Invisible Disability: How Brain Trauma Intersects with Homelessness, Mental Health, and Recidivism

(Image: An unhoused man sits on the sidewalk with a cardboard sign next to him that says "Seeking Human Kindness" as another person walks by.) March is Brain Injury Awareness Month. Brain injury, or traumatic brain injury (TBI) can be an invisible disability that has a far-reaching impact on individuals, and their ability to live independent and fulfilling lives. In addition to the loss of cognitive function, challenges with emotional regulation, physical mobility, and a host of other physiological changes, people with TBI often also face social barriers including mental health and housing challenges. Further, rates of TBI are high among incarcerated persons and correlate with higher rates of recidivism. Because TBI is not a visible disability, the actions, language, and capacities of individuals with TBI can be mistaken for a behavioral or attitudinal issue, lack of cooperation, or lack of intelligence. They may inadvertently wind up in conflict, confusion, and find it harder to maintain employment, housing, manage finances, and activities of daily living. Last year, we published an article describing the basics of brain injury to increase awareness. This year, we will address some of the lesser-known challenges that often accompany brain injury, including mental health, homelessness, and incarceration.  

Mental Health and Brain Injury

 Susan Brown, MA, LPC, CBIS (Certified Brain Injury Specialist) is a Mental Health Counselor with the Brain Injury Association of Colorado (BIAC). Susan explained that in the mental health field, it can be very challenging for people with TBI  to receive mental health support. Often, when counselors are approached by someone with a diagnosed brain injury, they may feel unprepared to provide adequate support and instead refer the individual to physical or occupational therapists. This means their mental health issues go unaddressed. This is especially concerning since brain injury can lead to anxiety, depression, PTSD, anger, and further personality changes. Also, people with undiagnosed brain injuries often get misdiagnosed with other mental health illnesses such as schizophrenia or bipolar disorder when, in fact, they are experiencing symptoms of a brain injury. Many mental health professionals are not trained to recognize the difference. For this reason, BIAC offers clinical therapy services with trained mental health professionals who specialize in brain injury, such as Susan. They provide services to both those who are living with brain injury as well as their family members and caregivers. BIAC is also actively working to educate mental health organizations about the importance of accurately identifying and providing treatment for people with brain injuries, and staffing counselors who are trained in brain injury mental health treatment. 

Loss of Home 

 The topic of unhoused people is often a controversial one. Many people who have never experienced being unhoused feel challenged to understand how individuals end up living on the streets. Many assume it’s drug use, laziness, or other factors that point to the poor character of the people living in that situation. However, some remarkable statistics around brain injury shed light on the difficulties unhoused people face. According to a study published in the Archives of Physical Medical and Rehabilitation, approximately 80% of the unhoused population studied has a traumatic brain injury. And of those people, 49% said their brain injury happened before the age of 18. This staggering statistic shows how deeply intersecting the issues of brain injury and being unhoused are, and how we can change our perspectives to hold unhoused people in a more compassionate light.According to the U.S. Department of Housing and Urban Development, in 2024 Colorado had a population of close to 18,000 people who were unhoused, a 30% increase from the prior year. BIAC has been at the forefront of recognizing the intersection of brain injury and being unhoused. From this recognition, they partnered with Brothers Redevelopment, Inc. to create Valor on the Fax, which is a 72-unit apartment community exclusively for persons who are unhoused, and who also have a brain injury or related disability. Valor On The Fax is permanent supportive housing (PSH) which allows residents to stay as long as needed. It was designed using Trauma-Informed Design. Susan Brown explained, “Oftentimes people who have been unhoused, when they come off the street, don't actually want to be contained indoors in a unit. They will prefer to sleep in a courtyard of the building, to be outside but still within the structure of the building itself. They then can go into their units when they feel ready.”For many unhoused people with brain injuries, this is due to the trauma they have experienced and the need to feel safe. The Trauma-Informed Design that was used for Valor on the Fax focuses on designing spaces that promote healing, safety, and well-being, especially for individuals who have experienced trauma. Trauma-informed design is guided by five key principles that create spaces promoting healing, safety, and well-being:  Safety and Security - to ensure environments feel physically and emotionally secure, incorporating clear sightlines, controlled access, and calming layouts. For example, in Valor on the Fax they designed the hallways so there were no blind corners, and all stairwells are open instead of being enclosed. This way residents have a clear view throughout the building.  Choice and Control - to empower individuals by offering flexible spaces, adjustable lighting, and private areas, helping to restore autonomy. The open courtyard Susan spoke about is one example of this. Comfort and Sensory Regulation - to focus on reducing stress through natural light, soft textures, and sound-dampening materials.  Connection and Community - to foster social engagement with shared spaces that encourage positive interactions while maintaining personal boundaries.  Empowerment and Inclusion- to integrate diverse needs by ensuring accessibility, cultural representation, and spaces that honor individual experiences. Valor on the Fax has become an example to communities throughout the country on ways to address the intersection between brain injury and being unhoused. Currently, the entire complex is full, as is the waitlist of people who are interested in living there. This illustrates the need for services and resources such as Valor on the Fax. Many organizations are using Valor on the Fax as a roadmap to design their own programs that support unhoused individuals with brain injury.  

The Justice System and Brain Injury

 In the U.S., brain injuries are alarmingly common among people who are incarcerated, with studies showing that up to 87% of inmates have experienced some form of TBI. This issue is especially prevalent among women, who tend to have higher rates of brain injuries than men in prison, often as a result of domestic violence. In Colorado, the situation is equally concerning. In some local jails, up to 96% of individuals have a history of TBI, with an average rate of 54%. This connection between brain injury and recidivism is significant. BIAC reports a 50% higher prevalence rate of recidivism in Colorado for people with brain injury. People with untreated brain injuries often struggle with communication, impulse control, and decision-making, which can make it harder to break the cycle of recidivism. With such high rates of brain injury in Colorado’s criminal justice system, it’s clear that better screening, early intervention, and specialized care are needed to help reduce recidivism and improve the lives of people with TBI.MINDSOURCE, part of the Colorado Department of Human Services, is another organization addressing these issues. MINDSOURCE is dedicated to raising awareness about brain injuries and ensuring that people with TBI get the help they need. One of their key programs is the Achieving Healing through Education, Accountability, and Determination (A.H.E.A.D.) program. This program is designed for justice-involved individuals who have been screened for TBI, and provides them with education about brain injury, the effects on behavior, and ways to manage both the injury and behavior. Participants learn about cognitive challenges such as memory issues, impulse control, and emotional regulation. The program offers a structured curriculum that helps individuals understand how their brain injury impacts their daily functioning, and provides strategies to cope with these challenges, ultimately supporting them in making better decisions and improving their behavior.MINDSOURCE also offers the Online Brain Injury Screening and Support System (OBISSS) to help individuals identify potential past brain injuries and offer personalized strategies to manage symptoms. This screening system is available to Colorado residents for free here. Together, BIAC and MINDSOURCE have developed programs to train correctional facility staff to identify signs of brain injury in incarcerated individuals. The two organizations also work together to advocate for policy changes that better support people with brain injury in the criminal justice system, in an effort to illuminate and address the functional and behavioral needs of people with TBI. They have also been instrumental in developing screening tools that help identify individuals with TBI early on, so they can receive the right resources and interventions at the right time. In addition, BIAC developed a community reentry program for people who have been incarcerated and who have brain injuries.These programs are making a notable difference, improving the quality of life for individuals with brain injuries and helping to break the cycle of incarceration. By providing education, resources, and support, BIAC and MINDSOURCE are working to create a more equitable and effective approach to addressing TBI in the criminal justice system. 

Educating Allies

 We asked Susan Brown where she sees the largest social gaps in understanding and supporting people with brain injury. “The internal experience of change is very very real for people with brain injury,” she explained. “You can't see it externally, because it’s an invisible disability, but it's very impactful on a person's life. Treating people with kindness, compassion, and respect and believing their experience is really the key to honoring people for who they are. So many of my clients feel not only traumatized by the experience of brain injury but also by people in the medical profession and other systems. I often have to coach people on how to ask for accommodations for their needs at work, with family members, and with society in general. They fear discrimination and feel misunderstood.”By understanding that brain injury not only affects individuals but also has far-reaching implications on larger social issues such as homelessness, mental health, and justice reform, we can begin to address the root causes of these problems. Brain injury often exacerbates vulnerabilities, making it more difficult for individuals to navigate systems that are already difficult to access or understand. Recognizing the connection between brain injury and being unhoused, incarceration, and recidivism, we should work to implement more systems, services, and solutions that are compassionate, informed, and supportive. This means developing policies and programs that not only address the immediate needs of individuals, but also provide long-term support for rehabilitation, mental health care, and reintegration into society. By building these systems of care with an emphasis on equity and inclusion, we can empower individuals to rebuild their lives and contribute to society, ultimately reducing the cycle of poverty, incarceration, and being unhoused. Creating a society that understands and accommodates people with TBI contributes to environments where all individuals have the opportunity to thrive and live independent and fulfilling lives.