**4. Promising preventive strategies using a cultural competence framework**

A cultural competence framework is one that guides healthcare providers' behaviors, attitudes, value and perspective on caring for individuals, families and communities. The culturally competent service provider takes into account an individual's multiple identities, preferences, norms, beliefs, as well as, their social determinants of health. The way in which healthcare providers' social and professional experiences impact their worldview, particularly as it relates to their delivery of care to diverse populations and it influences how and to what degree they are willing to ensure equity and parity in the mental healthcare services they provide. Furthermore, while homelessness is not considered to be a determinant of mental illness, interdisciplinary research and evidence-based theories suggest a strong correlation race culture, homelessness and access to healthcare [12, 13, 31]. Mental health providers have argued that it is extremely challenging to implement standard intervention strategies with this diverse population. The stigma associated with aging and mental health can make it rather difficult for providers to understand how to facilitate the same approaches with housing secure individuals, as one would implement with older adults living with homelessness. Changing the views and perspectives require a cultural competence lens through which to see and experience prevention and intervention this older adult populations. Based a comprehensive literature review, self-care and mindfulness are useful supporting cognitive behavioral modification interventions with person's managing mental health and substance use disorders [14]. These strategies may well have lasting, positive impacts on health outcomes. Promising preventive strategies for addressing mental health care among older persons that are homeless require a range of varied interventions. Some additional recommended approaches include self-help groups, integration of spiritual/religious beliefs, reminiscence therapy that incorporates the focus of balanced review and reflection of one's past life, and/or interdisciplinary clinical pharmacological treatments, as needed to maintain activities of daily living, physical exercise, and psychosocial health, while in recovery from substance use and homelessness [32]. The adaptation to cultural norms, attitudes and preference can increase accessibility and acceptability [13, 17, 22].

Cognitive behavioral literacy therapy using books, audiotapes, and video presentations also has been shown to alleviate mild depressive symptoms through promotion of self-help [33]. Such audio and video media for the elderly should take into consider educational level, readability, font size, and use of examples relevant different cultural groups. For example, appropriate content targeting older adults transitioning out of homelessness could involve retirement planning that includes development of positive expectations of a new life phase, a change of environment, developing new interests and stronger social support networks.

Preventive strategies aimed specifically at elders' spiritual/religious beliefs have been shown to be more effective than treatment-as-usual which neglects such beliefs and related practices [34]. These strategies may include religious participation involving prayer, spiritual music consumption, emotional and psychological preparation for an afterlife, a review of one's life journeys, and/or spiritual

*Healthcare Access - Regional Overviews*

**3. Approaches and frameworks**

in-home services with older adults, specifically [22, 29].

More specifically, racial minority groups, in the U.S., experience disproportionately higher rates of homelessness, than racially White groups. In considering homelessness as a public health problem that requires attention to access and acceptability of healthcare, food, shelter and social support, the clear link for older adults is the strong correlation between mental health and homelessness [11].

A practical definition of substance use is one of the most commonly described

Behavioral modification interventions have been proven to be effective. These approaches are client-centered and provide support for abstinence from substance use. Moreover, such flexible models of care offer a range of modifiable frameworks for addressing attitudes and behaviors related to addiction and recovery [28]. In the field of social work practice, in particular, problem-solving frameworks are often recommended because of the evidence-based, culturally informed, manualized strategic tools that give mental health care provider the options to tailor the intervention to diverse populations and can be implemented in a range of different settings, including clinics, hospital, community-based environments and even

Arguably, mental health intervention should take more of a community-based prevention approach versus a medical model, institutional treatment, when tailored to, and for persons living in homeliness [11]. The debate about the degree to which homeless persons will be able to access services to address their problems of substance use disorders, as well as, home and food insecurity, rest squarely on macro-level factors, including policies, legislation, research for evidence-based recommendations and solutions. The World Health Organization (WHO) recognizes mental disorders a public health concern, worldwide and its use of the term "disorder," implies the existence of observable behaviors or symptoms that interfere with normal functioning and that cause distress. Homelessness can exacerbate the symptoms of mental illness, causing an individual to become debilitated, depressed and anxious, all of which can be costly, socially and economically for individuals and families. Prevention of mental disorders and effective interventions, as well as, population-based policies that support and foster health accessibility among all person, are among the ongoing challenges that countries, worldwide must contend

**2. Homelessness, mental health and substance use disorders**

and identified health risks among people experiencing homelessness [25]. Homelessness is defined as the absence of a permanent home. Individuals and families may live on the streets, in a shelter, a single room occupancy facility, abandoned building or vehicle, or in any other unstable or non-permanent living arrangement (Section 330 of the Public Health Service Act (42U.S.C., 254b)). For more than a decade, studies reporting on the experiences of homeless persons have examined the association between living arrangement and substance use disorder treatment program characteristics, because housing instability is known to impact mental health and SUD prevention and intervention efforts [17, 26]. Substance use among older adults, specifically who are homeless, is associated with decreased mobility of physical and mental health capacity [25] and early onset morbidity and mortality [27]. For these reasons, more attention on older adults as a special population of concerns for mental health prevention and intervention is warranted.

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counseling. Research has shown [35] that involvement in spiritual/religious activities led to decreased depression among some other adults. In the U.S., the 12-Step model of addiction recovery has principles that guide the processes [36] and one of the core components is 'belief in a higher power.'

Reminiscence or life review therapy has yielded mixed results [33]. This potentially preventive approach involves literally reviewing one's life experiences as far back as one can remember and examining each life stage in terms of one's choices and the consequences of those choices for self and others. Given that the consequences of such experiences could be either positive or negative, perhaps it is the attitude toward such consequences that is critical to the effectiveness of this approach for prevention. If one believes that life is an opportunity to learn, then the results of the life review may prove to be positive and instructive for further learning and avoiding the same mistakes, thereby allowing for self-correcting and a sense of perceived control.

Psychodynamic therapy has also been evaluated empirically continue to have popularity as an approach within a managed care environment that reimburses only empirically supported treatments for older adults [33]. With homeless older adults, such interventions have been facilitated in substance abuse recovery program and in other shelter-based program that address mental health conditions, including SUDs [11].

Pharmacotherapy may also be an effective prevention strategy with older adults and there are a number of recommendation for addressing risk and side effects of antidepressant medication when prescribed to older adults, and especially those that are in addiction recovery [37]. One precaution is that approximately 20% of older adults have serious health problems that can be aggravated by antidepressant medications, including increased risk of physical injuries and hypertension disorders [33]. Moreover, research suggests that anti-anxiety and other sedative medications worsen conditions of depression and perhaps anxiety, among older people with substance use disorders [38–42]. Noteworthy is caveat methodological flaws and limitations may contribute to these negative findings in the research. Variations in interventions techniques, provider characteristic and sociocultural diversity of the participants are not clearly explained and such omissions can result in ambiguous and confounding effects.

## **5. Summary**

As a moral imperative, fundamental in the profession of social work, the core value and belief that every human being deserves a home, food, clothing and access to health care compel us to make this call to action. Older adults should not be excluded from the inalienable rights and dignities, worldwide [19] to have their basic needs met. As the risk of homelessness among older adults increases, this becomes a public health and human right concern for healthcare systems and providers. This call to action for expedient problem-solving to prevent older adults from living in poverty and becoming homeless. Solutions are within our local, regional, national and global reach, such as expanding and strengthening the existing safety net of health care and minimum income supports, such as Temporary Assistance for Needy Families (TANF), Child Support Enforcement, Medicare and Medicaid, as well as, including a livable wage for those whom continue to be employed. An increase in the supply and accessibility of affordable housing for the aging population and low-cost or no-cost community based mental health and substance disorder prevention and intervention services are a few of the recommended solutions [42].

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**Author details**

Ramona Bullock-Johnson and Karen Bullock\* North Carolina State University, Raleigh, NC, USA

provided the original work is properly cited.

\*Address all correspondence to: kbulloc2@ncsu.edu

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Exploring Mental Health Treatment and Prevention among Homeless Older Adults*

*DOI: http://dx.doi.org/10.5772/intechopen.89731*

*Exploring Mental Health Treatment and Prevention among Homeless Older Adults DOI: http://dx.doi.org/10.5772/intechopen.89731*
