resilience screening as a first responder begins work, one can identify which workers can most benefit from these targeted interventions to increase resilience, thus decreasing their chances of developing debilitating psychological disorders.[16] 

Thompson and Drew (2020) developed a 21-day program to enhance first responder resilience and tested the program with promising results. Every day over the course of 21 days, participants received a keyword which encouraged them to follow certain practices for the day, such as grit, calm, empathy, and gratitude. They also did 5 minutes of controlled breathing exercises, short readings on the keywords, reflections for the day, and an evening gratitude practice. Gratitude was incorporated into the program to increase sleep quality, life satisfaction, and decrease risk of depressive symptoms. In total, the practice work took only 15 minutes a day, accounting for the busy schedules of typical first responders. The participants responded to the 21 day course well, and a majority indicated that they would continue to use the practices they learned during the course of the program.[17]

Programs such as this one, and other resilience programs, would be beneficial for all first responders to incorporate into their lifestyles to increase resilience against developing mental health issues, promote the necessity of managing one’s mental health and reduce stigma in those suffering with PTSD, depression, anxiety and other work-related mental health disorders. 

If one has been suffering from any mental health disorder due to traumatic stress, such as PTSD or ASD, or is experiencing feelings of heightened anxiety or suicidal ideations, it is crucial to contact a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Ananya Udyaver

Editor: Jennifer (Ghahari) Smith, Ph.D.

References 

1 Heyman, M., Dill, J., & Douglas, R. (2018, April). The ruderman white paper on mental health and suicide of first ... https://firefightermentalhealth.org/system/files/First%20Responder%20White%20Paper_Final.pdf 

2 Stanley, I., Hom, M., & Joiner, T. (2015, December 12). A systematic review of suicidal thoughts and behaviors among police officers, firefighters, emts, and Paramedics. Clinical Psychology Review. https://www.sciencedirect.com/science/article/abs/pii/S0272735815300684?via%3Dihub 

3 Bond, A., & Anestis, M. (2021, October 26). Understanding capability and suicidal ideation among first responders. https://www.tandfonline.com/doi/full/10.1080/13811118.2021.1993397 

4 Lewis-Schroeder, N. F., Kieran, K., Murphy, B. L., Wolff, J. D., Robinson, M. A., & Kaufman, M. L. (2018). Conceptualization, Assessment, and Treatment of Traumatic Stress in First Responders: A Review of Critical Issues. Harvard review of psychiatry, 26(4), 216–227. https://doi.org/10.1097/HRP.0000000000000176 

5 Feldman, T. R., Carlson, C. L., Rice, L. K., Kruse, M. I., Beevers, C. G., Telch, M. J., & Josephs, R. A. (2021). Factors predicting the development of psychopathology among first responders: A prospective, longitudinal study. Psychological Trauma: Theory, Research, Practice, and Policy, 13(1), 75–83. https://doi.org/10.1037/tra0000957 

6 Lewis-Schroeder, N. F., Kieran, K., Murphy, B. L., Wolff, J. D., Robinson, M. A., & Kaufman, M. L. (2018). 

7 Ibid.

8 Ibid.

9 Bond, A., & Anestis, M. (2021, October 26). 

10 Heyman, M., Dill, J., & Douglas, R. (2018, April).

11 Stanley, I., Hom, M., & Joiner, T. (2015, December 12).

12 Jones S, Agud K, McSweeney J. (2020) Barriers and Facilitators to Seeking Mental Health Care Among First Responders: “Removing the Darkness.” Journal of the American Psychiatric Nurses Association. 26(1):43-54. doi:10.1177/1078390319871997

13 Heyman, M., Dill, J., & Douglas, R. (2018, April).

14 Jones S, Agud K, McSweeney J. (2020)

15 Lewis-Schroeder, N. F., Kieran, K., Murphy, B. L., Wolff, J. D., Robinson, M. A., & Kaufman, M. L. (2018). 

16 Joyce, S., Tan, L., Shand, F., Bryant, R., & Harvey, S. (2019). Can resilience be measured and used to predict mental... : Journal of Occupational and Environmental Medicine. LWW. https://journals.lww.com/joem/abstract/2019/04000/can_resilience_be_measured_and_used_to_predict.4.aspx 

17 Thompson, J., & Drew, J. M. (2020, July 27). Warr;OR21: A 21-day program to enhance first responder resilience and mental health. Frontiers. https://www.frontiersin.org/articles/10.3389/fpsyg.2020.02078/full 

Uncovering the Connection: Mental Illness & the Homeless Crisis

To be Homeless in America

A person or family are defined as homeless when they lack a fixed, regular, and adequate nighttime residence.[1] In addition to the extreme poverty they face, the homeless are often in a struggle to be met with sympathy from the general population. In a 2019 poll of Americans taken by the CATO Institute, 42% responded that poverty is a result of a “lack of personal responsibility”.[2] While existing societal stigmas have caused many Americans to blame the homeless for their condition, several other factors must be considered.[3]

Monetary issues, in part, contribute to this mounting crisis. Three years into the pandemic, the steadily increasing costs of living and limited access to affordable housing are compounding issues for the average American.[4] But as the conversation surrounding homelessness steers towards pointing the blame at the economy, it is important not to lose sight of a factor that makes someone more vulnerable to losing their home: mental illness.[5] Public health research has long come to the resounding conclusion that homelessness and mental illness have a complex, two-way relationship that compounds challenges for those who are afflicted.[6] With the added pressure of another recession looming, mental health and homelessness have an exacerbating relationship: mental illness greatens the chances of becoming homeless, and trying to survive while homelessness takes a toll on a person’s mental health.

The Mental Illness to Homeless Pipeline

In America, approximately 4% of the general population of adults have a severe mental illness (e.g., schizophrenia, bipolar disorder, or major depressive disorder).[7] In contrast, it is estimated that 45% of the homeless population experience a form of mental illness,[8] with 25% of this population suffering from severe mental illness.[9] Unfortunately, as researchers lack sufficient access to the homeless population, the actual number of homeless people living with any form of a mental illness is potentially much higher than these annual estimates.[10]

Since the last Census in 2020, rising housing costs combined with continuous inflation for basic goods and services have left an estimated 2,000 Americans newly homeless,[11] with thousands more fearing they will soon lose their homes. In June 2022, the inflation rate hit a 41-year high of 9.1%,[12] leaving the average family strained to pay for gas, energy bills, and groceries.[13]

For those diagnosed with a mental health condition, even more challenges arise against their efforts to keep a home. Research conducted by Luciano and Merea (2010) divided over 77,000 participants into groups of “none, mild, moderate, and serious mental illness” and found that employment rates decreased with increasing mental illness.[14] Further, within the group diagnosed with “serious mental illness”, nearly 40% made an annual salary of less than $10,000”,[15] which is roughly half of the annual minimum needed for a two-bedroom apartment, according to the National Low Income Housing Coalition.[16]

While anti-discrimination laws offer protection for workers who disclose their mental illness diagnosis, many of the symptoms behind mental disorders complicate a person’s ability to maintain continuous employment. The average work week is 40 hours over the span of five days, and requires employees to show up on time, remain productive, and limit their sick leave to the numbers prescribed by their organization. But those with a mental illness are more likely to call-in sick, take medical leave, and under-perform at work.[17] As a result, individuals with a mental illness are two to three times more likely to be unemployed, with their employment rate at 15 percentage points lower than for those without mental health problems.[18]

Struggles with employment are especially relevant for people with schizophrenia, who fare poorer than any other disadvantaged group in the labor market. Individuals with this condition experience a 70-90% unemployment rate, which is roughly 30 times higher than the general population.[19] Unemployed more than any other group with disabilities, those with schizophrenia are estimated to make up 40% of the homeless population.[20] 

Lacking the ability to maintain employment, Americans with mental illnesses have a higher likelihood of unpaid medical bills and missed rent/mortgage payments.[21] Eventually, cumulating costs increase their potential of losing a place to live. 

Navigating Homelessness with a Mental Illness

It is even more difficult to overcome mental health challenges once a person becomes homeless. Lacking necessities (e.g., food, water, and hygiene) often leads to the development of worry, fear, and sleeplessness, which can then compound into mental illnesses (e.g., anxiety, depression, and substance abuse disorder) in those who may not have even had them prior to losing their home. For those that already had a diagnosis prior to losing their home, these conditions only further exacerbate their illness, and resources like medication, therapy, and hospitalization are often difficult to obtain without medical insurance. Facing relentless pressure to have basic necessities as well as gain treatment, many homeless people can barely cover the short-term costs of food, medicine, and soap,[22] and are unable to build any savings that could be used to contribute to paying rent.

Housing Discrimination

Of course, once a person becomes homeless, the natural question is: “How do they get back into a home?” Unfortunately, the compounding factors of poor mental health and lack of a steady income introduce a large barrier to owning or renting a home. When a person applies to rent a property, they are often expected to submit proof of at least six months of employment, consent to having their credit score checked, and provide information for a background check. Not only does a homeless person often have no proof of current employment, but their chances of having a low credit score from prior financial difficulties are more likely than not.[23] If they surpass these points in a renter’s application, many renters are then expected to provide a downpayment or 1.5 months’ rent for their first month. Even if an individual is eligible to rent or own a house from a financial standpoint, they may be unable to pass a background check. This predicament lands many in motels, which are non-permanent shelter, and often amount to more than the median $1,715 dollars spent monthly on rent.[24] Unable to afford motels for an extended period of time, many individuals become vulnerable to returning to living on the streets.

Adding to their difficulties, the concepts of homelessness, incarceration, and poor mental health are often inseparable. Severe mental illness is more prevalent among the homeless population and is associated with increased risk of involvement with the criminal justice system.[25] In fact, over 25% of people experiencing homelessness report being arrested for activities that are a direct result of their homelessness, such as loitering and sleeping or lying down in public spaces.[26] As aforementioned, these arrests can add to the vicious cycle facing homeless populations, as a criminal record often impacts future employment and housing opportunities. 

Not all is lost

Despite these alarming numbers, specific demographics have shown improvements in the homeless crisis in recent years, with even the most at-risk subpopulations experiencing a steady decrease in homelessness:

• While 20% of veterans are diagnosed with PTSD in any given year, their rate of homelessness has steadily decreased 55% since 2010.[27]

• Black Americans comprise only 13% of the U.S. population, yet make up 40% of the homeless population. However, between 2020 and 2021, the number of Black or African American people staying in shelters decreased by 12%.[28]

• While the number of homeless families increased between the 2020 Census and 2022, the overall number of homeless independent adults dropped.[29]

• The number of people under 25 experiencing homelessness has decreased by 12%, with youth homelessness down 6%.[30]

Further, the Federal Government continues to emplace financial interventions to support Americans with mental illness. According to a Continuing Disability Review from the Social Security Administration in 2014, mental illness is now the primary diagnosis for one-in-three persons under the age of 50 who receive disabled worker benefits.[31] As the number of disability beneficiaries with mental illness grows steadily, policy makers have an increased interest in monitoring employment rates by mental health status,[32] a sign of progress that will directly aid the homeless population.

The implications? Why does it matter

Much of the advocacy for homeless rights supports increasing the visibility of this crisis and placing additional responsibility on the general population. Since 1991, when the United Nations declared housing to be a fundamental right,[33] American society has made strides in its perception and support of the homeless population. However, mental illness is a significant hurdle to overcome, and this is often only one of a homeless person’s marginalized identities. Too often, women, people of color, and members of the LGBTQ+ community are overrepresented in the annual numbers of people without permanent housing.[34] The multiple layers of discrimination these marginalized communities combat on a daily basis also cause them to face higher barriers to reintegrate into society.

Ways We Can Help

While government intervention is key to continuing to improve the homelessness crisis, there are several ways people can continue to help:

1. Practice Kindness & Respect: While much of the responsibility to fix discrimination against the homeless falls on policy changes, it is still within every individuals’ control to manage the ways they personally engage with homeless people. Even in small interactions with a homeless person, it is damaging to treat them as though they are invisible, or try to judge them for their state. Instead, simply saying “good morning” and treating them as though they are a normal human being have the potential to improve someone’s day. No one wants to be judged for their worst day, and the homeless are often in a unique position where they are experiencing hardship on a daily basis.

2. Advocate Against Homelessness Discrimination: Employers are not only responsible for knowing anti-discrimination laws, but further, they must practice them in a manner that supports employees with mental illnesses and prior criminal records. It is illegal in every state to deny someone employment because of a prior felony, but employers often find work-arounds to make employment more difficult for this demographic. The “Ban the Box” campaign, which has already been implemented in 150 cities across 30 states, removed questions about criminal history from Federal job applications and pushed background checks to later in the hiring process.[35] With this change, an individual has the opportunity to be judged for other qualifications instead of being discounted over one aspect of their past. This initiative and others like it are key to combating the incarceration-to-homeless pipeline.

3. Decriminalize Homelessness: Walking around major cities, it is often easy to find excessively slanted benches, spiked window sills, and raised grate covers, all of which all intended to keep the homeless from sheltering in public spaces. Other communities have taken measures even further, adopting laws that criminalize people for behaviors that are side effects of their survival. According to the National Homelessness Law Center, 48 states have at least one law restricting behaviors of people experiencing homelessness (e.g., loitering, trespassing, or sleeping in public spaces) and these types of laws continue to gain traction across the country.[36] Members of a community can counteract these laws through protest, by voting, and by encouraging local business owners to enact more homeless-friendly provisions.

For more programs and resources on how to help the homeless, click here.

Contributed by: Kate Campbell

Editor: Jennifer (Ghahari) Smith, Ph.D.

REFERENCES

1 General definition of a homeless individual, 42 U.S.C § 11302 (1994). 

https://www.law.cornell.edu/uscode/text/42/11302#:~:text=(1),(2).

2 Ekins, E. What Americans Think About Poverty, Wealth, and Work. CATO Institute Website. https://www.cato.org/publications/survey-reports/what-americans-think-about-poverty-wealth-work. Updated 2019. Accessed February 15, 2023.

3 Ibid.

4 Homelessness: The Problem. The National Low Income Housing Coalition Website.  https://nlihc.org/explore-issues/why-we-care/problem. Updated 2023. Accessed February 12, 2023.

5 Mental Health by the Numbers. National Alliance on Mental Illness Website. https://nami.org/mhstats?gclid=CjwKCAiA_6yfBhBNEiwAkmXy50NgnpQVgRjIdYOunA1ZbReAHYOORBq_P_wvqkK7uH9AXWh-Y2rOHRoCcmwQAvD_BwE. Updated June 2022. Accessed February 12, 2023.

6 About Mental Health. Center for Disease Control and Prevention Website.  

https://www.cdc.gov/mentalhealth/learn/index.htm. Updated June 2021. Accessed February 11, 2023.

7 Mental Health by the Numbers. National Alliance on Mental Illness Website. https://nami.org/mhstats?gclid=CjwKCAiA_6yfBhBNEiwAkmXy50NgnpQVgRjIdYOunA1ZbReAHYOORBq_P_wvqkK7uH9AXWh-Y2rOHRoCcmwQAvD_BwE. Updated June 2022. Accessed February 12, 2023.

8 Ibid.

9 Ibid.

10 Ibid.

11 U.S. Department of Housing and Urban Development. (2022). Annual Homelessness Assessment Report. https://www.hud.gov/press/press_releases_media_advisories/HUD_No_22_253. HUD Public Affairs.

12 Carter, C. With inflation at a 41-year high, USF economics professor explains what to expect. WUSF Public Media Website. 

https://wusfnews.wusf.usf.edu/economy-business/2022-07-14/inflation-41-year-high-usf-economics-professor-explains-what-to-expect. Updated July 2022. Accessed February 12, 2023.

13 Ibid.

14 Luciano A, Meara E. Employment Status of People with Mental Illness: National Survey Data from 2009 and 2010. American Psychological Association Publishing, 2014;65(10):1-9. https://doi.org/10.1176/appi.ps.201300335.

15 Lloyd, A. Average Rent is 32% of the typical Americans’ pay; that’s more than financial experts recommend budgeting for housing. Business Insider Website.

https://www.businessinsider.in/policy/economy/news/average-rent-is-32-of-the-typical-americans-pay-thats-more-than-financial-experts-recommend-budgeting-for-housing/articleshow/90428300.cms. Updated March 2022. Accessed February 14, 2023.

16 National Low Income Housing Coalition (2022). Out of Reach: The High Cost of Living. https://nlihc.org/oor

17 How your Mental Health may be Impacting your Career. PBS Website.

https://www.pbs.org/newshour/health/how-mental-health-impacts-us-workers. Updated 2013. Accessed February 13, 2023.

18 Ibid.

19 Greenstein, L. Can Stigma Prevent Employment? National Alliance on Mental Illness Website.

https://www.nami.org/Blogs/NAMI-Blog/October-2017/Can-Stigma-Prevent-Employment. Updated 2017. Accessed February 10, 2023.

20 Ayano G, Tesfaw G, Shumet S. The prevalence of schizophrenia and other psychotic disorders among homeless people: a systematic review and meta-analysis. BMC Psychiatry. 2019;19:370.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6880407/.

21 Colato EG,  Enard KE, Orban BL, Wiltshire JC.  Problems paying medical bills and mental health symptoms post-Affordable Care Act. 2022;7(2):274-286. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7327393/

22 Fleury MJ, Grenier G, Sabetti J, et al. Met and unmet needs of homeless individuals at different stages of housing reintegration: A mixed-method investigation. PLOS One. 2021;16(1). https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0245088. Accessed February 15, 2023.

23 Bharat N, Cicatello J, Guo E, Vallabhaneni V.  University of Michigan School of Public Health Website. https://sph.umich.edu/pursuit/2020posts/homelessness-and-job-security-challenges-and-interventions.html. Updated 2019. Accessed February 14, 2023.

24 Joint Center for Housing Studies of Harvard University. (2022). America’s Rental Housing. https://www.jchs.harvard.edu/sites/default/files/reports/files/Harvard_JCHS_Americas_Rental_Housing_2022.pdf. 

25 Greenberg GA, Rosenheck RA. Jail Incarceration, Homelessness, and Mental Health: A National Study. Psychiatric Services. 2008;59(2):135-143.

https://doi.org/10.1176/ps.2008.59.2.170

26 Gillison, D. Veteran Mental Health: Not All Wounds are Visible. National Alliance on Mental Illness Website. https://www.nami.org/Blogs/From-the-CEO/November-2021/Veteran-Mental-Health-Not-All-Wounds-are-Visible. Updated November 2021. Accessed February 10, 2023.

27 U.S. Department of Housing and Urban Development (2022)

28 Ibid.

29 Ibid.

30 Ibid.

31 Social Security Administration. (2013). Annual Statistical Report on the Social Security Disability Insurance Program. https://www.ssa.gov/policy/docs/statcomps/di_asr/2013/di_asr13.pdf.

32 Luciano & Meara (2014)

33 United Nations Higher Commissioner for Human Rights. (2009). The Right to Adequate Housing. (UN Publication FS 21-1). https://www.ohchr.org/sites/default/files/Documents/Publications/FS21_rev_1_Housing_en.pdf.

34 Oliva, A. Ending Homelessness: Addressing Local Challenges in Housing the Most Vulnerable. Center on Budget and Policy Priorities Website. 

https://www.cbpp.org/research/housing/ending-homelessness-addressing-local-challenges-in-housing-the-most-vulnerable. Updated 2022. Accessed February 12, 2023. 

35 Avery B, Lu H. Ban the Box: U.S. Cities, Counties, and States Adopt Fair Hiring Policies. National Employment Law Project Website. https://www.nelp.org/publication/ban-the-box-fair-chance-hiring-state-and-local-guide/. Updated 2021. Accessed February 12, 2023. 

Citations:

1 General definition of a homeless individual, 42 U.S.C § 11302 (1994). 

https://www.law.cornell.edu/uscode/text/42/11302#:~:text=(1),(2).

2 Ekins, E. What Americans Think About Poverty, Wealth, and Work. CATO Institute Website. https://www.cato.org/publications/survey-reports/what-americans-think-about-poverty-wealth-work. Updated 2019. Accessed February 15, 2023.

3 Ibid.

4 Homelessness: The Problem. The National Low Income Housing Coalition Website.  https://nlihc.org/explore-issues/why-we-care/problem. Updated 2023. Accessed February 12, 2023.

5 Mental Health by the Numbers. National Alliance on Mental Illness Website. https://nami.org/mhstats?gclid=CjwKCAiA_6yfBhBNEiwAkmXy50NgnpQVgRjIdYOunA1ZbReAHYOORBq_P_wvqkK7uH9AXWh-Y2rOHRoCcmwQAvD_BwE. Updated June 2022. Accessed February 12, 2023.

6 About Mental Health. Center for Disease Control and Prevention Website.  

https://www.cdc.gov/mentalhealth/learn/index.htm. Updated June 2021. Accessed February 11, 2023.

7 Mental Health by the Numbers. National Alliance on Mental Illness Website. https://nami.org/mhstats?gclid=CjwKCAiA_6yfBhBNEiwAkmXy50NgnpQVgRjIdYOunA1ZbReAHYOORBq_P_wvqkK7uH9AXWh-Y2rOHRoCcmwQAvD_BwE. Updated June 2022. Accessed February 12, 2023.

8 Ibid.

9 Ibid.

10 Ibid.

11 U.S. Department of Housing and Urban Development. (2022). Annual Homelessness Assessment Report. https://www.hud.gov/press/press_releases_media_advisories/HUD_No_22_253. HUD Public Affairs.

12 Carter, C. With inflation at a 41-year high, USF economics professor explains what to expect. WUSF Public Media Website. 

https://wusfnews.wusf.usf.edu/economy-business/2022-07-14/inflation-41-year-high-usf-economics-professor-explains-what-to-expect. Updated July 2022. Accessed February 12, 2023.

13 Ibid.

14 Luciano A, Meara E. Employment Status of People with Mental Illness: National Survey Data from 2009 and 2010. American Psychological Association Publishing, 2014;65(10):1-9. https://doi.org/10.1176/appi.ps.201300335.

15 Lloyd, A. Average Rent is 32% of the typical Americans’ pay; that’s more than financial experts recommend budgeting for housing. Business Insider Website.

https://www.businessinsider.in/policy/economy/news/average-rent-is-32-of-the-typical-americans-pay-thats-more-than-financial-experts-recommend-budgeting-for-housing/articleshow/90428300.cms. Updated March 2022. Accessed February 14, 2023.

16 National Low Income Housing Coalition (2022). Out of Reach: The High Cost of Living. https://nlihc.org/oor

17 How your Mental Health may be Impacting your Career. PBS Website.

https://www.pbs.org/newshour/health/how-mental-health-impacts-us-workers. Updated 2013. Accessed February 13, 2023.

18 Ibid.

19 Greenstein, L. Can Stigma Prevent Employment? National Alliance on Mental Illness Website.

https://www.nami.org/Blogs/NAMI-Blog/October-2017/Can-Stigma-Prevent-Employment. Updated 2017. Accessed February 10, 2023.

20 Ayano G, Tesfaw G, Shumet S. The prevalence of schizophrenia and other psychotic disorders among homeless people: a systematic review and meta-analysis. BMC Psychiatry. 2019;19:370.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6880407/.

21 Colato EG,  Enard KE, Orban BL, Wiltshire JC.  Problems paying medical bills and mental health symptoms post-Affordable Care Act. 2022;7(2):274-286. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7327393/

22 Fleury MJ, Grenier G, Sabetti J, et al. Met and unmet needs of homeless individuals at different stages of housing reintegration: A mixed-method investigation. PLOS One. 2021;16(1). https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0245088. Accessed February 15, 2023.

23 Bharat N, Cicatello J, Guo E, Vallabhaneni V.  University of Michigan School of Public Health Website. https://sph.umich.edu/pursuit/2020posts/homelessness-and-job-security-challenges-and-interventions.html. Updated 2019. Accessed February 14, 2023.

24 Joint Center for Housing Studies of Harvard University. (2022). America’s Rental Housing. https://www.jchs.harvard.edu/sites/default/files/reports/files/Harvard_JCHS_Americas_Rental_Housing_2022.pdf. 

25 Greenberg GA, Rosenheck RA. Jail Incarceration, Homelessness, and Mental Health: A National Study. Psychiatric Services. 2008;59(2):135-143.

https://doi.org/10.1176/ps.2008.59.2.170

26 Gillison, D. Veteran Mental Health: Not All Wounds are Visible. National Alliance on Mental Illness Website. https://www.nami.org/Blogs/From-the-CEO/November-2021/Veteran-Mental-Health-Not-All-Wounds-are-Visible. Updated November 2021. Accessed February 10, 2023.

27 U.S. Department of Housing and Urban Development (2022)

28 Ibid.

29 Ibid.

30 Ibid.

31 Social Security Administration. (2013). Annual Statistical Report on the Social Security Disability Insurance Program. https://www.ssa.gov/policy/docs/statcomps/di_asr/2013/di_asr13.pdf.

32 Luciano & Meara (2014)

33 United Nations Higher Commissioner for Human Rights. (2009). The Right to Adequate Housing. (UN Publication FS 21-1). https://www.ohchr.org/sites/default/files/Documents/Publications/FS21_rev_1_Housing_en.pdf.

34 Oliva, A. Ending Homelessness: Addressing Local Challenges in Housing the Most Vulnerable. Center on Budget and Policy Priorities Website. 

https://www.cbpp.org/research/housing/ending-homelessness-addressing-local-challenges-in-housing-the-most-vulnerable. Updated 2022. Accessed February 12, 2023. 

35 Avery B, Lu H. Ban the Box: U.S. Cities, Counties, and States Adopt Fair Hiring Policies. National Employment Law Project Website. https://www.nelp.org/publication/ban-the-box-fair-chance-hiring-state-and-local-guide/. Updated 2021. Accessed February 12, 2023. 

36 National Homelessness Law Center. (2021). Housing not Handcuffs 2021: State Law Supplement. https://homelesslaw.org/wp-content/uploads/2021/11/2021-HNH-State-Crim-Supplement.pdf.