The Myths and Truths about Homelessness among Iraq and Afghanistan Veterans

Stephen Metraux (@SteveMetraux) is a researcher at the National Center for Homelessness Among VeteransStephen Metraux _ Portrait _ Contigo Photography-9641b of the US Department of Veterans Affairs (VA) and has done extensive research on homelessness. More information on him and his research is at www.stephenmetraux.com. Opinions are his and do not reflect official VA positions.

 

Americans feel a keen obligation to, in the words of Lincoln (and the VA motto): “care for [the veteran] who shall have borne the battle.” Yet for all the public expenditures, bipartisan political support, charitable outpouring, and multitudes of thank-yous for service, there is a sense that this covenant has frayed. That veterans have performed their duty but have not received the support they need to care for their wounds, be they physical or psychological, and to successfully return to their civilian lives. One of the most salient symbols of this betrayal is when veterans become homeless.

Veterans have a higher vulnerability to becoming homeless; why this is so is poorly understood presents a paradox. Veteran status should be a protective factor, as veterans have higher levels of education and lower levels of poverty and unemployment than non-veterans. In addition, veterans have access to extensive health care, housing and financial assistance resources that are unavailable to non-veterans. There is bipartisan popular and political support for helping veterans. Yet still this disparity persists.

Particular concern focuses upon homelessness among veterans returning from the current wars in Iraq and Afghanistan. In 2007, both the New York Times and the Washington Post sounded alarms with Veterans Day articles independently warning of an impending “tsunami” of homelessness among returning war veterans. Subsequent media and advocacy accounts explained how this tsunami has its roots in service-connected factors, particularly posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), in addition to the more general economic conditions they face on reentering civilian life. But the symbolic potency of this issue has not been weighed against the empirical realities of such homelessness.

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What Do We Know? Examining the Evidence

A first step in examining this is to quantify the problem. Yet there are no counts, or even credible estimates of the number of veterans who return from Iraq and Afghanistan and subsequently become homeless. One fairly credible guess from 2010 put the annual number of Iraq and Afghanistan war veterans at 12,700, that number has almost certainly increased since then. This is not due to increased risk as much as it is to increased numbers, as in 2017 the number of veterans who served in Iraq and Afghanistan stood at about 2.8 million, and is still growing by roughly 100,000 new veterans annually. There is no indication that a “tsunami” ever materialized among this cohort; a more appropriate metaphor may be “rising tide.”

Another perception of homelessness among these veterans is that the onset of homelessness now occurs much sooner after leaving the military than it did with previous veteran cohorts. Verifying this is difficult, however, as it has only been during this current service era that researchers could track homelessness among veterans from the point that they exited the military. Two studies have found median times to homelessness for recent veterans to be approximately 2 to 3 years (Blackstock et al. 2012; VA OIG 2012). This means that, for veterans who do become homeless, for most it will occur only after having returned to civilian life for at least a few years. Qualitative research shows how precipitating factors often precede actual homelessness by several years. These factors can include unstable living arrangements, unemployment, financial mismanagement, strained family relations, and behavioral health issues (Ahern et al. 2015; Elbogen et al. 2013; Smith and True 2014; Spitzer 2016; IOM 2013).

Measuring wartime experience and linking it to subsequent risk for homelessness is fraught with challenges. The most common and straightforward way to measure wartime exposure is deployment. Three studies looked at differential rates of homelessness between post-9/11 veterans who deployed to Iraq and Afghanistan and those who did not. Of these, none produced conclusive findings (Edens et al. 2011; Metraux et al. 2013; Tsai et al. 2016). One other study focused on specific deployment experiences (combat experience, multiple deployments, etc.) and links to homelessness, and similarly found inconclusive results. While combat experience or some other factor associated with deployment might in fact increase the risk for subsequently becoming homeless (either by itself or in conjunction with other factors), the scant research on this topic has yet to identify it.

Similarly, the empirical evidence for an association between PTSD and homelessness has been far less robust than the popular belief in this association.  The most rigorous study that examined this connection looked at Vietnam veterans and did not find a direct association between the two.17 In the context of the Afghanistan and Iraq wars, four of the studies that examined homelessness among OEF/OIF/OND veterans reported findings related to PTSD. Two of these studies found associations between PTSD and modestly increased risks for homelessness, while two others reported no significant associations after controlling for other factors.

Conversely, studies have found a high prevalence of PTSD among post-9/11 veterans who experience homelessness. One study found high levels of PTSD diagnosis (67%) among Iraq and Afghanistan war veterans who were placed into VA supportive housing, and much lower rates among older cohorts of homeless veterans. Another study that interviewed post-9/11 veterans who experienced homelessness showed the mechanisms by which PTSD symptoms led to homelessness. These mechanisms included difficulties maintaining employment and family relations, factors that directly contributed to homelessness. Both studies showed how PTSD and homelessness interact to exacerbate one another.

There has been no evidence that links TBI, the second so-called signature injury of the Iraq and Afghanistan wars, with increased risk for homelessness. Two studies have examined TBI among veterans who are homeless and, while both noted a high prevalence of TBI, they found most incidences were not military-related (Barnes et al. 2015; Russell et al. 2013). Homelessness itself increases the risk, regardless of veteran status, of sustaining a TBI due to accidents, assaults, and other hazards of living on the streets.

A defining feature of the current service era has been the expanded role of women in executing the wars. Women’s growing presence in the military accounts for their disproportionate representation among younger veterans. Gender-related age disparities also manifest themselves in homelessness. Among male veterans, the risk for experiencing homelessness increases with age up to age 65, while among women the younger age groups have the highest risk (Byrne et al. 2013; Fargo et al. 2012).

Studies have not found female veterans in the post-9/11 cohort to be any more likely than their male counterparts to use VA homeless services (Blackstock et al. 2012; Rosenheck 2011). However, female veterans are much more likely than male veterans to use non-VA, community-based homeless services for shelter and other assistance. When women seek veteran-specific homeless services, they often have to negotiate almost exclusively male environments that lack services specific to women and families with children.

The other issue most frequently associated with gender with respect to veteran homelessness is military sexual trauma (MST). An estimated 38% of female service members experienced MST, compared to 4% among men, with several studies (Hamilton et al. 2011; Pavao et al. 2013) finding even higher rates of MST among female veterans who experience homelessness. One study linked MST to significantly higher risk of homelessness among both female and male OEF/OIF veterans. Furthermore, MST is associated with mental health comorbidity, including PTSD, that may contribute to a greater risk for and longer duration of homelessness.

Another key feature of the recent wars that may also impact homelessness is the exclusive reliance on volunteer recruits. VA researcher Robert Rosenheck and his colleagues ascertained that the cohort of veterans at greatest risk of homelessness were those who served in the early years of the post-Vietnam era, and during the implementation of the All-Volunteer military. This was a time when military service was unpopular and the pay was low, forcing recruiters to reduce standards to meet quotas. This may have led to a higher number of recruits with issues such as behavioral health problems and criminal histories that would predispose them to a higher risk for homelessness over their post-military lifecourse.

A similar situation may have occurred during the mid-2000s, during the early war years. As recently as 2005 the military fell substantially short of its recruiting goals, and up through 2009 the military regularly provided waivers for health and legal situations that would ordinarily bar potential recruits from enlisting (Gallaway et al. 2013). This situation has since reversed, but these relaxed recruiting standards may correspond to elevated risk for homelessness and other adverse outcomes over the lifecourse of veterans during this era.

Recruiting shortfalls during the course of the two wars have also led to the deployment of large numbers of National Guard and Reserve personnel, and to active duty personnel being deployed for extended periods (i.e., “stop loss”), for multiple deployments, and with less time between the multiple deployments. The added stress and uncertainty surrounding these deployment policies have been linked to increased difficulty with transitioning back into civilian life and, possibly, to greater vulnerability to homelessness.

Another focal point for homelessness involves other than honorable discharges from the military. The advocacy group Swords to Plowshares reported that 125,000 veterans (6.5% of all post-9/11 veterans) are ineligible for VA services due to other than honorable (OTH), bad conduct, or dishonorable discharges. The US Government Accountability Office found that 62% of servicemembers who separated due to misconduct had PTSD or TBI diagnoses, supporting contentions of how the military systematically discharges personnel with medical or psychiatric conditions for punitive reasons.

This connects to homelessness, with one study finding that veterans with misconduct-related discharges comprised 5.6% of all VA-eligible Iraq and Afghanistan war veterans, but comprised 20.6% of those among deployed veterans who became homeless in the subsequent 5 years. In contrast to the veterans in this study, the large majority of post-9/11 veterans with misconduct-related discharges are ineligible for VA services and this alone would presumably contribute to an even higher risk for homelessness. Verifying these presumptions, however, is difficult as these veterans are invisible to the VA. They do, however, appear to be disproportionately represented among veterans in the mainstream homeless systems, as when a 2016 survey of Minnesota’s homeless population found that 11% of the veterans (from all eras) reported negative discharges. This is almost twice the rate cited in the Swords to Plowshares study.

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What Can Be Done? Actionable Steps Based on Relevant Research

Looking at what has been reviewed here, research indicates that the oft-mentioned links between Iraq and Afghanistan war veterans and homelessness are more nuanced than they appear in public discourse. The ties aren’t as clear cut, and the impact isn’t as severe. But the connections nonetheless appear salient. Current research also supports several measures that can reduce the risk that these veterans have of becoming homeless after their return home.

  1. The first measure is to continue current expenditures on homeless housing and services, which has been connected to the reduction in the overall homeless veteran population by about half over the past eight years. This trend has undoubtedly mitigated the extent of homelessness among recent veterans.
  2. A second measure would be to consolidate these reductions in veteran homelessness by focusing on preventive services. Advances in predictive analytics make it possible to identify at-risk veterans at the point of VA enrollment. Prevention services could then monitor these veterans as they return to civilian life, and potentially identify and help address housing problems before they become housing crises.
  3. Another prevention approach is to focus on issues that disproportionately impact Iraq and Afghanistan war veterans and are linked to homelessness. For example, behavioral health issues, including PTSD, have been tied to homelessness, but there are also indications that receiving treatment for these issues may protect against homelessness. The expansion of VA access to recent veterans stands to also indirectly reduce homelessness. Further efforts such as expediting and simplifying veteran appeals of punitive discharges, if this were implemented, may function in a similar fashion. Eliminating military sexual trauma, something that should be done in its own right, would also likely have an added benefit of reducing homelessness risk.

Homelessness among veterans is a powerful symbol of injustice, and while this mobilizes support it also simplifies the process of becoming and being homeless. A clearheaded understanding of the actual dynamics of homelessness is essential as a foundation for eliminating homelessness. The issue will get more complicated as the number and diversity of Iraq and Afghanistan war veterans continue to grow, and as homelessness occurs over the unfolding lifecourse of these veterans.

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Material from this blog post is adapted from the book chapter “Homelessness Risk among Post-9/11 Era Veterans” (co-authored with R. Tyson Smith) that is forthcoming in the book Homelessness Among U.S. Veterans: Critical Perspectives. (Jack Tsai, ed., Oxford University Press). A copy of the manuscript is available here.

 

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