Low-Barrier Therapy for All: Rethinking Where Healing Happens

Homelessness is often considered a barrier to delivery of psychotherapy.Lack of housing is associated with poor retention in care, difficulty managing care systems, and instability.Yet the need for therapy is high for this population; compared with the general population, individuals experiencing homelessness have more psychiatric issues, including psychotic disorders, posttraumatic stress disorder (PTSD), and substance use disorders.Mental health services for homeless individuals often prioritize managing psychosis or obtaining housing, with other therapy considered unfeasible.Although trauma is a widely recognized precipitating factor for homelessness and psychiatric issues, trauma-focused therapies are rarely integrated into the treatment systems most used by the homeless population.Without PTSD treatment, individuals may manage trauma-related symptoms with drugs and alcohol.In this issue, Hamilton and colleagues (1) provide a counterpoint to the notion that people experiencing homelessness cannot be retained in treatment.They present a compelling demonstration trial of cognitive-behavioral therapy (CBT) for homeless people who have a serious mental illness, substance use disorder, or both.Their population was majority Black, male, and unsheltered.Individuals received CBT with trauma-focused strategies, and community health workers provided linkages to services.Over 12 sessions, participants meeting criteria for PTSD decreased (from 65% to 16%), and attendance (mean=10.6sessions) and retention (42% completed all 12 sessions) were good.Restlessness, recent emergency department visits, feelings of belonging at shelter sites, and higher alcohol use risk scores were positively associated with retention.Countering previous assumptions, the evidence suggests that individuals with psychotic disorders and acute illness were more likely to be retained in care.Treatment research has confirmed that addressing traumarelated symptoms yields positive impacts on substance use, reinforcing the importance of engaging this population in trauma-focused care.Together, these findings challenge beliefs about treatment readiness and suggest that trauma-focused therapy can be feasible and effective for persons experiencing homelessness.Positive regard and feeling of community at shelter sites were associated with retention, suggesting the impact of embedding care in spaces where those experiencing homelessness feel respected and comfortable.Prior work clearly shows that stigma impedes care among