substance abuse
Integrative Services Help Homeless Drug Abusers in Recovery
Alcohol and drug abuse and addiction are common among those with mental illness, and contribute a variety of issues including, recurrent crises, chaotic lifestyles, and antisocial behavior. This can and often does result in chronic or long term homelessness (Meisler et al 1997). The current and prevailing mental health and substance abuse systems provide services to people with co- occurring substance abuse and mental disorders during periods of crisis, but have not shown effective long term outcomes. This suggests that other approaches may be promising to integrate the mental health and substance abuse aspects into one, long term treatment option that is inclusive of case management, group and individual counseling, mutual self-help, assertive outreach, and social control (Meisler et al 1997). Results of studies that have been done on this integrative, inclusive approach have only recently surfaced, and blatantly show the inadequacies of the current systems. One consequence of these inadequacies is chronic incarceration. Many of these individuals have no other resources for acquiring care and housing in jail facilities (Meisler et al 1997).
Studies have shown that persons with co-occurring mental health and substance use disorders have higher recovery and abstinence rates when treatment is inclusive, and basic needs are met, such as
housing and food, than those persons who are only provided certain services, but not integrative care like housing services.
One study done by the state of Delaware in 1992 used 114 study subjects who were persons with “serious mental disorders (67 dually diagnosed) who were homeless or about to be released without a residence to return to. The sample was forty-seven percent Caucasian, forty- seven percent African American, and six percent Hispanic. Fifty percent were male. The mean age was 39 years (range from 19 – 61). All had one of the following psychiatric disorders: schizophrenia, schizoaffective disorder, bipolar affective disorder, major depression, recurrent, paranoid personality disorder, or borderline personality disorder. Sixty-seven (59%) met DSM-III-R criteria for lifetime diagnoses of psychoactive substance abuse or dependence (none of whom were abstinent at baseline)” (Meisler et al 1997).
The experimental intervention was a program named “Connections”. In this study, participants were given comprehensive care for their substance and psychiatric problems, and were also connected with case workers, and support groups, and also provided basic necessities, such as food and shelter.
“The program is self- contained, incorporating core psychiatric, supportive, and rehabilitating services within the team, which serves as a fixed point of responsibility, accountable for client’s psychiatric and social welfare” (Meisler et al 1997).
“the intervention’s treatment team includes a half- time psychiatrist, an M.S.W. team leader, two registered nurses, and seven masters and bachelors level staff, representing social work, substance abuse counseling, and vocational rehabilitation disciplines” (Meisler et al 1997).
The specific services include: administering medications and close monitoring; facilitating getting basic needs such as housing, healthcare, and entitlements; support for regular life stresses and problems; teaching and reinforcing life skills; changing pathological dependency relationships; and developing supportive networks of people, such as friends and family. These are all essential for reducing the stressors that might otherwise overwhelm these people (Meisler et al 1997).
This case study was retrospective and based on the client records from all who received services during a four year period. The clients were assessed at baseline, which was within forty-five days of admission into the program, and then at “one year intervals after entry” (Meisler et al 1997). The information obtained included demographic information, changes in employment, arrests, a chronology of life events, such as detox admissions, psychiatric admissions, and changes in living arrangements, substance use and medical history, psychiatric history, mental status examination, and DSM-III-R diagnosis.
The results of this study suggest that this kind of comprehensive program and treatment increases the rates of recovery.
“The sixty- seven dually diagnosed participants at baseline were reevaluated using the Case Managers Rating Scale in 1992, during the fourth year of the program” (Meisler et al 1997).
The severity of substance abuse for these sixty- seven people with dual diagnosis dropped and remained at low levels after the intervention. Twenty- four percent remained completely abstinent from substances, seventeen percent were at a mild rate of substance use, twenty- eight percent were at
moderate levels of substance use, and thirty- one percent were at severe levels of substance abuse” (Meisler et al 1997).
As far as employment goes, “forty- three percent of the total 114 participants attained competitive employment at the time of measurement” (Meisler et al 1997).
It was also acquired by twenty- eight of the sixty- seven dually diagnosed participants, and by twenty- one of the forty- seven non- dually diagnosed participant (Meisler et al 1997).
The group that was dually diagnosed at the time of entry who attained complete abstinence at the follow- up had a sixty- nine percent employment rate. Those who were mildly abusive with substances had a thirty- six percent rate of employment at the time of follow- up, and those with a moderate level of substance abuse had a thirty- two percent level of employment at the time of follow- up. Those people who were at severe levels of substance abuse at the time of follow- up had a thirty- three percent employment rate (Meisler et al 1997).
“There was no significant relationship between work and severity of substance abuse. There was also no significant relationship between work status and length of time in service” (Meisler et al 1997).
Regarding hospital admissions and service utilization, “the mean number of psychiatric hospitalizations were .3 with 75% having had no psychiatric hospitalizations in 1992” (Meisler et al 1997). Five percent of these had no hospitalizations for psychiatric issues twelve month before their enrollment.
“There was no significant difference in the mean number of psychiatric hospitalizations experienced by those diagnosed with and without co- occurring substance use disorders” (Meisler et al 1997).
The amount of arrests for the group of 114 participants was relatively low as well. The means number of arrests was .35. This had a low correlation to length of service, so it was not significant (Meisler et al 1997).
The data from this study suggests that there are possible benefits from the comprehensive, inclusive approach “for a homeless, largely minority, urban population of seriously mentally ill clients with a high lifetime prevalence of substance use disorders. Although only 24 percent of dually diagnosed clients had been abstinent for a year or longer at follow- up, the reduction of homelessness and psychiatric hospital use, compared to their status prior to entry was dramatic. Those who were able to cease or control their substance use had favorable outcomes in regard to criminal justice involvement, hospital use, residential stability and employment” (Meisler et al 1997). This data also suggests strongly that the level of severity of the substance abuse is a very strong predictor of positive or negative outcomes than the length of service (Meisler et al 1997). This means that a comprehensive program is needed to help reduce the stresses of life in order for these individuals to cease or reduce their substance use, and all these aspects need addressed in order for there to be success.
“The results of this study provide hope and encouragement that a significant number of homeless people with substance abuse and mental illness can achieve sobriety, and even without sobriety can achieve marked improvement in their ability to maintain themselves in the community” (Meisler et al 1997).
We must advocate continuously to develop and maintain integrated, comprehensive treatment to ensure outcomes will be favorable for these people who are dually diagnosed and homeless. Also, an evolution must continue as we learn more about these disorders, and the best ways to treat them for successful outcomes. There may or may not be new, and more effective models for treatments, but effort must be spent on eliciting the most favorable outcomes. As the data suggests from this research study, there are vast benefits from using these comprehensive models. Homelessness can be greatly reduced, possibly even eliminated altogether by the use of program models such as this one.
Works Cited
Bassuk, E. L., Buckner, J. C., Perloff, J. N., & Bassuk, S. S. (1998). Prevalence of mental health and substance use disorders among homeless and low-income housed mothers. American Journal of Psychiatry, 155(11), 1561-1564.
Drake, R. E., McHugo, G. J., Clark, R. E., Teague, G. B., Xie, H., Miles, K., & Ackerson, T. H. (1998). Assertive community treatment for patients with co-occurring severe mental illness and substance use disorder: a clinical trial. American journal of orthopsychiatry, 68(2), 201.
McNiel, D. E., Binder, R. L., & Robinson, J. C. (2014). Incarceration associated with homelessness, mental disorder, and co-occurring substance abuse. Psychiatric Services.
Meisler, N., Blankertz, L., Santos, A. B., & McKay, C. (1997). Impact of assertive community treatment on homeless persons with co-occurring severe psychiatric and substance use disorders. Community mental health journal, 33(2), 113-122.
Tsemberis, S., Gulcur, L., & Nakae, M. (2004). Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health, 94(4), 651-656.
Tsemberis, S., Kent, D., & Respress, C. (2012). Housing stability and recovery among chronically homeless persons with co-occuring disorders in Washington, DC. American Journal of Public Health, 102(1), 13-16.