Evidence-Based Solutions to Mental Health and Homelessness Issues

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1 Quality Improvement Project on Mental Health and Homelessness Student’s Name Institutional Affiliation Course Date

2 Problem Statement While the world struggles with various challenges such as climate change, inflation and unemployment, mental illness and homelessness are rising in the United States of America. The homelessness problem occasioned by limited and expensive homes in America makes it a challenge for low-income earners to own homes. Following the Covid-19 pandemic, many Americans became jobless due to the shutting down of companies' operations. These winding up of business operations worsened the unemployment rate, increasing the number of people who could not afford the scarce and expensive homes. On the same note, the emergence of the Covid-19 pandemic destabilized the world's economic activities, reducing household per capita income and slimming the chance to own a home among low-income earners. As a result, such experiences have become sources of cognitive disorders causing stress, depression, schizophrenia, and bipolar complications. A study by Marano (2022) shows that approximately 40% of Americans are on the verge of losing their paycheck due to post-Covid 19 economic challenges. As a result, this point to the possibility of an increased mental illness and homelessness menace due to the inability to afford some basic needs like a decent home. Therefore, the research paper discusses evidence-based interventions for mental illness and homelessness in America. Background Information Although the challenge of mental illness and homelessness is not strongly correlated, several studies link mental illness and homelessness due to shared outcomes. In other words, an individual suffering from a mental disorder caused by other factors stands a high chance of becoming homeless. At the same time, a homeless person, due to expensive homes, tough

3 economic times and unemployment, is at high risk of developing mental disorders such as stress, depression and bipolar disorders. Some of the risk factors for mental illness emanate from an individual's immediate surroundings. A person living a stressful life due to tough economic times is likely to develop unhealthy thoughts that negatively impact mental health. Genetic inheritance, unhealthy habits and substance abuse also directly contribute to mental illnesses. When these factors advance, then an individual is likely to lose it by being unable to perform normal daily routines like going to work, resulting in financial instability. Inadequate finances put an individual at risk of homelessness as the limited homes in America are pretty expensive. Similarly, homeless person risks developing mental illness in their life. Due to the hardship of life on the streets, the majority of homeless people become stressed and depressed because street life offers nothing to enjoy. Together with their families, the homeless persons find life unbearable on the street because of a lack of basic necessities such as good shelter, food and proper medication. Nearly 26.6% of homeless persons are reported to suffer from severe mental illnesses (Marano, 2021). As a result, the homelessness trend and mental illnesses put pressure on the health sector of many developed countries. In addition, the challenge of mental illness and homelessness in America partly dates back to the legislation of key policies in the housing sector. According to the New York Times (2022), the implementation of restrictive housing policies within different states prevents the construction of many affordable homes to accommodate the expanded population in recent times. The single-family housing policy and zoning rules reduced the number of available units that were constructed in the past. To make this worse, the objection by homeowners to increasing housing units within their environment makes the housing challenge even more complicated.

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4 Therefore, the intervention aimed at solving the housing challenge in America will also greatly impact the mental health of many homeless Americans. Data on Mental Illness and Homelessness Data from the National Alliance on Mental reveals that millions of people in America have mental illness-related diseases each year. Based on the 2021 statistics on mental health, approximately 22.8% of U.S. adults, an equivalent of 57.8 million, suffer from mental illnesses annually. The same data shows that adults with severe mental illnesses accounted for 5.5%, translating to 14.1 million people. Notably, the mental disorder occurrences also varied, with schizophrenia standing at 1%, obsessive-compulsive disorder at 1.2%, borderline personality disorder at 1.4%, bipolar disorder at 2.8%, posttraumatic stress disorder at 3.6%, major depressive episode 8.3% and anxiety disorders 19.1% (National Alliance on Mental Illness, 2020). Therefore, the data shows why there is a need to establish evidence-based intervention on mental health to improve the quality of mental health among U.S. citizens. Mental Health and Homelessness Literature Review The mental health and homelessness debate attracts interest from scholars due to its rapid rise in developed countries. The high rate of mental illness and subsequent pressure on healthcare facilities necessitates developing urgent interventions to address the challenge. A study by Walker et al. (2022) acknowledges that mental illness and homeless patients face several challenges, including rejection when they seek medications. To address this, the authors suggest a rapid change in attitude among the nursing staff towards mentally ill and homeless patients. Walker et al. note that this can only be realized when an appropriate educational intervention modelling nurses' attitudes towards the patients is instilled.

5 Similarly, Collins et al. (2021) point out in their study that homelessness is attributed to unhealthy behaviors such as alcohol abuse, increasing the risk of contracting mental illnesses. The researchers also note that the non-abstinence technique aimed at improving individual behaviors reduces drug abuse habits and contributes to general cognitive wellness. The authors also argue that implementing a cognitive behavioral therapy intervention among people experiencing homelessness will help develop positive thoughts, feelings and actions, improving the quality of mental health among homeless people. As a result, data from this article provides an alternative intervention to improving mental illness and homeless persons' thoughts and actions through behavioral therapy guidance. Since the homelessness persons occasionally develop negative thoughts leading to stress, anxiety and sometimes depression, Aubry et al. (2020) argue in their study that homelessness intervention indirectly improves the quality of mental health among millions of homeless people in major developed countries. The authors recommend permanent supportive housing and income assistance as one of the interventions to solve the homelessness challenge. Other than solving the housing challenge, the housing and income assistance intervention reduces stress and depression among the affected persons, thus leading to mental wellness. Another by Shinn and Cohen (2019) reveals that intervention in mental illnesses and homelessness in society starts by addressing societal factors that directly or indirectly contribute to the problem. According to Shinn and Cohen, interventions targeting to provide affordable homes, increase employment opportunities and support community-based efforts help a lot in curbing the mental health and homelessness challenge. Specifically, the authors recommend adopting community-based services that connect the most affected mental health patients to vital health services such as counseling and therapies. At the same time, the authors insinuate that

6 critical time interventions targeting the severely affected mental health patients and linking them to community-based providers aid in close monitoring of patients' progress. Therefore, the knowledge from this article provides an evidence-based approach to acting quickly and supporting severely mentally ill patients in community-based programs that fastens their recoveries. Duke and Searby (2019) recognize in their study that mental health challenges are more rampant among homeless women than those who are not homeless. Besides, these authors also acknowledge that though homelessness and mental illness have no direct cause-effect relationship, most homeless women have developmental disorders such as depression, anxiety and post-traumatic stress disorder. In other words, the article reveals that the probability of homelessness precipitating mental disorder is high, thus the need to adopt interpersonal psychotherapy to shape individual emotions such as stress, anxiety and depression. As a result, using this article provides knowledge about interpersonal psychotherapy intervention, which will be vital in helping the mentally ill and homeless persons manage their situations, thus improving their cognitive health. In addition, Kakhramonovich (2022) also reveals in his study that mental disorder impairs cognitive functionality, altering an individual's routine activities like work. The situation sometimes worsens, causing mental disorders such as anxiety disorders, depression, post- traumatic stress disorder, schizophrenia, and destructive behavior. In this regard, the author points out that implementing a behavioral family therapy plays an integral role in educating the patient's family members about the severity of the mental health condition and how to aid the patient's recovery. The intervention is also important in providing knowledge to deal with health

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7 stressors due to mental illnesses. As a result, knowledge from this article will educate and provide coping strategies for family members of mentally ill patients. Moreover, a study by Bai et al. (2020) investigated the effectiveness of acceptance and commitment therapy in reducing depression. The authors reviewed different electronic databases from 2010 to 2018 on the efficiency of the intervention in solving depression disorder. The result from the study revealed that acceptance commitment therapy significantly reduced depression in the treatment group than the control group after a post-intervention that took three months with SMD recording of 0.59, 95% confidence interval recorded at (0.38, 0.81). Based on this data, acceptance and commitment therapy will be vital in managing the psychological challenges faced among the homeless and mentally ill persons in society. Evidence-Based Interventions being implemented Mental disorder and homelessness challenge is a dynamic health condition affecting thoughts, feelings, behavior, and actions among the affected patients. For this reason, addressing mental illness and homelessness in society requires a multifaceted intervention program. Some of the interventions implemented in this project include interpersonal psychotherapy, cognitive behavior therapy, behavioral family therapy, and acceptance and commitment therapy. Each of these interventions addresses specific challenges precipitated by either homelessness or mental illness. The implementation of interpersonal therapy will aim to solve personal problems that cause mental illness. The interpersonal therapy intervention revolves around helping mentally ill patients and homeless people manage emotions, thoughts, and feelings that cause depression (U.S. Department of Veterans Affairs, 2022). This therapy will be implemented in sessions lasting for a maximum of 50 minutes weekly. Besides, the learning sessions will focus on

8 providing detailed information on episodic depression and how to manage them. At the same time, implementing an interpersonal therapy intervention will encourage mental disorder patients to open up about the most disturbing experiences making it possible to develop an effective management strategy. Secondly, a cognitive behavior therapy intervention will also be implemented to positively influence behavior and cognitive aspects among mentally ill patients and people experiencing homelessness. This intervention's first aspect will aim to achieve positive behavioral changes by eliminating negative habits. At the same time, the cognitive therapy part will seek to end all the disturbing thoughts that result from unhealthy behavioral practices. This will be achieved through consistent cognitive restructuring and self-instructional training to develop positive thoughts which promote mental health wellness. In addition, the study also implements behavioral family therapy as an intervention for patients who occasionally experience psychosis. Primarily, the behavioral family therapy intervention targets to encourage family members of mentally challenged patients to become more supportive by offering the necessary assistance that would hasten the recovery process (U.S. Department of Veterans Affairs, 2022). By viewing the mental disorder as a family challenge rather than an individual problem, family members become integral to the healing process among cognitively distressed patients. Besides, this intervention provides family members of mental health patients with basic ideas on how best to handle specific conditions without making the patients feel discriminated against due to their health conditions. At the same time, this intervention could include educating family members on introductory therapy sessions that can be applied to improve the quality of health among people with mental disorder conditions at home.

9 Moreover, the study implements acceptance and commitment therapy intervention to control mental health patients' thoughts, feelings, and sensations. This intervention aims to train people with mental disorders to accept and manage their disturbing current experiences and shape them towards a restructured behavior to develop positive thoughts and feelings, thus improving mental health (U.S. Department of Veterans Affairs, 2022). The intervention also encourages mental health patients to fully embrace their experiences to achieve more desired mental health outcomes by reducing negative thoughts and feelings. Besides, the intervention helps an individual identify personal goals and values, thus a source of motivation to realize the desired quality of mental life. Implementation Plan of Mental Health Interventions Mental illness and homelessness problem has become universal problem with severe impacts reported in the developed countries. Recent health statistics show that developed countries like the USA record an upward trajectory of mental health cases and homeless Following these rapidly growing cases of mental disorders, an inclusive implementation plan of the various mental health interventions will be integral in promoting mental health awareness in society. As a result, the implementation plan to be adopted will bring together different stakeholders from the health department, the housing sector, the public and private sector, learning institutions, and community members. First, the study will use a community-based mental health implementation plan involving social workers and targeting the local community members to create mental awareness. Although this plan aimed at creating mental health awareness in society, it encouraged community members to undergo frequent mental health checkups. At the same time, implementing a community-based program will help identify and rehabilitate severely affected mental disorder

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10 patients. The patients would then be subjected to positive thoughts and experiences in an effort to improve their judgment, conception, and feelings, thus improving their mental health. On the same note, a community-based interactive implementation process that helps shelter people experiencing homelessness provides social support and reduces negative thoughts among homeless people, contributing to quality mental health. The implementation plan will also target workplaces that attract stress, anxiety, and sometimes depression among employees due to excessive workload, struggles, and workplace discrimination on a gender basis. By becoming supportive and establishing counseling departments at the workplace, staff members get to interact with professional psychologists who guide them on emotional, thoughts and feelings management mechanisms, thus promoting good mental health. In addition, the implementation plan of the mental health intervention will also seek to reach students in different learning institutions in America. Most students suffer from various forms of mental-related disorders such as anxiety, post-traumatic stress, and depression emanating from the pressure to pass the examination and the hardship undergone as students causing suicidal thoughts. A well-executed plan targeting restructuring behavioral changes among learners will be vital in shaping positive thoughts and improving students’ interpersonal skills to solve basic life problems. For instance, therapeutic services such as counseling of learners will provide students with knowledge on how to control distressful thoughts in life, improving mental health quality. Several cognitive changing theories supported the implementation of the plans above. For instance, a social cognitive theory focusing on the social learning and conceptualization processes helped cement the above interventions. According to the social cognitive theory

11 assumption, individuals express behavioral change by acquiring a new behavior in the immediate environment. Besides, the theory also insinuates that rewarding behaviors are more easily imitated than punishable ones that attract less association. Application of a similar analogy among mental disorder patients was vital in creating positive thoughts and reducing depression, thus improving the quality of mental health. Behavioral learning theory was another important source of theoretical knowledge on understanding individualistic behaviors and actions. The theory insinuated that human behaviors are acquired through conditioned association with forces in the immediate surroundings (Mcleod, 2023). An observable response is automatically generated depending on the nature of forces around mentally ill patients. Moreover, the implementation plan was also in line with the cognitive theory that sort to improve the internal mental growth processes by training learners. A good training program on learners’ perceptions, judgmental approaches, and issues improves cognitive structure growth (Feder, 2022). Unlike behavioral theory, where learners’ thoughts change by observing what happens in the environment, cognitive theory encourages learners to develop unique and good mental thoughts. Ethical considerations when implementing mental health interventions The successful implementation of mental health intervention plans must conform to the ethical requirements protecting the rights and well-being of mental health patients. Besides, good ethics enhances professionalism and promotes a healthy patient-to-nurse relationship. Some ethical practices to be adhered to while implementing mental health interventions include confidentiality and privacy. Since mental health is sensitive to personal information, health

12 professionals like psychologists, doctors, and counselors will be responsible for keeping safe information about the patients as stipulated within the law on sensitive and personal information. Similarly, implementing any mental health intervention will only be performed after obtaining informed consent from the patients. The affected patients will be briefed first about the nature of the intervention, its purpose with regard to improving the quality of mental health, the benefits and risks, and alternative options. The intervention will then be initiated after the patient makes an autonomous decision and okays it. At the same time, ethics on competence and professionalism was a critical pillar that guided the implementation of the various mental and homelessness interventions. All health professionals implementing mental health interventions must demonstrate a great understanding, knowledge, skills, and experience in handling mental-related disorders. Also, the health providers were only allowed to act within professional framework and guidelines, including becoming conversant with the latest trends in the mental health sector. The more health professionals become knowledgeable of the latest trends, the better they position themselves to develop effective evidence-based mental health intervention programs, thus improving the quality of mental health among patients with different cognitive disorders. Ethical matters on non-discrimination and cultural sensitivity will also be prioritized during the implementation of mental health interventions. Health professionals will be expected to treat all mental health patients equally without discrimination based on race, ethnicity, gender, sexual orientation, religion, or socioeconomic status (Kung & Johansson, 2022). Health providers will also be sensitive to cultural diversity among mental health patients and adopt interventions that align with individual patients’ way of life, enhancing the high acceptance rate of mental health interventions.

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13 Boundaries and dual relationship ethics will be key in establishing a professional association between health professionals and patients. By understanding the limits of engagement, health professionals will be able to avoid unhealthy relationships with patients that could compromise therapeutic mental health interventions. In other words, the boundary and dual relationship ethic enhanced professionalism by creating a healthy environment for successfully implementing mental health interventions. Moreover, the interventions will be implemented per the ethics on the duty to protect life. Primarily, all the interventions will protect people with mental health disorders from causing harm to themselves or people around them. For this reason, health professionals will be allowed to act beyond their limits but within the mental health guidance and the law when a patient happens to be at risk of harming themselves or others. The bleach might include data privacy and confidentiality breaches but only in exceptional cases. Therefore, all the interventions to be implemented in this project will be in line with the necessary ethical considerations. Resources Required Several resources are essential in the implementation of mental health intervention. For instance, labor is a critical element that facilitates the performance of various mental health interventions. Labor can be in the form of trained mental health professionals such as psychologists, nurses, psychiatrists, counselors, therapists, and social workers who work around the corner to promote a healthy mental life among patients. Besides, the services these professionals provide, such as therapy and counseling, help people with mental complications conceive positive thoughts, feelings, and behaviors, which are vital in improving the quality of mental health among patients.

14 On the same note, the availability of infrastructural resources will also be crucial during the implementation exercise. Under this, facilities like clinics, hospitals, mental health center nursing homes, counseling centers, and community-based rehabilitation centers will provide venues to safely and professionally execute the interventions (Mental Health America, 2023). Having such facilities also instills confidence among mentally ill patients to seek medical help on cognitive-related challenges In addition, training and capacity-building resources targeting improving skills and knowledge among mental health professionals are crucial to developing efficient interventions. Trained mental health professionals on recent mechanisms to handle dynamic mental disorders have the capacity and ability to research evidence-based cognitive interventions that suit different groups of patients (Mental Health America, 2023). As a result, this promotes equality and fairness in the implementation process. As if this is not enough, medication and treatment resources such as pharmaceutical supplies, diagnostic tools, and checkup devices will form an integral part of the resources required to implement mental health intervention. Supposedly, the checkup result reveals a severe mental disorder; a medication intervention would be recommended. Follow-up on the patient was also made using technology-enabled devices to monitor the patient’s response to the medical interventions. Moreover, some of the interventions on mental health will require awareness creation among mental patients. The sensitization and education activities require a lot of financial resources to reach out to a larger target group of patients suffering from different mental disorders. Besides, financial resource aids evidence-based research activities seeking to find the most appropriate mental health intervention.

15 Leadership theory to help guide implementation and sustain it The research will adopt the use of two leadership theories in implementing various mental health interventions. The theories include the transformational leadership theory and participative leadership theory. In the first case, James MacGregor Burns pioneered the transformational leadership theory, which focuses on a leader-follower relationship in building particular values and behaviors. According to this model, leaders have a huge role in influencing good thoughts, morals, and behaviors among their followers (Xu, 2017). The theory reveals that leaders with great vision and aspirations to succeed influences their followers positively and change their opinions toward success. Besides, the transformational leadership theory will be crucial in motivation and stimulation of personal desires among people with mental health disorders to think positively, thus leading a life free of stress, anxiety, or depression hence promoting mental health wellness. Secondly, the study will also use the ideas in the participative leadership theory to aid in implementing mental health interventions. The main idea in the participative leadership theory revolves around democracy and consideration of other people's opinions (Xu, 2017). A participative leadership theory works by valuing contrary opinions from colleges and staff. As a result, this makes the staff feel respected and valued, especially when key deliberations have to be made. Similarly, this theory will be important when implementing mental health interventions as it will first seek to understand patients' opinions on the matter before any plan is actualized. Doing so will enhance ethical adherence when dealing with mentally ill patients and help tailor an intervention that best meets a patient's needs. Change theory that will facilitate the implementation

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16 The study will use Lewin’s change theory to facilitate the implementation of the mental health intervention. The theory is subdivided into three stages: unfreezing, changing, and refreezing. Each stage will play an essential part in implementing the mental health intervention. A critical component of Lewin’s change theory insinuates that individuals accede to different forces pulling in different directions, thus contributing to a delicate balance in life. In other words, Lewin’s change model links human life to a system that faces constant obstacles, thus needing to remain updated on the most effective problem-solving techniques. Besides, the subdivision of this theory’s parts not only helps understands it but gives a pictorial mimicry of how a positive change would facilitate the implementation of mental health interventions. Under the unfreezing stage, Lewin’s theory of change focuses on creating the need for mental health awareness by embracing changes toward promoting healthy mental life (Simple Nursing, 2023). Also, the theory encourages mental health professionals to become innovative and develop new ideas to help transform the existing norms and beliefs on mental disorders among patients. The stage also prepares patients to let go of outdated beliefs and behaviors that comprise mental health and embrace new ones that promote brain wellness. On the same note, the changing section of the Lewin’s change theory tests mental health professionals’ abilities to implement suggested cognitive interventions. At this point, mental health professionals will be required to have gained relevant and latest skills and knowledge on evidence-based mental interventions that improve the quality of mental health among patients. Finally, the refreezing part of Lewin’s change theory will seek to implement the identified mental health intervention. For mental health professionals, this could take the form of undertaking internship programs aimed at encouraging the practical application of the newly acquired mental health intervention, hence aiding in implementing all the suggested mental

17 health interventions in the hospitals, at the workplace, within learning centers, and community- based nursing centers. Evaluation Procedures Evaluation of mental health intervention plays an important role in the final legislation of acceptable mental health standards. Besides, a good evaluation method reveals the successes and the challenges facing various interventions, thus making it possible to adjust accordingly. For this reason, the study will adopt an elaborate evaluation procedure touching on mental health interventions. The first step in the evaluation procedure will entail the determination of study objectives. By clearly defining the objectives of the study, it will become easy to evaluate an alignment of objectives and the interventions implemented. Matching study objectives and intervention goals will enhance understanding of intervention goals. The second evaluation procedure will involve establishing an appropriate study design that defines interventions to implement, participants, and required resources. This procedure could also involve pre-test and post-tests of the targeted population to determine the influence of particular interventions. In addition, the evaluation exercise will take keen note of the measurements recorded such as clinical assessments outcomes, psychometric instruments readings, data responses in the questionnaires and results from qualitative and quantitative studies. Moreover, the evaluation exercise will also encompass data collection using surveys, interviews, observation and focus group methods. Intervention data gathered using different methods will promote the reliability and validity of data on mental health interventions. At the same time, the evaluation procedure will establish whether ethical considerations were followed

18 during the implementation of the mental health interventions. Issuance of informed consent and data confidentiality principles are some of the signs of ethical compliance. The evaluation procedure will also encompass the identification of data analysis methods used, including determining differences among treatment and control groups. Checking on fidelity adherence also forms a critical part of the evaluation exercise that seeks to capture the changes made to the interventions during the implementation exercise. Furthermore, the evaluation procedure will also aim to establish long-term follow-up to assess and sustain the success of an intervention over time. Alternative processes plan for Sustainability Sustainable and alternative plans are important in the promotion of long-term mental health wellness in society. The process includes implementing holistic and preventive care services to eliminate cognitive stressors. For instance, encouraging a healthy lifestyle free from stressful choices will enhance long-term mental wellness. Besides, preventive services aiming at the early identification and mitigation of mental disorders also promote long-term mental wellness. At the same time, nature-based therapies stand a chance to reduce mental disorders on a long-term basis significantly. Other than taking the usual therapeutic services, a shift to nature walks could provide an alternative plan that enables individuals to let go of stressful thoughts, opinions, and feelings. As a result, this would provide a long-lasting intervention as it is easy to implement and cost-free. Similarly, encouraging mindfulness and meditation practices among people with mental health disorders cultivates a long-lasting culture of self-awareness and control. The more patients take control of their interpersonal life, the better they advance in managing mental health-related

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19 challenges. Besides, mindfulness and meditation activities are daily programs that can be performed continuously for a long time, ensuring mental health sustainability. In addition, mental health policy legislation and advocacies towards cognitive wellness also ensure that mental health remains a priority in society. By creating an enabling environment through friendly legislation, insurance companies will be encouraged to cover many mental health-related illnesses. As a result, this will promote quick access to mental health treatment upon risk occurrence. Moreover, alternative interventions and plans will improve mental health care outcomes by providing reliable therapeutic alternatives that do not require guidance from professional psychiatrists. Using natural therapies such as nature walks and meditation programs will help create good habits toward mental wellness (Bohlmeijer & Westerhof, 2021). Furthermore, policy and advocacy legislation will also improve mental health outcomes by increasing mental health awareness and accessibility of cognitive treatment in the event that insured risk occurs. Conclusion According to recent statistics on mental health, the mental disorder and homeless challenge has continued to increase. Unlike in the past, when mental disorders were associated with the elderly population, a rise in the mental stressors in modern society, such as stress, anxiety, and depression, has become major causes of mental disorders among youthful and aging populations. As a result, this precipitated the development of evidence-based mental intervention programs to reduce cases of mental disorder patients. Some of the interventions used include interpersonal psychotherapy, cognitive behavior therapy, behavioral family therapy, and acceptance and commitment therapy. At the same time, the study adopted alternative interventions and plans such as nature walks, mindfulness, and meditation, as well as mental

20 health policy legislation targeting to improve accessibility to quality mental health services among all mental health patients.

21 References Aubry, T., Bloch, G., Brcic, V., Saad, A., Magwood, O., Abdalla, T., ... & Pottie, K. (2020). Effectiveness of permanent supportive housing and income assistance interventions for homeless individuals in high-income countries: a systematic review. The Lancet Public Health , 5 (6), e342-e360. Bai, Z., Luo, S., Zhang, L., Wu, S., & Chi, I. (2020). Acceptance and commitment therapy (ACT) to reduce depression: A systematic review and meta-analysis. Journal of affective disorders , 260 , 728-737. Bohlmeijer, E., & Westerhof, G. (2021). The model for sustainable mental health: future directions for integrating positive psychology into mental health care. Frontiers in psychology , 12 , 747999. Collins, S. E., Duncan, M. H., Saxon, A. J., Taylor, E. M., Mayberry, N., Merrill, J. O., ... & Ries, R. K. (2021). Combining behavioral harm-reduction treatment and extended-release naltrexone for people experiencing homelessness and alcohol use disorder in the USA: a randomized clinical trial. The Lancet Psychiatry , 8 (4), 287-300. Duke, A., & Searby, A. (2019). Mental ill health in homeless women: a review. Issues in mental health nursing , 40 (7), 605-612. Feder, M. (2022). What is cognitive learning theory? https://www.phoenix.edu/blog/what-is- cognitive-learning-theory.html Kakhramonovich, T. P. (2022). Epidemiology of Pysichiatric Disorders. Texas Journal of Medical Science , 12 , 102-105. Kung, W. W., & Johansson, S. (2022). Ethical mental health practice in diverse cultures and races. Journal of Ethnic & Cultural Diversity in Social Work , 31 (3-5), 248-262.

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22 Mcleod, S. (2023). Behaviorist approach to psychology: Definition, history, concepts and impact. https://www.simplypsychology.org/behaviorism.html#:~:text=Behaviorism%2C%20also %20known%20as%20behavioral%20learning%20theory%2C%20is,are%20learned %20through%20conditioned%20interaction%20with%20the%20environment. Mental Health America (2023). Prevention and early intervention in mental health. https://www.mhanational.org/issues/prevention-and-early-intervention-mental- health#:~:text=This%20includes%20access%20to%20resources%20like%20adequate %20housing%2C,like%20school%20based%20supports%20and%20mental%20health %20treatment . National Alliance on Mental Illness (2020). Mental health by the numbers. https://nami.org/mhstats Peterson, T. (2019). Mental illness and homelessness. https://www.healthyplace.com/other- info/mental-illness-overview/mental-illness-and-homelessness#:~:text=Homelessness %20can%20contribute%20to%20mental%20illness%20because%20of,on%20the %20streets%2C%20as%20can%20other%20mental%20illnesses . Shinn, M., & Cohen, R. (2019). Homelessness prevention: A review of the literature. Center for Evidence-Based Solutions to Homelessness. http://www. evidenceonhomelessness. com/wp . Simple Nursing (2023).What is change theory. https://simplenursing.com/change-theory/ U.S. Department of Veterans Affairs (2022). Evidence-Based therapy. https://www.mentalhealth.va.gov/get-help/treatment/ebt.asp Walker, J. N., Vanderhoef, D., Adams, S. M., & Fleisch, S. B. (2022). The impact of an educational intervention on nursing staff attitudes toward patients experiencing

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23 homelessness and mental illness. Journal of the American Psychiatric Nurses Association , 28 (6), 474-479. Xu, J. H. (2017). Leadership theory in clinical practice. Chinese Nursing Research , 4 (4), 155- 157.

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