research

Helping Homeless Individuals with Co-occurring Disorders: The Four Components

An-Pyng Sun

Homeless individuals with co-occurring disorden (CODs) of severe mental illness and sub- stance use disorder are one of the most vulnerable populations. This article provides practi- tionen with a framework and strategies for helping this client population. Four components emerged from a literature review: (1) ensuring an effective transition for individuals with CODs from an institution (such as a hospital, foster care, prison, or residential program) into the community, a particularly important component for clients who were previously home- less, impoverished, or at risk of homelessness; (2) increasing the resources of homeless indi- viduals with CODs by helping them apply for govemment entitlements or supported employment (3) linking homeless individuals to supportive housing, including housing fint options as opposed to only treatment first options, and being flexible in meeting their housing needs; and (4) engaging homeless individuals in COD treatment, incorporating modified assertive community treatment, motivational interviewing, cognitive-behavioral therapy, contingency management, and COD specialized self-help groups.

KEY WORDS; co-occurring disorder; homelessness; mental disorder; substance use disorder; treatment

H elping vulnerable cUent populations has long been a major mission of the social work profession (National Association

of Social Workers, 2008). Homeless individuals with co-occurring disorders (CODs) of severe mental illness (SMI) and substance use disorder (SUD) are one of the most vulnerable cHent pop- ulations. Compared with homeless individuals without CODs, SMI, or SUD, who often are just transitionally homeless, individuals with CODs are more likely to experience chronic homeless- ness (Caton, Wilkins & Anderson, 2007; Kuhn & Culhane, 1998). Compared with individuals with CODs, SMI, or SUD who are not homeless. Homeless individuals with CODs, SMI, or SUD are less likely to engage in treatment and to recover from their diseases. Social workers may come across chronically homeless clients in various practice fields. During 2008, among the 642,000 positions held by social workers, 46 percent were in family, school, and chud social work; 22 percent were in pubhc health and medical social work; 21 percent were in substance abuse and mental health social work; and 11 percent were in other types of social work (Bureau of Labor Statistics, n.d.). Practitioners in all four fields, though particularly the pubhc health and medical field and the mental health

and substance abuse field, are hkely to encounter, directly or indirectly, homeless clients with CODs and related challenges. It is critical that both social work students and practitioners be equipped with knowledge and skills to help this client population.

This article discusses strategies for helping homeless individuals with CODs on the basis of a hterature review. Relevant articles were located via database searches of PubMed, PsycINFO, and Social Work Abstracts^ using the key words "home- less individuals," "homelessness," "housing," "co-occurring disorders," "dual diagnosis," "mental disorders," "schizophrenia," "bipolar," "substance abuse," "substance dependence," "sub- stance use disorders," and "treatment," plus the reference hsts of located articles. Because research on the homeless population with CODs and SMI using randomized controlled trials (RCTs) is stül very limited (Caton et al., 2007), all relevant located studies on the homeless population with CODs that used various levels of designs— for example, RCTs; meta-analyses; quasi-experimen- tal designs; observational studies; quahtative studies; the 'consensus of expert clinicians,' in a few sources in which research evidence was com- bined with consistent expert opinion (Burt et al., 2004; Caton et al., 2007; Center for Substance

doi: 10.1093/sw/swr008 O 2012 National Association of Social Workers 23

Abuse Treatment [CSAT], 2005; Ziedanis et al., 2005)—were adopted. Rog (cited in Catón et al., 2007, p. 4-12) stated that although studies may fall short of the most rigorous standard, "when [they] produce a consistent pattern of findings, may also be considered as additional evidence to determine whether an intervention is considered evidence based." Four components emerged from the review of the study fmdings: (1) ensuring ef- fective transition, (2) increasing resources via gov- ernment entitlements and supported employment (SE), (3) providing linkages to housing, and (4) offering COD treatment.

COMPONENT 1: ENSURING EFFECTIVE TRANSITION FROM INSTITUTION TO COMMUNITY Reducing the flow of at-risk individuals being re- leased from institutions (for example, psychiatric hospitals, substance abuse treatment programs, correctional facilities, foster care) into the com- munity without receiving proper transitional ser- vices is critical to reducing homelessness among individuals with CODs (Burt et al., 2004). The literature contains six strategies for niore effective transitions, with the enhancement of continuity of care being common feature (Compton et al., 2003).

Establishing Rules Regarding Discharge Planning State and local agencies should establish rules to ensure a well-executed discharge plan that links an institution that discharges an individual with the community that takes in the individual (Burt et al., 2004). Some states have required discharge planning as a formal responsibüity of the institu- tion releasing a person, whereas other states treat it only as an informal responsibility. The lack of policies about discharge may contribute to the deemphasis on discharge planning, precipitating discontinuity of care (Burt et al., 2004).

Developing a Thorough Discharge Plan Lauber, Lay, & Rössler (2006) suggested that insti- tutions develop a discharge plan for a homeless client with CODs immediately after his or her ad- mission to an inpatient setting. A thorough dis- charge plan provides a projected discharge date, gathers medical records, arranges postrelease housing, coordinates medical and mental health

care, and brings together other community servic- es (Caton et al., 2007; Community Shelter Board, cited in Burt et al., 2004).

Offering Critical Time Intervention The institutions that release individuals into the community can offer critical time intervention (CTI) (Susser et al., 1997), an evidence-based treatment that goes one step beyond a discharge plan. During the fint months after discharge, when a client's relationship with people in the community may be frague, CTI strengthens the client's adjustment to the community by pairing the client with a social worker who visits the client's community residence, accompanies the client to appointments, and helps the client develop relationships with people at the appoint- ments and provides advice in periods of crisis (Susser et al., 1997). Susser et al.'s RCT study (N = 96) found that during the 1.5-year follow-up period, the mean number of homeless nights was 30 for CTI recipients, whereas it was 91 (p = .003) for usual-service recipients. Later em- pirical studies also showed that CTI recipients tend to do better with respect to housing, alcohol and other drug (AOD) use, and psychiatric symp- toms (Kasprow & Rosenheck, 2007, a non- randotnized two-cohort cotnparison study) and negative psychiatric symptoms (Herman et al., 2000, a randomized two-group design). Psychiat- ric symptoms may include positive and negative symptoms. Positive symptoms may include delu- sions, hallucinations, grossly disorganized/cataton- ic behavior, and so on. Negative symptoms may include affective flattening, alogia, avolition, and so on. Research shows that CTI not only reduces recurrent homelessness among people with SMI, but it is also cost-effective in that it reduces home- less nights at a lower expense compared with the usual care approach Qones et al., 2003).

Providing Motivational Interviewing before Discharging Clients Research suggests that a motivational interviewing (MI) session prior to hospital discharge may in- crease the likehhood of a patient attending an initial outpatient appointment (CSAT, 2005; Swanson, Pantalon, & Cohen, 1999). The MI session addresses the differences between hospital and outpatient treatment regarding the treatment goals and methods and engages the client to

24 Social Work VOLUME 57, NUMBER I JANUARY 2012

explore his or her own understanding of his or her clinical condition and commitment to treatment.

Engaging Clients Early Community agencies that accept clients released from institutions can play a role in promoting an effective transition. Data indicate that the begin- ning period of treatment is one of three high-risk periods for dropout among homeless clients (Orwin, Garrison-Mogren, Jacobs, & Sonnefeld, 1999). It is risky because the clients need to adjust to new rules and demands, which may take a toll on their already fragile survival skills (Lipton, Siegel, Hannigan, Samuels, & Baker, 2000; O'Brien, Fahmy, & Singh, 2009; Orwin et al., 1999). Strategies to reduce early hazards include reducing waiting time (for being formally accept- ed or admitted to the treatment program or for actually starting the treatment), providing orienta- tion, engaging clients early (to buud a trust rela- tionship or alliance with chents during the early stage [for example, when clients initially enter treatment] and therefore motivate clients to stay in treatment) (Orwin et al., 1999), and forming a short-term reentry group that facilitates outpatient treatment participation and compliance using a psychoeducational approach (Kamiel-Lauer et al., 2000 [N= 75]).

Allocating Funds Providing funds for rent, deposits, and utility pay- ments to homeless clients with CODs before they secure employment or government benefits can help them transition firom institutions to the com- munity (Foote, Tucker, & MOlspaugh, 2008). Forchuk et al.'s (2008) randomized study (N =14) showed that intervention group participants who received immediate assistance with housing access and rent on discharges from psychiatric settings maintained housing after three and six months, whereas all but one of the control group partici- pants remained homeless (the exception traded sex to avoid homelessness).

COMPONENT 2: INCREASING THE RESOURCES

OF HOMELESS INDIVIDUALS WITH CODS

Many homeless individuals with mental disorders consider their homelessness to be caused by their lack of income rather than by their psychiatric dis- ability (Tsemberis & Eisenberg, 2000). Compton

et al. (2003) found that whether individuals with SMI have "sufficient income for housing" was one factor predicting homelessness. Linking indi- viduals to government enddements and connect- ing them with SE are two strategies to increase their income.

Applying for Government Entitlements Many homeless people, although eligible for gov- ernment entidements, do not receive, apply for, or maintain such benefits (Long, Rio, & Rosen, 2007; Page & Nooe, 2002; Zuvekas & HiH, 2000). Wechsberg et al. (2003) found that having an income below $500 in the preceding month predicted women's homelessness {p= .014), whereas receiving welfare income in the preced- ing month predicted women's nonhomelessness (p=.OOl). Some individuals may exit from the original Temporary Assistance for Needy Families (TANF) roUs because they were sanctioned; others may be removed from TANF roUs without knowing what they needed to do to comply with the rules (Page & Nooe). Nwakeze, Magura, Rosenblum, and Joseph (2003) considered the low use of Medicaid and food stamps by homeless people puzzMng, because those two government entitlements are not affected by the Welfare Reform Act (part of the Personal Responsibility and Work Opportunity^ Reconciliation Act of 1996 [P.L. 104-193]). They offered three possible explanations:

1. Homeless individuals have a lower sense of self-efficacy, which leads to deficient service-seeking behavior.

2. Agency bureaucracy and staff discrimination discourage homeless individuals fiom seeking services.

3. Homeless individuals consider their housing needs the top priority and Medicaid and other entidements secondary and do not pursue the secondary needs.

In addition, lack of verifying identity or other documentadon and permanent address often pre- vents homeless individuals from successfully com- pleting the appHcation process. Furthermore, many homeless individuals lost their Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) under the 1997 pohcy change that eliminated AOD addiction as a legitimate

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disability. Despite this, statistics showed that only 11 percent of homeless individuals surveyed were getting SSI and only 8 percent of homeless indi- viduals were getting SSDI, whereas it is estimated that 46 percent of homeless individuals had physi- cal disabüities and 39 percent of homeless individ- uals had mental health problems (cited in Long et al., 2007).

Practitioners should be equipped with knowl- edge of community resources and the skills for linking a homeless individual with government entitlements. The Substance Abuse and Mental Health Services Administration's SSI/SSDI Out- reach, Access and Recovery (SOAR) program provides technical assistance to case managers and program staff in this regard. Data showed that the success rate among SSDI/SSI apphcations was only 10 percent to 15 percent prior to SOAR, whereas it dramatically increased in states that par- ticipated in SOAR. For example, the average success rate in the 32 states involved in SOAR was about 71 percent during spring and summer of 2009 (Policy Research Associates, Inc. [PRA], 2009). The application processing times were also significantly reduced after SOAR implementation. For example, the processing time was eight months before SOAR training and 4.5 months after SOAR training in Oregon (Long et al., 2007), and the average time to reach a decision during spring and summer of 2009 was 89 days among the 32 SOAR-participating states (PRA, 2009). According to the Substance Abuse and Mental Health Services Administration (2011), 37 states reported SOAR-assisted 8,978 applications from 2006 to June 2010, with an approval rate of 73 percent and an average time of 91 days from application submission to approval.

Connecting with Employment Homeless individuals with SUD consider housing and employment to be two major factors that keep them homeless (Governor's Advisory on the Homeless, Oklahoma Department of Human Services, cited in Foote et al., 2008). Caton et al.'s (2005) study found that being currently employed at time of homeless shelter admission or having a previous employment history, even if currently unemployed, was associated with a shorter dura- tion of homelessness.

However, individuals with CODs face obstacles in seeking and maintaining employment. One

hindrance is the fear that employment may jeop- ardize their government benefits. Studies show that receipt of SSI/SSDI benefits may discourage individuals with mental disorders from pursuing competitive employment (Becker, Whitley, Bailey, & Drake, 2007 [N= 38]; Rosenheck et al., 2006 [N= 1,411]). Federal regulations require a person's disability status to be reviewed on his or her return to work; an SSDI recipient's cash payment may cease if his or her allowable income exceeds the substantial gainful activity level for a particular number of months. Furthermore, indi- viduals who lose SSDI due to employment may be at risk of losing other benefits, such as food stamps, utility supplements, and housing subsidies (Polack & Warner, cited in Cook, Terrell, & Jonikas, 2004). Becker et al. (2007) found that participants seemed to prefer part-time work, owing not only to its lesser demands, but also to their perception of its allowing them to maintain their Social Security and other benefits. It is thus critical to provide benefits counsehng to chents with CODs and their families to empower them to make informed decisions regarding employ- ment (Biegel, Ronis, & Boyle, 2008). Although various attempts have been made to address the issue of SSI and SSDI being disincentives for ben- efits recipients to pursue better financial security, the results seem to be disappointing, and more efforts are needed in this regard (Cook et al., 2004).

Other barriers to employment are an individu- als' COD symptoms, lack of self-efficacy, agency- level barriers, and society's biases. Becker et al. (2007) found that psychiatric illness is the primary hurdle and that long-term supports and part-time employment are the major facilitators to work. SE has been recognized as an evidence-based practice for linking individuals with mental disorders or CODs to competitive employment; clinical studies reporting SE success include Becker et al. (2001 [N=127]; 2007 [N=38]), Biegel et al. (2008 [N=194]), and Drake et al. (1999 [N = 152]). SE encourages all individuals, regardless of whether they have mental disorden or CODs, to seek competitive employment (that is, work that pays at least minimum wage and provides a non- segregated work setting) directly and swiftly. The eligibility for job placement is an individual's choice rather than his or her job readiness or abstinence from AOD (Becker, Drake, & Naughton,

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2005). Studies have found that clients with mental disorders may achieve more success in obtaining and maintaining competitive employment if they are being linked to competitive employment right from the beginning rather than being linked to prevocationaJ training and sheltered jobs before being hnked to competitive jobs (Drake et al., 1999). One key person in SE is an employment specialist, who helps clients seek a competitive job, provides them with individuaHzed and long- term support after they obtain employment so as to prolong job tenure, and works coUaboratively with other team members (Becker et al., 2005).

More SE studies, however, have been done on individuals with mental disorders than on individ- uals with CODs (Biegel et al., 2008). Biegel et al's study revealed that although the competitive em- ployment rates of clients with CODs who re- ceived SE were lower than those in SE chnical trials, they were nonetheless significantly higher than the rates of the control groups in those trials. Furthermore, Biegel et al. found that alcohol use was not an impediment to the participants' em- ployment. Both findings facüitated the inference that SE can be effective with clients with CODs (Biegel et al., 2008). Becker et al. (2005) suggested three guidehnes for applying SE to help individu- als with CODs:

1. Employment specialists and other team memben should ensure optimism about a client's ability to recover and to work and instiU hope in the client, as the chent may have low self-efficacy.

2. Employment speciahsts and other team members should work together with the client to create a detailed vocational profile and include in it the client's substance abuse situation. The specialist should unk the client with a job that supports recovery (for example, not a bartending job) and design an individualized treatment plan, so that, for example, the client and the treatment team can develop a mutually agreeable money management plan so that the money earned from employment wul not be used to pur- chase AOD.

3. Employment specialists and other team members should coordinate systems of mental health treatment, AOD treatment, and vocational services.

COMPONENT 3: LINKING HOMELESS INDIVIDUALS WITH CODS TO HOUSING To successfriUy treat the COD problems of home- less clients, practitioners must help them obtain and maintain housing. The literature has consis- tendy suggested that most homeless clients with CODs or SUD place housing over other needs, such as psychiatric and addiction treatments (Nwakeze et al., 2003; Orwin et al., 1999). Three strategies to help link COD homeless individuals to housing were addressed in the hterature.

Providing Effective Outreach Research and consensus of expert clinicians (Burt et al., 2004; Murray, O'Donnell, & Speedling, 2005) suggested that effective outreach may require

• offering "repeated engagements over time" and "familiarity with the same outreach worker," as both enable a relationship that comprises consistency and trust, elements that are often missing in a street-dweüing home- less person's Ufe;

• organizing various agencies under one central unit so that the operation can be more effi- cient and each client's data can be more complete;

• ensuring that the outreach team has direct access to supportive and "low-demanding" housing and fuU support from the city's mental health, AOD treatment, and health treatment programs, as an outreach would be fritile if "the other end of the spectrum" is not ready to provide housing or treatment when a homeless person is initially reached;

• conducting outreach during the day instead of only at nighttime, as more resources are available during the day;

• creating 24-hour homeless hotlines to involve the entire conimunity to engage homeless in- dividuals; and

• targeting the areas where chronically home- less individuals cluster.

Some experts suggest involving trained law en- forcement officers who understand the philosophy of the helping professionals, as this may smooth the outreach work and protect the outreach workers.

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Triaging and Linking Clients with Proper Permanent Housing Nelson, Aubry, and Lafi:ance's (2007) review of 16 controlled studies showed that supported and pemianent housing have a positive effect in com- bating chronic homelessness among people with mental disorders. Hurlburt, Wood, and Hough (1996) found a strong positive relationship between individuals with CODs, SMI, or SUD having access to pubhc housing (for example. Section 8) and their finding steady independent hving arrangements. Clark and FUch (2003) found that a comprehensive housing program that ensures both housing and case management, as opposed to a program with only case manage- ment, appean to be more critical to people with severe psychiatric symptoms and high substance use than it is to their counterparts with only medium- or low-level symptoms. For individuals with only medium- or low-level psychiatric symptoms and a low level of AOD use, a case management-only program can do as well as a comprehensive housing program.

Although offering permanent housing and support appean to be successful for combating chronic homelessness, it may be easier for chents with SMI than for clients with SUD or CODs to obtain and maintain pubhc housing. Individuals with SUD or SUD histories may face more diffi- culty in applying for public housing than do others because of their AOD problems and the frequent connection between AOD use and crim- inal behaviors. Both the official and unofficial housing pohcies may place individuals with SUD at a disadvantage (Dickson-Gomez, Convey, Hilario, Corbett, & Weeks, 2007).

The "one strike, you're out" policy permits federal housing authorities to take into account the AOD and convictions problems of an appli- cant and his or her family members when deter- mining eligibility for or eviction from federally subsidized housing (Dickson-Goniez et al., 2007). The Quality Housing and Work Responsibihty Act of 1998 (P.L. 105-276) (QHWRA) also re- quires Section 8 and pubhc housing agencies to exclude any applicant who was "evicted from pubhc, federally assisted, or Section 8 housing because of drug-related criminal activity," and that ban may last for three years after the appli- cant's eviction (CSAT, n.d.). Despite the fact that the QHWRA also indicates that the ban can be

lifted or shortened if the applicant completes a treatment program, overall the rules are not favor- able toward individuals with SUD or SUD histo- ries, and the ultimate ehgibOity decision is up to the housing authorities. Although some states (for example, Connecticut) opted out of the "one strike, you're out" policy and do not use drug convictions to deny housing applications, the routine criminal background checks in apartment rental applications still put drug usen in a disad- vantageous position (Dickson-Gomez et al., 2007).

Unofficial policy may further exacerbate substance-abusing clients' housing applications (Dickson-Gomez et al., 2007). Dickson-Gomez et al.'s quahtative study revealed that housing caseworkers can exercise much discretion in the final say regarding housing apphcations, and they may favor apphcants without an AOD problem or history due to their higher hkehhood of maintain- ing housing tenure. The drug-using participants in Dickson-Gomez et al.'s study stated that housing caseworkers often disrespected and imposed bureaucratic red tape on them. It is thus critical for practitioners to work closely with housing authorities to advocate for homeless chents with CODs. Other barriers may include fi-equently long waiting hsts and the recent short- fall of federal funding. For example, the Las Vegas Housing Authority (LVHA) has currently closed its housing apphcation process, and it is not ex- pected to reopen for three or more years when federal funds become available (personal commu- nication, LVHA, August 2009).

Considering Housing First as Opposed to Treatment First Practice Unlike the traditional treatment fint (TF) ap- proach, which places homeless clients with CODs or SUD first in treatment programs before they are ready for (permanent) housing, the housing first (HF) approach shifts the paradigm and places them directly into (permanent) housing without first requiring treatment or sobriety (Burt et al., 2004; Pathways to Housing, Inc., New York, 2005). Studies have shown that compared with TF, HF can not only better retain cHents, but also results in similar AOD treatment outcomes (Padgett, Gulcur, & Tsemberis, 2006 [RCT { J V = 2 2 5 } ]

Tsemberis & Eisenberg, 2000 [quasi-experimental {N= 1,842}] Tsemberis, Gulcur, & Nakae, 2004

28 Social Work VoLinnE 57, NUMBER I JANUARY 2012

[RCT {N=225.}]) Lipton et al. (2000 [quasi- experimental {N= 2,937}]) also found that indi- viduals with CODs residing in highly structured housing programs may have a lower level of resi- dential stability than their counterparts residing in housing programs flexible regarding AOD issues. Homeless individuals who have "faüed" almost all of the traditional treatment or housing programs have emphasized the significance of "having control over their own service uptake" and having program staffs respect regarding "their right to move at their own pace" (Burt et al., 2004, p. 27). They also appreciate programs that respect person- hood and that stress chent autonomy (for example, "no curfew") and privacy (for example, "a room with a key") (Lincoln, Plachta-EUiott, & Espejo, 2009 [qualitative study {N= 16}]).

An HF program is not completely uncondi- tional; it may impose various minimal demands on tenants. For example, HF programs sponsored by the U.S. Department of Housing and Urban Development prohibit tenants from using illegal drugs on the premises (Burt et al., 2004). Some HF programs only require tenants to cotnply with the conditions specified in their lease. Some require tenants to participate in a representative payee program or a money management program to ascertain tenants' abuity to pay rent reliably and to manage their money effectively (Burt et al., 2004; Tsemberis & Eisenberg, 2000). Some require clients to meet with program staff at least twice each month (Tsemberis & Eisenberg, 2000) and some require tenants to attend sessions focus- ing on skills development and job seeking and to not have too many visitors (Pratt, 2008). Some HF programs may be "applied flexibly to all tenants" and have pohcies that "housing or servic- es would not be denied to a person coming off the streets after many years who feels mistrustful about agreeing to money management" (Tsembe- ris & Eisenberg, 2000, p. 489).

Although an HF program does not require tenants to receive treatment, it is required to provide treatment. When providing treatment, a division of labor between property management and COD treatment is appropriate as it helps to avoid conflicts of interest with respect to nonpay- ment and other lease-related issues (Burt et al., 2004). Second, if most tenants with CODs are clustered, it may be more effective to bring the treatments to them instead of referring them out

to the agencies, as "the demand that they deal directly with service systems may be enough to prevent them from getting the services they need" (Burt et al., 2004, p. 30). Third, because tenants are not required to receive treatments, it is essen- tial to make treatment attractive to them. A modi- fied assertive commutiity treatment approach (introduced in the next section) that emphasizes consumers' decision-making power may be useful in this regard (Tsemberis & Eisenberg, 2000). Other strategies include making oneself available to clients, making friendj with clients, and creat- ing social activities (for example, holding birthday parties) (Burt et al., 2004). Burt et al. emphasized that the best referrals actually come frotn tenants talking about the program to their friends and neighbors, who then come into the program themselves.

COMPONENT 4: OFFERING COD TREATMENT

Empirical data are sriU limited regarding effective techniques that produce change among individu- als with CODs iBellack, Bennett, Gearon, Brown, & Yang, 2006; Cleary, Hunt, Matheson, & Walter, 2009). Nonetheless, the literature stressed three elements: (1) an integration of psy- chiatric and AOD treatments, (2) treatment as a long-term process, and (3) harm reduction (Bellack et al., 2006). Drake et al. (2001) also sug- gested four stages: (1) engaging individuals with CODs by using outreach techniques. Unking them with practical assistance, and estabUshing a trusting relationship; (2) motivating them to get involved in COD treatment and offering individ- ual counseUng and groups (persuasion); (3) equip- ping them with the skiUs and support (groups or family) to manage ulnesses and pursue goals (active treatment); and (4) preparing them with relapse prevention skills and support to maintain treatment progress (relapse prevention). The stages are not necessarily Unear. A client may enter treat- ment at an advanced stage or may relapse back to an earlier stage, or a client may be in different stages in terms of mental illness and substance abuse. Different stages should be paired with stage-specific interventions. The following five methods help in the implementation of tasks in- volved in the elements and stages of COD treatment.

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Assertive Community Treatment To engage homeless individuals with CODs, a more intense and proactive intervention may be necessary (DiClemente, Nidecker, & BeUack, 2008). Assertive community treatment (ACT)— an approach that emphasizes outreach, communi- ty tenure, practical and intensive case manage- ment, small caseloads (usually a client-worker ratio of 10 to 1), 24-hour service, and interdisci- plinary teamwork (Drake et al., 1998)—may fulfill the goal. ACT is an evidence-based approach proven by some studies to reduce hospital days (for example. Bond et al., 1990), increase time in housing or decrease homeless rates, and improve psychiatric symptoms (Coldwell & Bender, 2007). The ACT outcomes findings, however, are not completely consistent; findings in the United States are more consistent in generating a positive effect than are those in the European studies (Bums, Fioritti, Holloway, Malm, & Rössler, 2001). The inconsistency could be related to dif- fering operational definitions for the variables (Coldwell & Bender, 2007), lack of model fidelity, and "treatment quality" improvement of the control group (Verhaegh, Bongers, Kroon, & Garretsen, 2009).

Although ACT has been criticized for being expensive and lacking a recovery orientation, recent studies have shown that ACT does not have to be time unlimited, and some clients can transition from ACT to less intensive community mental health services or step-down programs (Hackman & Stowell, 2009; Rosenheck, Neale, & Mohamed, 2010). Recent studies also found that not all clients with CODs need ACT and that ACT may be necessary only for clients with more severe problems. For example, Essock et al. (2006 [N= 198]) found that, compared with ACT, clin- ical case management (a less intensive form than ACT [for example, with a client-worker ratio being 25 to 1 instead of 10 to 1]) created similar treatment outcomes among homeless or unstably housed clients with CODs. However, Frisman et al. (2009 [N= 124]) found that ACT appeared to be more effective than the cHnical case man- agement approach for clients with CODs and an- tisocial personality disorder (ASPD), whereas ACT and the clinical case management approach created similar treatment outcomes for dually dis- ordered clients without ASPD. More research is needed regarding successfully matching clients

with ACT, step-down programs, and regular clin- ical case management.

Modified Motivational Interviewing/ Motivational Enhancement Therapy Modvational interviewing (MI)/motivational en- hancement therapy (MET) produces some evi- dence of decreasing substance use and psychiatric symptoms and increasing treatment engagement during the short term among individuals with CODs (see Cleary et al.'s, 2009, review of nine empirical studies, mosdy with a randomized design). For example, Graeber, Moyers, Griffith, Guajardo, & Tonigan's (2003 [A/=30]) RCT found that, compared with an educational treat- ment intervention, MI was more likely to reduce drinking days and increase abstinence rates among schizophrenic patients with drinking problems. Santa Ana, Wulfert, and Nietert's (2007 [N = 101]) RCT revealed that, compared with controls, clients with CODs receiving group MI attended more aftercare sessions and drank less. Other RCTs also suggest that combining MI with cognitive—behavioral therapy (CBT) and family intervendon may help clients with CODs of schizophrenia and substance use disorders (Bar- rowclough et al., 2001 [N=36]) and that com- bining MI, contingency management, and social skills training resulted in better treatment out- comes than did the control condition ("a suppor- tive group discussion") among clients with CODs (BeUack et al., 2006 [N= 175]).

MI/MET facilitates change and helps a client move from a more initial stage (for example, pre- contemplation) to a more advanced stage (for example, contemplation, determination, action. CUents compare their baseline AOD use with the normadve data, develop discrepancies between where they are and where they want to be, discuss the role of AOD use as a barrier preventing them fiom being where they want to be and the role of quitdng AOD as a facilitator promodng their well-being, explore ambivalence related to changing AOD use, tip the decisional balance toward change, and develop goals and action plans (Miller & Rollnick, 2002). Individuals with CODs, particularly those with an SMI, may expe- rience a lower motivation to change because of their positive symptoms (for example, delusions, hallucinations) and negative symptoms (for example, anergia, avolidon), other cognitive

30 Social Work VOLUME 57, NUMBER I JANUARY 2012

limitations, low self-efficacy, or limited external resources and support systems (Carey, Pumine, Maisto, & Carey, 2001; DiClemente et al., 2008; Horsfall, Cleary, Hunt, & Walter, 2009). Al- though the research on motivation to change among individuals with CODs is preliminary (DiClemente et al., 2008), it suggests that—with proper cues, guidance, encouragement, and struc- ture—clients with CODs (including cUents with schizophrenia) can reflect on the pros and the cons of their substance-using behavior and be in- volved in decisional balance and goal setting (Carey et al., 2001). Research evidence and the consensus of expert clinicians (for example, CSAT, 2005; Ziedonis et al., 2005), systemic reviews of empirical studies (for example, DiCle- mente et al., 2008; Horsfall et al., 2009), and em- pirical studies (for example, Carey et al., 2001) suggest the following strategies to modify MI/ MET to help chents with CODs.

Empathy and an Alliance with the Client. Clients with CODs, especially those with SMI, are less able than others to tolerate stress, confron- tation, and criticism. Practitioners thus need to be nonjudgmental, friendly, passive, low-key, and patient (Evans & Sullivan, 2001). Many clients with CODs also suffer from low self-efficacy (Zie- donis et al., 2005), which can be helped by con- veying admiration for clients' strengths in daily coping, but this should be done without imposing too much pressure on them (DiClemente et al., 2008; Evans & Sullivan, 2001).

Psychoeducation and Counseling on Illness Self- Management and Psychiatric Medication Compli- ance. Modified MI/MET should be applied not only to SUD, but also to SMI problems. Psychiat- ric medication noncompliance is especially preva- lent among individuals with CODs with psychosis (CSAT, 2005). Individuals with schizophrenia and co-occurring SUD are less hkely to adhere to medication regimens than are individuals with only schizophrenia (Ziedonis et al., 2005). Psychi- atric medication noncomphance has a tremendous effect on a person's function and presenting symp- toms (CSAT, 2005); individuals with psychotic disorders must take antipsychotic medications to control their psychotic symptoms (Evans & Sulli- van, 2001). Clients with CODs need to be moti- vated to manage their psychiatric disorders (including medication compliance) and to under- stand how not doing so may prevent them from

attaining their goals (Drake et al., 2001; Ziedonis et al., 2005).

Research shows that psychiatric medication noncompliance may be related to side effects, dis- trust of the effectiveness of a medication, or denial of one's illness and the need to take medications (Weiss et al., cited in Weiss, 2004). A person who is active in AOD use may stop taking the medica- tions for fear of the alcohol—medication interac- tion (Weiss, 2004; Ziedonis et al., 2005), or the person may be so disorganized that it becomes too difficult for him or her to get anything done, including taking medications (CSAT, n.d.; Evans & Sullivan, 2001; Ziedonis et al., 2005). Medica- tion compliance may be facilitated by

• using all appointments to discuss the medica- tions—the purpose, the expected time coune and results, side effects, and AOD-psychiatric medication interaction effects and to promote hope and realistic expectations to increase medication adherence;

• simplifying medication regimens (for example, administering long-acting puls, depot injec- tions, or once-a-day regimens) and starting low and going slow in dosing;

• discontinuing medications with side effects that lead to nonadherence;

• encouraging patients to continue taking anti- psychotic medications despite their AOD use, as discontinuing the former may be more risky than the concurrent use of both; and

• involving significant others in medication psychoeducation and treatment monitoring (CSAT, n.d.; Ziedonis et al., 2005).

Harm Reduction and Smaller Goals. Theoreti- cally, it would be safer to adopt total abstinence (venus reduced use) as the treatment goal for clients with CODs, because people with mental disorders may be more sensitive to the biological effects of AOD, and AOD even in moderate amounts may exacerbate psychiatric symptoms and worsen problems (Evans & Sullivan, 2001; Mueser et al., cited in Drake, Wallach, & McGov- em, 2005). In reality, however, clients with CODs may experience more difficulty in achiev- ing total abstinence than do clients with SUD because of their impaired cognitive functions and other psychiatric symptoms (Carey et al., 2001;

StJN / Helping Homeless Individuals with Co-occurring Disorders: The Four Components 31

DiClemente et al., 2008; Horsfall et al., 2009). Reduced use and harm reduction goals rather than total abstinence may be more attainable by individuals with CODs, especially individuals with SMI (Carey et al., 2001; DiClemente et al., 2008).

Structure, Concreteness, Repetitiveness, and Degree of Alertness. Group sessions with a topical focus are better than process groups; in-session role playing and in-session homework can also enhance session structure (Carey et al., 2001; Evans & Sullivan, 2001). Providing written cues with respect to daily activity checklists and using written worksheets to guide each session may be helpful to individuals with schizophrenia as they may have difficulty with auditory materials (Carey et al, 2001; Evans & Sullivan, 2001; Ziedonis et al., 2005). Information related to CODs and the link between AOD and negative consequenc- es needs to be presented to clients repeatedly, and opportunities need to be offered to practice newly learned skills over and over (Evans & Suüivan, 2001; Ziedonis et al., 2005). Ziedonis et al. further suggested adapting interventions according to a patient's level of alertness.

Modified CBT CBT helps a chent identify- his or her internal triggers (thoughts, feelings, and emotions) and ex- ternal triggers (events, acti\'ities, and incidents) and learn skills to effectively deal with those trig- gers. RCTs have reported efficacy in MI with CBTs in improving alcohol problems among chents with CODs of depression and AOD disor- den (Baker et al., 2010) and in CBTs and CBT plus contingency management reducing substance use and posttraumatic stress disorder (PTSD) and other psychiatric symptoms among clients with CODs of PTSD and AOD disorder (Hien, Cohen, Miele, Litt, & Capstick, 2004 [N = 107]; Lester et al, 2007 [N=118]). Cleary et al.'s (2009) review of another four RCTs revealed that a combination of MI and CBT over a longer term improves substance abuse and mental health out- comes of clients with CODs, including chents with comorbid schizophrenia and AOD disorden. Their revie^v further showed inconsistent support for the application of stand-alone CBT to help in- dividuals with CODs—a 16- to 20-session round of CBT targeting clients with bipolar disorder ap- peared to be effective, whereas a 6- to 12-session

round of CBT working with clients with schizo- phrenia created no significant difference compared with a control group.

Research evidence and the consensus of expert clinicians argue for the following modifications to CBT to accommodate clients with CODs:

• offering CBT only when chents are stabihzed (both their SUD and their mental disorders);

• building a working alliance and rapport; • having clients be active participants, with the

chnician being mainly an educator; • starting low and going slow, with the chni-

cian undentanding that it takes trust and time for the clients to change and refraining from pushing clients too soon to address their in- grained habits of thoughts;

• using concrete methods (for example, role playing) and arranging highly structured, small-group sessions, if a group modality is adopted;

• helping chents leam specific coping skills to deal with the combined trials of SUD and mental disorder;

• accommodating clients' cognitive limitations and refraining from addressing too many spe- cific skills; and

• enhancing clients' self-efficacy by reinforcing their early successes (CSAT, 2005; Ziedonis et al., 2005).

Contingency Management Contingency management (CM) systematically reinforces a chent's desirable behaviors by provid- ing incentives and discourages the client's undesir- able behavion by using disincentives (Petry, 2000). Numerous studies have indicated the posi- tive effects of CM in reducing the substance use and other negative behavion of chents with SUD, at least in the short term (Higgins, Alessi, & Dantona, 2002; Prendergast, Podus, Finney, Greenwell, & Roll, 2006). Contingency manage- ment has also recendy been found to be effica- cious with chents with CODs (Cleary et al.'s, 2009, review of three RCT studies Prebing et al., 2005; Ries et al., 2004; Tracy et al., 2007]; Drake, O'Neal, & Wallach's, 2008, review of five experimental/quasi-experimental studies [Bellack et al., 2006; Drebing et al., 2005; Heimus, Saules, Schoener, & Roll, 2003; Ries et al., 2004;

32 Social Work VOLUME 57, NUMBER I JANUARY 2012

Sigmon et al., 2000]). Drake et al. (2008), citing Ledgerwood and Petry, stated that "improvements related to contingency management are probably unrelated to motivation and other cognitive factors" (p. 134); they suggested that this may be an advantage for dual-diagnosis chents.

However, two issues need to be noted. Some researchen beheve that both a chent's extrinsic and intrinsic motivations should be enhanced; CM often increases only extrinsic motivations, and the improved behavior may not last long when the reinforcers stop (Moos, 2007; Prendergast et al., 2006). For example, Drebing et al. (2007) found that military veterans with CODs who receive both vocational rehabUitation and CM do better in job searching and have a higher AOD abstinence rate than do those who receive only vocational rehabilitation. However, the CM impact on abstinence was not sustained after rein- forcers stopped. Research suggests combining MI/ MET with CM (BeUack et al, 2006; Drebing et al., 2007). The second issue is the cost, as CM necessitates provision of a concrete reward to a chent each time a desirable behavior is performed. Strategies targeting this issue are

• considering a prize-based CM (drawing to determine receiving a prize or not and the value of a prize), as it is less expensive than a voucher-based CM;

• seeking donations from community organiza- tions and companies;

• applying CM only to individuals with severe impairments (not aU individuals need CM to change); and

• using nonmonetary rewards.

Although CM is considered highly promising in helping chents with CODs, research is stiU in the beginning stage (Cleary et al., 2009; Drake et al. 2008; Drebing et al., 2007).

Dual-Focus Mutual-Aid Groups Mainstream 12-step group involvement appears to be associated with better outcomes with respect to AOD abuse, self-efficacy, motivation, and coping skills (Kownacki & Shadish, 1999; McKay, 2001), but a mainstream 12-step group may not be appropriate for individuals with CODs, because

• it may be prejudicial toward meniben with CODs because of the stigma attached to having a mental disorder;

• it may stick to the total abstinence orienta- tion, \vhich may influence members with CODs to stop taking prescribed psychiatric medications, despite this not being the official position of the Alcohohcs Anonymous or Narcotics Anonymous organizations; and

• its coUective insights may not necessarily benefit memben with CODs, as members with SUD may have very different needs for recovery than do members with CODs (CSAT, 2005;Magura, 2008).

A specialized 12-step group allo^vs for open dis- cussion of not only AOD issues, but also issues related to mental disorders, psychiatric medica- tions, medication side effects, psychiatric hospitah- zations, and other issues regarding which participants might expedence stigma if discussed in mainstream 12-step groups (Bogenschutz, 2005). Magura et al. (2003) of specialized 12-step groups showed that by helping othen, an individ- ual reinforces self-learning of valued behaviors and that by sharing recovery experiences, individ- uals learn from each other. Although few studies have researched the outcomes of specialized 12-step groups, they suggest that such groups benefit individuals with CODs more than main- stream self-help groups do (Bogenschutz, 2007). A two-year foUow-up study of Double Trouble in Recovery (DTR), a speciahzed 12-step group (A/=310), conducted firom 1998 to 2000 by Magura and coUeagues produced 13 articles. Based on this 1998-2000 study, Laudet et al. (2004) reported that continuing DTR attendance was related to a higher likelihood of abstinence, and Magura, Laudet, Mahmood, Rosenblum, and Knight (2002) observed that weekly DTR atten- dance, not attendance at mainstream self-help groups, was associated with psychiatric medication adherence. Magura's (2008) solo review of this 1998-2000 study suggested DTR's effectiveness in four areas: (1) AOD abstinence, (2) psychiatric medication adherence, (3) self-efficacy for recov- ery, and (4) quality of Hfe.

Most specialized self-help group studies (for example, Magura et al.'s, 1998-2000, study) suf- fered firom a lack of a control group (the same issue apphes to the studies of mainstream self-help

SUN / Helping Homeless Individuals with Co-occurring Disorders: The Four Components 33

groups). To improve the research design, Magura et al. (2008) recently conducted a quasi-experi- mental study and found that a cohort with DTR exposure had significantly fewer days of AOD use than did a cohort without DTR exposure, a finding consistent with the team's previous find- ings. Because the speciaUzed 12-step group has a relatively shorter history, treatment programs should faciUtate Unkages between their cUents with CODs and such groups. CUents with CODs who are in more advanced recovery should also be encouraged to assume a facilitator's role; both a manual and facüitator training are available from the founden of some dual-focus 12-step self-help groups (Magura et al., 2003).

CONCLUSION

Helping chronically homeless individuals who are afflicted with CODs—one major calling for social workers—involves multiple complex and chal- lenging tasks. This article suggests four compo- nents in this regard: (1) ensuring effective transition of homeless individuals from institutions into community living; (2) helping them apply for govemment entitlements and obtain SE; (3) linking them with supported and supportive housing, a task that particularly demands practi- tioners' creative thinking in the context of the current economic crisis, which has cut housing re- sources; and (4) applying and combining modified ACT, cUnical case management, MI/MET, CBT, CM, and speciaUzed 12-step groups to maximize treatment effects. All four components are consis- tent with social work values; they help social workers to affirm and empower cUents and link them with resources.

This article has limitations. The empirical studies covered here included many more male than female subjects (for example, about 50 percent to 90 percent of subjects were men, whereas about 25 percent :o 60 percent were women, with a few studies being extreme, includ- ing 100 percent men, 100 percent women, or only seven percent women in a veterans study). Although this reflects the actual gender distribu- tion in that chronically homeless individuals are more Ukely to be men, understanding of chroni- cally homeless women with CODs wül require more studies with larger samples of women. The ethnic gap appeared narrower than did the gender gap. Although a couple of the studies contained

mainly white participants, many had equivalent portions of white and nonwhite participants, and in many other studies, African American partici- pants composed a higher percentage than did other ethnic groups. This is consistent with statis- tical data indicating a higher percentage of African Americans among the homeless population. Also, the research data covered here were mostly col- lected from major cities in the United States, with only Uttle from rural areas; rural homeless individ- uals may have different needs than do urban homeless individuals. One other issue is that this article focuses only on individual homeless clients, not homeless famiUes, as it targets chronic home- lessness (or homeless clients with CODs), and homeless famiUes are less likely than homeless in- dividuals to be chronically homeless. (Nonethe- less, 30 percent of the U.S. homeless population are famuies with chüdren, and practitioners should prepare themselves to help these famuies.) Finally, COD treatment methods, although emerging and promising, are stul in their infancy, and more studies with rigorous designs are needed.

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An-Pyng Sun, PhD, LCSIV, is professor. School of Social Work, University of Nevada, Las Vegas, 4505 Maryland Parkway, Box 455032, Las Vegas, Nevada, 89154-5032; e-mail: an-pyng.sun@un'lv.edu. An earlier version of this article was presented at the 2010 annual program meeting of the Council on Social Work Education, October 14-17, 2010, Portland, Oregon.

Original manuscript received November 24, 2009 Final revision received May 31, 2010 Accepted June 9, 2010

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