Homelessness Prevention in Treatment of Substance Abuse and Mental Illness

Logic Models and Implementation of Eight American Projects

Kendon J Conrad, Michael D Matters, Patricia Hanrahan, Daniel J. Luchins

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317844549
• Edition: 1
• Topic: Psychologie
• Subtopic: Conseil en psychothérapie

Through Homelessness Prevention in Treatment of Substance Abuse and Mental Illness: Logic Models and Implementation of Eight American Projects, psychiatrist, psychologists, and social workers will discover the results of eight, three-year long development projects funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) designed to prevent homelessness in high- risk populations who have problems with alcoholism, drug abuse, and/or mental illness. Through this informative book, you will examine the theory or logic guiding each program, including an up-to-date review of the literature supporting each theory. You will also find a description of the implementation of the program as well as its history, the practical issues involved in delivering services, the pitfalls, lessons learned, and recommendations for the future so you can use the best ideas to implement in your own community and stop these individuals from reaching the streets.

Homelessness Prevention in Treatment of Substance Abuse and Mental Illness provides insight into how to deal with many common issues that you are faced with every day, such as matching clients to appropriate services, preventing relapse, case management, training in independent living skills and money management, acquiring and maintaining housing, and benefits and employment for your disadvantaged clients. Compelling and informative, this unique book provides you with many tips and suggestions on how you can help the disadvantaged in our population avoid the added trauma of becoming homeless, such as:

• examining a new modified therapeutic community (TC) intervention program for mothers recovering from substance abuse who live with their children so you can learn to treat the family as a whole and not just treat the person with a "problem"
• gaining insight into a new intervention program for families caring for another family member with serious mental illness or substance abuse disorders so you can address such issues as the importance of respite for the family and home visits for relationship building among the entire household
• discovering a new, independent living model which allows clients with serious mental illnesses to select their own apartments
• learning about a new program in Philadelphia that offers support services to clients with serious mental illnesses and substance use disorders and provides several levels of housing from emergency shelter to highly supportive permanent housing
• discovering a community counseling center in Chicago that operates a "bank" that helps mentally ill clients or those with substance use disorders develop skills to independently manage their financial affairs through the use of "vouchers" that can be redeemed for cash for the payment of monthly bills

Homelessness Prevention in Treatment of Substance Abuse and Mental Illness provides you with new insights into how you can help your clients overcome political, economic, and environmental barriers to treatment that can lead to homelessness. This essential book will help you improve your services to your clients as well as give you step-by-step guide to implement these new programs in your community.

Homelessness Prevention
Therapeutic Community (TC)
for Addicted Mother

JoAnn Y. Sacks, PhD
Stanley Sacks, PhD
Michael Harle, MHS
George De Leon, PhD

SUMMARY. This chapter describes a homelessness prevention therapeutic community (TC) for addicted mothers and their children developed by Gaudenzia in response to increasing numbers of homeless addicted mothers and families entering the Philadelphia shelter system. The program uses TC principles and methods as the foundation for recovery and the structure within which the homelessness prevention interventions unfold. The mothers progress through program stages and typically move from residential to permanent housing. The chapter describes the program’s conceptual framework and logic model, setting, client profiles, goals and interventions. The specific homelessness prevention activities include 14 distinctive interventions that address family preservation, employment; housing stabilization; societal reintegration and building a supportive community. The study design includes two groups and 185 subjects: a homelessness prevention TC (n = 104); and a standard TC (n = 81). The process evaluation assesses the fidelity of implementation of the homelessness prevention interventions. The outcome evaluation compares the effectiveness of the homelessness prevention TC with a standard TC on both traditional outcomes (e.g., substance abuse) and homelessness prevention outcomes (e.g., housing stabilization). This program has considerable significance for policy and planning, especially for the development of integrated mother-child programs and for the application of TC principles and methods to homelessness prevention. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@lza wortlzpress inc. com]

KEYWORDS. Therapeutic community (tc), addicted/single mothers, family preservation, “housing as treatment,” housing stages perspective, program evaluation

THE PROBLEM OF HOMELESS SUBSTANCE ABUSING WOMEN WITH CHILDREN

Homelessness represents one of our most pressing and complex social problems. Homeless people suffer from a variety of associated difficulties, including those related to health and medical problems (Institute on Medicine, 1990), HIV disease (Schutt & Garett, 1992), criminality (both as victims and participants; Rahav & Link, 1995), alcohol and drug use (Fischer & Breakey, 1991 ), and mental illness (Rossi, 1990).

A rapidly increasing number of women are joining the ranks of the homeless (Merves, 1992). For the past decade, the fastest growing subgroup of the homeless population in the US has been women with children; families comprised 33% of the total homeless population in 1987, rising to 38% by 1996 (US Conference of Mayors, 1987; 1996). Homeless women face more discrimination than men in seeking shelter, food, and employment; homeless mothers are substantially more likely to be on welfare (Merves, 1992; Calsyn & Morse, 1990). The generally poorer economic state of women, combined with the demands of single parenthood are seen to imperil a woman’s ability to maintain her home (Bassuk, 1993).

Diminished social supports have been cited as a significant factor in placing the family at risk for homelessness (McChesney, 1992; Wood, Valdez, Hayashi, & Shen, 1990); the loss of social supports are often a component of the process of becoming homeless. Homeless mothers report perceiving the members of their social support system as unavailable to assist them with housing, finances or child care, suggesting that even those with an identified support network of family and friends may have “worn out their welcome” by the time they became homeless. Other homeless women are members of social networks whose constituents are only marginally better off than themselves (Shinn, Knickman & Weitzman, 1991; Letiecq, Anderson & Koblinsky, 1996). Increased time homeless, transient homelessness, and maternal substance abuse are each associated with reduced assistance from the social network (Letiecq et al., 1996).

Homeless women with children, interviewed in the Maryland shelter system, differed from other homeless women in citing needs for child care, parenting skills training, help with their children, job training, finding work, education, and service coordination (DiBlasio & Belcher, 1995). Not surprisingly, a growing body of studies of homeless families provides evidence that homelessness profoundly and disproportionately affects the youngest family members. Homeless children are at increased risk for: severe and chronic health problems; poor and inadequate nutrition; developmental and emotional problems; educational problems; and child abuse (Bassuk & Cohen, 1991; Bassuk, Rubin & Lauriat, 1986).

Evidence of increased drug use among homeless women has emerged throughout this decade; many of these women have children and/or are pregnant (Hausman & Hammen, 1993). Homeless women with dependent children report rates of drug abuse ranging from two to eight times higher than those for housed women with children (McChesney, 1995; Robertson, 1991). Substance abuse poses a threat to housing, not only by causing disrupted functioning, but also by virtue of evictions as a consequence of national policy for public housing (Cranston-Gonzalez Affordable Housing Act, 1990). Homelessness and substance abuse also present serious threats to family preservation by virtue of being major factors in the decision to separate children from their mothers for placement in foster care (Allen, 1991; Steinbock, 1995).

The therapeutic community (TC) is a program model capable of addressing the extensive needs of homeless women with dependent children. A comprehensive, psychosocial intervention, the TC approaches substance abuse as a “whole person disorder.” TC programs are designed to treat substance abuse and foster change in psychological functioning and social behavior. As modified for women and children, the TC incorporates the educational, developmental and social needs of the children.

THERAPEUTIC COMMUNITIES (TCs)

Several articles (De Leon, 1995; De Leon & Ziegenfuss, 1986) describe the perspective and approach of the traditional TC for recovery from drug abuse. Briefly, drug abuse is a disorder of the whole person reflecting problems in conduct, attitudes, moods, emotional management and values. The goals of the TC approach are to promote freedom from alcohol and illicit drug use, to eliminate antisocial behavior, and to affect a global change in lifestyle, including personal attitudes and values.

A number of NIDA-funded, multi-site, and program-based evaluations document the effectiveness of TCs. Short- and long-term follow-up studies show significant decreases in alcohol and other drug use, reduced criminality, improved psychological functioning, and increased employment (De Leon, 1984; Simpson & Sells, 1982; Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997; Condelli & Hubbard, 1994). The demonstrated effectiveness of the TC, in terms of drug use, prosocial behavior, and psychological outcome, provided the rationale for the development of TCs for special populations such as homeless mentally ill chemical abusers (MICAs) and homeless addicted mothers.

The past decade has seen the development of modified TC programs relevant to the current article. Modified TCs for homeless individuals, often developed within the shelter systems, are generally of shorter duration than traditional TC programs and focus on engaging clients in the peer community and initiating treatment. Homeless, addicted clients have multiple needs and modified TC treatment programs for these populations incorporate educational, vocational, legal and housing placement services (Liberty et al., in press; Leaf et al., 1993). Specialized, modified TCs for homeless MICAs are more flexible and less intense than standard TCs and provide a comprehensive multi-dimensional program of integrated mental health, substance abuse, and rehabilitative services designed to meet the complex needs of the population (Sacks et al., 1996; 1997). Modified TCs for women and children provide family style housing, day care and after-school programs, a gender-specific curriculum focusing on parenting issues for the mothers and modifications of the daily program routine to accommodate the mother’s parenting responsibilities (Stevens & Glider, 1994; Wexler, Cuadrado & Stevens, in press; Coletti et al., 1997).

The findings from this work indicate: (i) homeless substance abusing men participating in shelter based short-term TCs showed significant declines in alcohol and drug abuse, criminal activity (drug possession and property offences), and depression (Liberty et al., in press); (ii) homeless MICA men and women show significantly greater improvement for the modified TC group on measures of illegal drug use, crime and depression as compared to a treatment-as-usual group receiving standard services (Sacks et al., 1997; De Leon, Sacks, Staines & McKendrick, submitted); and (iii) women in TCs modified to accommodate mothers with their children show decreases in alcohol and drug use, increases in employment, decreased depression, and improvement in other measures of mental health (Wexler et al., in press).

The TC approach, based on several core principles and methods now widely accepted in the drug treatment field, may be ideally suitable to address the needs of homeless, substance abusing women with children. These core principles and methods include: providing a highly structured daily regimen; coping with life difficulties through personal responsibility and self-help; using peers as role models and guides; recognizing the peer community as the healing agent and employing community-as-method (the community as both the context of and mechanism for change); understanding change as a gradual, developmental process, reflected by movement through treatment stages; stressing work, self-reliance, and acquiring skills to support vocational development and independent living; and promoting prosocial values accompanied by healthy social networks to sustain recovery.

The current project, evaluating a homelessness prevention TC, advances research in several ways. First, it documents specific homelessness prevention program elements, greatly increasing the ease of future applications. Second, although treatment effectiveness has been documented for homeless substance abusers, evaluations of homelessness prevention programs, especially those that provide services for addicted mothers and their children, are virtually nonexistent. The proposed study will provide a rigorous evaluation of an innovative homelessness prevention TC program and data on outcomes for both the mothers and their children. Third, the study will provide data on the relationship between process measures (i.e., specific homelessness prevention elements) and outcome measures, thereby identifying the “active ingredients” of the homelessness prevention program. Finally, and perhaps most significantly, the project evaluates TC methods found effective in reducing substance abuse, extending both the range and potential of these methods by adding components specific to homelessness prevention.

PROGRAM DESCRIPTION

This paper describes a modified TC program that focuses on the prevention of homelessness in substance abusing women with dependent children. This program is similar to other TC programs for women and children, but differs in its focus on preventing homelessness and in the richness of services designed to achieve this goal.

The goal of the present program is to prevent homelessness among homeless, substance abusing women and their children. The program addresses homelessness by focusing on several broad and interrelated goals: (1) using recovery from substance abuse as a foundation for homelessness prevention; (2) improving parenting and the mother-child relationship; (3) reuniting the family; (4) sustaining gainful employment; (5) stabilizing housing; (6) building a healing and supportive community; and (7) achieving reintegration with mainstream society. During the course of the program, mothers progress through program stages and move from residential to transitional and/or permanent housing. The specific homelessness prevention interventions begin early in the residential phase, increase in frequency and intensity ( especially in the latter part of the residential program), and continue at somewhat reduced frequency upon entry into transitional and permanent housing (see Figure 1).

Setting

Agency and Facilities. Gaudenzia is a private, not-for-profit TC-oriented agency, incorporated in Pennsylvania in 1968, to provide treatment, prevention and other services to people with substance abuse and related problems. Two of Gaudenzia’s 34 programs, New Image in Philadelphia and Kindred House in Westchester, were developed in 1989 (in cooperation with the City of Philadelphia Health Department and the US Public Health Service) as programs to prevent homelessness among those homeless, substance abusing women who were pregnant and/or who were parenting one or more children. Each mother entering the program is allowed to bring up to two of her dependent children with her.

Both pro...