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Blueprint for Change: Ending Chronic
Homelessness for Persons with Serious
Mental Illnesses and Co-Occurring Substance Use Disorders

Chapter 6: Use Evidence-Based and Promising Practices

The good news about service provision for people with serious mental illnesses and/or co-occurring substance use disorders who are homeless can be summed up simply: We know what works. Now we need to put what we know to work.

This is not to say that the work is done, however. On the contrary, there is a need for continued research into effective interventions for groups with specific needs, such as trauma survivors, and for individuals with severe disorders.

However, evidence-based and promising practices can be used immediately to help prevent and end homelessness for people with serious mental illnesses and/or co-occurring substance use disorders. SAMHSA plays a key role in getting information about evidence-based practices into the hands of the people who deliver services.

This chapter examines (1) a range of evidence-based and promising practices that have proven effective to prevent and end homelessness among people with serious mental illnesses and/or co-occurring substance use disorders, and (2) additional needed service system components of a comprehensive service system. The full array of services and supports essential to address homelessness among people with serious mental illnesses and/or co-occurring substance use disorders are summarized in Table 6.1.

Evidence-Based and Promising Practices

Federal research and demonstration programs and the experience of hundreds of community-based providers have shown that the services described here help decrease symptoms of mental illnesses and substance use, and increase residential stability for people with serious mental illnesses or co-occurring disorders who are homeless. Communities can adopt or adapt these practices to local needs.

Outreach and Engagement

Compared to people with serious mental illnesses and/or co-occurring substance use disorders who are housed, individuals who also are homeless are likely to be more severely impaired, to have more basic service needs, and to be unwilling or unable to seek treatment (Federal Task Force on Homelessness and Severe Mental Illness, 1992). If they won’t seek help, help has to go to them.

Once considered a nontraditional service, outreach now is recognized as the initial, most critical step in connecting or reconnecting a person who is homeless to needed health, mental health, substance abuse, and social services and to housing. However, people who are homeless are not focused initially on receiving mental health or substance abuse treatment. Outreach workers must meet them "on their own terms and on their own turf" (Federal Task Force on Homelessness and Severe Mental Illness, 1992). Outreach workers find people on the streets, under bridges, in parks, and in shelters, and they focus on meeting the individual’s immediate needs for food, clothing, and shelter.

This process of engagement is essential to develop the trust and rapport needed to help individuals accept more long-term services, the ultimate goal of outreach efforts. Regardless of how or where outreach is provided, successful outreach workers must adopt a nonthreatening approach; must be flexible in the number and types of services offered, as well as the manner in which they are provided; and must make numerous contacts over extended periods of time (Interagency Council on the Homeless, 1991; McMurray-Avila, 1997). Outreach workers who have been homeless and are recovering from mental illnesses and/or co-occurring substance use disorders may be especially effective at engaging individuals who are difficult to reach (Van Tosh, 1993; Dixon et al., 1994).

What the Research Says. Outreach, whether in shelters or on the streets, is effective (CMHS, 2001c; Lam and Rosenheck, 1999; Tsemberis and Elfenbein, 1999; Morse et al., 1996; Bybee et al., 1995). Given the opportunity, most people with serious mental illnesses and/or co-occurring substance use disorders who are homeless are willing to accept treatment and services voluntarily. Indeed, skilled outreach teams eliminate the need for involuntary treatment for most individuals. A study of individuals enrolled in the SAMHSA Access to Community Care and Effective Services and Supports program who were contacted through street outreach revealed that even individuals with the most severe disorders, who are the most reluctant to accept treatment, will enroll in services and show improved outcomes when served by an outreach team (Lam and Rosenheck, 1999).

A study of the effectiveness of outreach with homeless people who abuse substances found that nearly half of persons contacted through outreach became enrolled in services (Tommasello et al., 1999). More important, those contacted through outreach had significantly higher levels of substance use than walk-in clients, and were more likely to be engaged in HIV risk behaviors. This indicates that outreach can be successful in reaching individuals most in need of services.

Consistent, caring, personal relationships, and the introduction of services at the client’s pace are critical elements in outreach efforts designed to engage people who are homeless into treatment. Unfortunately, few health insurance programs consider outreach a reimbursable expense. Outreach is the most common service offered by providers who receive SAMHSA’s Projects for Assistance in Transition from Homelessness (PATH) funds; for more than one-third of these providers, PATH funds are their only source of outreach revenues.

Housing with Appropriate Supports

People without homes need housing; that goes without saying. Yet, to match housing to an individual’s needs, several factors are at work. For example, housing for people with serious mental illnesses historically has been in some type of congregate setting such as a group home, but preference studies show that people with serious mental illnesses want to live in integrated, regular housing rather than in segregated, mental health programs (Carling et al., 1987; Brown et al., 1991).

Initially, some individuals, especially those with substance use disorders, may require a type of low-demand housing, such as a Safe Haven, to help them re-engage in services (see the section on Low-Demand Services in this chapter for more information about Safe Havens). Indeed, while the provision of housing increases retention in substance abuse treatment for people who are homeless, individuals do less well when high-intensity services are required as a condition of housing (Orwin et al., 1999, p. 45). Ultimately, people with substance use disorders need safe housing with the appropriate level of support to help them maintain their treatment gains.

Second, housing is necessary but not sufficient to help individuals with serious mental illnesses and/or co-occurring substance use disorders who have been homeless regain psychiatric and residential stability and maintain sobriety. They require unique, flexible supportive services that are not a requirement to maintain housing. The Corporation for Supportive Housing defines these services as those (1) designed to maximize independence; (2) flexible and responsive to individual needs; (3) available when needed; and (4) accessible where the individual lives (CSH, 1996).

What the Research Says. Providing supportive services to people in housing is effective in achieving residential stability, improving mental health and recovery from substance abuse, and reducing the costs of homelessness to the community (Culhane et al., 2001; Lipton et al. , 2000; Tsemberis and Eisenberg, 2000; Rosenheck et al., 1998; Shern et al., 1997; Goldfinger and Schutt, 1996; Hurlburt et al., 1996). Recent studies indicate that supportive housing may be cost-effective, as well (Culhane et al., 2002; Houghton, 2001).

Most people with serious mental illnesses who are homeless prefer supportive housing, and they do well, despite widely held assumptions about the need for more structured housing for people with the most severe disorders. In fact, many people can move directly from homelessness to independent housing with supports. However, the transition from homelessness to housing is a critical time requiring intensive support and attention. Many individuals who have lived on the streets feel isolated and disoriented when they begin living inside; services may have to be increased, rather than decreased, at this time (Susser et al., 1997).

Finally, research also reveals that consumer choice in housing is critical for success and that housing subsidies are a key component to making housing affordable for this group. However, as noted previously, subsidies do not guarantee that housing will be available.

Cost Studies

A study that tracked 4,679 homeless people with mental illnesses placed into service-enriched housing in New York City found reductions in housing and service costs compared to a control group of homeless people with similar characteristics who were not placed into service-enriched housing. The housing was created as part of the 1990 New York/New York Agreement to House Homeless Mentally Ill Individuals, a joint initiative between New York City and New York State that created and continues to maintain 3,615 units of affordable housing supported with clinical and social services (Houghton, 2001).

Researchers (Culhane et al., 2002) found that people placed in supportive housing had marked reductions in shelter use, hospitalizations, length of stay per hospitalization, and time incarcerated. Before placement in supportive housing, homeless people with serious mental illnesses used about $40,451 per person, per year in services (1999 dollars). Placement in supportive housing was associated with a reduction in services use of $16,281 per housing unit per year (Culhane et al., 2002). Much of the savings resulted from fewer and shorter stays in state psychiatric hospitals, as well as decreased shelter use.

Results from the Connecticut Supportive Housing Demonstration Program, conducted from 1993 to 1998, are similar. Researchers found that supportive housing created positive outcomes for tenants while decreasing their use of acute health services and increasing their use of less expensive ongoing and preventive health care (CSH, 2002a). Also, property values in the neighborhoods surrounding the supportive housing have increased or remained steady since the housing was developed.

Multidisciplinary Treatment Teams/Intensive Case Management

People with serious mental illnesses and/or co-occurring substance use disorders who are homeless have complex problems that require comprehensive treatment and services. A multidisciplinary treatment team provides individuals with a type of "one-stop shopping" to arrange for or provide all of the services they require.

Assertive Community Treatment (ACT) is a good example of this approach. Begun in the late 1970s with the Program of Assertive Community Treatment in Madison, Wisconsin, ACT is acknowledged as a successful approach to providing a full range of community-based services to people with serious mental illnesses and/or co-occurring substance use disorders. ACT teams feature a multidisciplinary group of mental health, substance use, and social service specialists who provide, or arrange for, each individual’s clinical, housing, and rehabilitation needs. Client/staff ratios are low (typically 10 to 1), and services are available around the clock.

The ACT model has been modified successfully to meet the needs of people who are homeless. For example, because some people who have been homeless have trouble forming trusting relationships, they may be assigned to one or two members of the team, rather than the whole team. All team members are knowledgeable about each client, however (Dixon et al., 1995). Many ACT teams use mobile outreach to serve people who are unwilling or unable to come to them.

What the Research Says. ACT and similar models of intensive case management reduce inpatient hospitalization, decrease substance use and symptoms of mental illnesses, and increase community tenure for people with serious mental illnesses and/or co-occurring substance use disorders who are homeless. Regular assertive outreach, lower caseloads, and the multidisciplinary nature of the services available on these teams lead to positive treatment and housing outcomes (Ziguras and Stuart, 2000; Morse, 1999; Lehman et al., 1997; Morse et al., 1997; Burns and Santos, 1995; Dixon et al., 1995).

The provision of substance abuse services on an ACT team is a critical ingredient of success. Research indicates that ACT is not effective in reducing substance use when the substance abuse services are brokered to other providers and are not provided directly by the ACT team (Morse et al., 1997).

Integrated Treatment for Co-Occurring Serious Mental illnesses and Substance Use Disorders

Mental health and substance abuse providers frequently cite the problem of co-occurring serious mental illnesses and substance use disorders as the most difficult situation they face. Individuals with co-occurring disorders tend to be more symptomatic, to have other multiple health and social problems, and to require more costly care (NASMHPD and NASADAD, 1999). They are at risk for homelessness and incarceration. Among people with serious mental illnesses who are homeless, approximately half have a co-occurring substance use disorder (SAMHSA, 2002b).

Providers struggle to fund and develop effective approaches to treat people with co-occurring disorders who are homeless. Three common approaches are:

• Sequential approach. The individual receives treatment first for one disorder and then for the other, with treatment provided by two different agencies.
• Parallel approach. Two different providers, one offering mental health services and the other providing substance abuse treatment, treat the individual simultaneously. However, treatment plans rarely are coordinated.
• Integrated services approach. The individual participates in concurrent and coordinated clinical treatment of both mental illnesses and substance use disorders provided by the same clinician or treatment team, often in a single agency. Unfortunately, such programs are rare.

What the Research Says. An integrated approach is superior to a parallel or a sequential approach to treatment for people who have co-occurring serious mental illnesses and substance use disorders. Integrated treatment reduces alcohol and drug use, homelessness, and the severity of mental health symptoms (CMHS and CSAT, 2000a; Drake et al., 1998; Drake et al., 1997). Though people with co-occurring disorders who are homeless drop out of treatment programs in high numbers, the SAMHSA’s Collaborative Demonstration Program for Homeless Individuals had retention rates as high as 74 percent in its programs that offered integrated treatment. Individuals did best when their treatment was combined with other services such as housing, legal services, and income support. Further research is needed to confirm the effectiveness of this approach for people with less severe disorders.

Motivational Interventions/Stages of Change

Many homeless individuals with substance use disorders are not ready for abstinence-oriented programs (Oakley and Dennis, 1996). Further, they also may lack the motivation to engage in active treatment. Motivational interventions that emerged in the substance use field (Miller and Rollnick, 1991) have been adapted for people with serious mental illnesses and/or co-occurring disorders, as well as for people who are homeless.

Motivational interventions include a range of clinical strategies designed to enhance motivation for change, including counseling, assessment, multiple sessions, and brief interventions. The five key principles of motivational enhancement are (Swanson et al., 1999; CSAT, in press):

• Express empathy;
• Note discrepancies between current and desired behavior;
• Avoid argumentation;
• Refrain from directly confronting resistance; and
• Encourage the individual’s belief that he or she has the ability to change.

Further, motivational enhancement techniques must be matched to the client’s stage of recovery and often are integrated as part of the Stages of Change Model (Prochaska and DiClemente, 1992). This model describes predictable stages of change for people with substance use disorders from precontemplation to contemplation, determination, action, maintenance, and relapse prevention.

What the Research Says. Research has demonstrated that motivational enhancement techniques are associated with greater participation in treatment and positive treatment outcomes. These outcomes include reductions in consumption, increased abstinence rates, better social adjustment, and successful referrals to treatment (Landry, 1996; Miller et al., 1995). A positive attitude toward change and a commitment to change also are associated with positive treatment outcomes (Miller and Tonigan, 1996; Prochaska and DiClemente, 1992).

Modified Therapeutic Communities

Therapeutic communities (TCs) have been implemented as a method to address substance use disorders for more than 30 years. The concept is based on a clearly defined theoretical model that views drug abuse as a disorder of the whole person, requiring a focus on conduct, attitudes, moods, values, and emotional management. The community is the therapeutic method in a TC.

Modified therapeutic communities (MTCs) adapt the principles and methods of the TC to the needs of individuals with co-occurring mental illnesses, as well as the needs of those who are homeless. Key modifications for people with co-occurring disorders include increased flexibility, decreased intensity, and greater individualization (Sacks, 2000). MTCs for people who are homeless, often developed in shelter settings, incorporate services to address clients’ multiple needs, such as education, vocation, legal, and housing placement services (Zerger, 2002).

What the Research Says. Recent studies of the MTC approach reveal significant decreases in drug use and criminal activity, and increases in psychological functioning and employment (DeLeon, 2000; Rahav et al., 1995; Sacks et al., 2001). MTCs tend to result in more positive outcomes for individuals with the most severe mental illnesses and for those who remain in treatment for longer periods of time (Zerger, 2002). Several studies have found MTCs to be cost-effective relative to the provision of services as usual (French et al., 1999; McGeary et al., 2000).

Self-Help Programs

Self-help programs represent a central feature of most substance abuse treatment plans and recently also have become an important source of support for individuals with mental illnesses. During the past decade, dual recovery/self-help programs also have emerged as an important adjunct to treatment for people in recovery from co-occurring mental illnesses and substance use disorders (Dupont, 1994; Pepper and Ryglewicz, 1996).

Self-help approaches have their roots in Alcoholics Anonymous (AA) and have grown to address a wide variety of addictions. Narcotics Anonymous and Cocaine Anonymous are two of the largest self-help organizations in the area of chemical addictions (CSAT, in press). Recovery Anonymous and Schizophrenics Anonymous support individuals with mental illnesses (Chamberlin and Rogers, 1990).

Self-help programs typically include the AA 12-step method, with a focus on developing personal responsibility within the context of peer support. However, specific applications vary according to the needs and orientation of individuals and agencies/communities. Secular groups emphasize individual empowerment without focusing on the spirituality of the 12-step approach. Perhaps because of their low cost, and the fact that they provide an important source of support, self-help programs are among the most commonly used outpatient services for people with substance use disorders who are homeless (Zerger, 2002).

What the Research Says. Self-help program participation decreases inpatient treatment and substance use and increases self-esteem for people with mental illnesses and substance use disorders. Individuals with mental illnesses in self-help groups report greater-self esteem, fewer hospitalizations, and better community adjustment (HHS, 1999). People with co-occurring mental illnesses and substance use disorders who are homeless experience a greater decrease in substance use when they have a high level of self-help group participation (Gonzalez and Rosenheck, 2002).

Self-help groups specific to co-occurring disorders can be an important adjunct to recovery for people who have both mental illnesses and substance use disorders. One study found that people with higher levels of support and greater participation in dual recovery programs reported less substance use and mental health distress and higher levels of well-being (Laudet et al., 2000). However, these results did not hold true for people with co-occurring disorders who participated in the more traditional single-focus, self-help groups.

Involvement of Consumers and Recovering Persons

Individuals recovering from serious mental illnesses and/or co-occurring substance use disorders play an increasingly important role in helping their peers recover. Indeed, the social model approach to recovery from substance use disorders is built on the belief that individuals in recovery can help each other as much, if not more, than professional staff can help them. People with serious mental illnesses and/or co-occurring substance use disorders who have been homeless may be especially effective in reaching their peers who are reluctant to seek help. Shared experiences between prospective clients and workers may ease the engagement process.

Some unique characteristics of staff in recovery and those who have been homeless include: their knowledge of the service system; their "street smarts"; their ability to develop alternative approaches; their flexibility, creativity, and patience; their understanding of an individual’s basic needs and preferences; and their ability to build rapport with people who are homeless. Consumers and recovering persons serve as positive role models, are a major force in the elimination of stigma and discrimination, and make good team members (Van Tosh, 1993).

Programs run by consumers and recovering persons—including drop-in centers, recovery support programs, case management programs, outreach programs, businesses, employment and housing programs, and crisis services—may be more "user-friendly" for people who are homeless or at risk of homelessness. The focus of service delivery in these organizations is on choice, dignity, and respect (Glasser, 1999). Further, such programs provide meaningful work for consumers and recovering persons. Staff in recovery from mental illnesses and substance use disorders, and those who have been homeless, also enhance the sensitivity of the system to the needs of their peers.

Finally, consumers and recovering persons should be involved actively in the design, implementation, and evaluation of community mental health and substance abuse services. They make valuable members of planning councils and advisory boards. People who were homeless can make equally important contributions to the development of services for people who currently are homeless.

What the Research Says. Consumers and recovering persons can make a unique and valuable contribution as program and agency staff. In particular, consumers and recovering persons have experiences and characteristics that enhance their ability to provide services to individuals who are homeless (Glasser, 1999; Van Tosh, 1993; Dixon et al., 1994). Programs must be prepared to support staff in recovery with adequate supervision and workplace accommodations, if necessary, and to educate and train other staff about employment for consumers and recovering persons (Van Tosh, 1993; Fisk et al., 2000).

Prevention Services

Services that prevent people with serious mental illnesses and substance use disorders from becoming homeless in the first place should be a critical component of a community’s plan to end homelessness. In its report, Outcasts on Main Street, the Federal Task Force on Homelessness and Severe Mental Illness called prevention efforts both humane and cost-effective (Federal Task Force on Homelessness and Mental Illness, 1992). Two years later, with publication of Priority: Home! The Federal Plan to Break the Cycle of Homelessness, the Interagency Council on Homelessness proposed a two-pronged approach to address homelessness: (1) expanding services to help those who have become homeless, and (2) addressing structural inadequacies in housing and social services to help prevent people from becoming homeless (Interagency Council on the Homeless, 1994).

Strategies designed to prevent homelessness among people with serious mental illnesses and/or co-occurring substance use disorders must be designed to reduce risk factors, such as lack of treatment for co-occurring disorders, which make individuals more susceptible to becoming homeless. Many of these risk factors have been discussed elsewhere in this report. Further, program planners and providers must work to enhance protective factors, such as supportive services in housing, that will mitigate against homelessness among vulnerable people (Lezak and Edgar, 1998).

What the Research Says. Homelessness among people with serious mental illnesses and/or co-occurring substance use disorders can be prevented. Discharge planning, sometimes referred to as re-entry or transition planning, is one effective prevention strategy. Providing short-term intensive support services immediately after discharge from hospitals, jails, or residential treatment has proven effective in preventing recurrent homelessness during the transition to other community providers (Rosenheck and Dennis, 2001; Shinn and Baumohl, 1999; Lezak and Edgar, 1998; Averyt et al., 1997; Susser et al., 1997).

Effective discharge planning should begin when an individual enters a hospital or jail. Elements of the discharge plan, which should be developed with the individual and should be culturally appropriate, include housing, health care, treatment, income, employment, entitlements, personal support, and life skills training (Rosenheck and Dennis, 2001; Shinn and Baumohl, 1999; Lezak and Edgar, 1998; Avery et al., 1997; Susser et al., 1997).

In addition to discharge planning, studies show that subsidized housing helps prevent homelessness, even for people with serious mental illnesses and/or co-occurring substance use disorders. Income support also is critical, since housing affordability is a function of both income and housing costs (Shinn and Baumohl, 1999).

Other Essential Services

Housing, treatment, and support services are the backbone of a comprehensive system of care for people with serious mental illnesses and/or co-occurring substance use disorders who are homeless or at risk of becoming homeless. But these evidence-based and promising practices must be offered as part of a full range of services that are appropriate, accessible, and acceptable to consumers and recovering persons.

The hallmarks of these services are outreach, choice, and ongoing support. Some of the services, such as psychosocial rehabilitation and supported employment, were designed for people with serious mental illnesses and have been adapted for individuals who are homeless. Other programs that were designed for people who are homeless also serve people who have serious mental illnesses and/or co-occurring substance use disorders. All of these efforts help prevent or end homelessness.

Primary Health Care

As noted previously, people with serious mental illnesses and/or co-occurring substance use disorders who are homeless are at risk for both minor and life-threatening diseases, including diabetes, liver disease, tuberculosis, Hepatitis B and C, and HIV/AIDS. Life on the streets makes it difficult to receive appropriate care.

Because of their low incomes, the high cost of health care, and inadequate or nonexistent private health insurance, most people with serious mental illnesses rely on Medicaid, Medicare, and other government programs to provide mental health services, medications, and general medical care. People with substance use as their primary disorder are ineligible for SSI and Medicaid, which increases their risk of homelessness and makes it especially difficult for them to get medical care once they become homeless.

Further, people with serious mental illnesses who become homeless may be unable to enroll in these programs or continue to receive their benefits. Complicated eligibility requirements, lack of a permanent address, and untreated mental illnesses and substance use disorders make it difficult for individuals to obtain and maintain the benefits to which they are entitled (GAO, 2000a; CHSF, 2003). As a result, they frequently use such high-cost services as emergency room and inpatient care. When they present in emergency rooms, they are at increased risk for hospitalization, where their medical conditions may prolong their stay. Their debilitated condition also makes them more vulnerable to attack on the street or in drop-in shelters (Fischer, 1992).

Special health care programs designed for people who are homeless feature outreach and intensive case management to address an individual’s full range of needs. These include the Health Care for the Homeless (HCH) program, administered by the HRSA’s Bureau of Primary Health Care in HHS.

HCH projects, many of which serve individuals who have serious mental illnesses and/or co-occurring substance use disorders, are designed to be comprehensive, accessible, and culturally competent in an effort to help patients exit homelessness (McMurray-Avila, 1997). Many of these programs use mobile, interdisciplinary treatment teams to reach people on the streets or in shelters rather than requiring facility-based care.

Trauma-Sensitive Services

Health care providers working with people who are homeless must screen for and address trauma, including past and ongoing physical and sexual abuse. Individuals unable or unwilling to speak about the trauma they have experienced may present with somatic disorders such as headaches and backaches. Untreated trauma may complicate the treatment for mental illnesses and substance use disorders, leaving individuals at risk for recurrent homelessness.

Alcohol and Drug Abuse Services

The goal of substance abuse treatment for people who are homeless is to prevent, deter, or eliminate substance use and addictive behaviors. Treatment services may include outreach, counseling and education, case management, day programs, detoxification, and self-help and peer support activities (McMurray-Avila, 2001). These services may be provided in outpatient settings and alternative living arrangements, such as residential treatment settings and community-based halfway houses.

Substance abuse treatment is particularly critical for individuals with co-occurring mental illnesses. A recent study revealed that among homeless clients with co-occurring disorders, those who reported extensive participation in substance abuse treatment showed clinical improvement comparable to or better than individuals without co-occurring disorders (Gonzalez and Rosenheck, 2002).

Mental Health and Counseling Services

People who are homeless must have access to a full range of outpatient and residential mental health services, including crisis interventions, individual supportive therapy, family or group therapy, medication management, and therapeutic approaches that address multiple problems. As noted previously, access to coordinated treatment for co-occurring mental illnesses and substance use disorders also is necessary and superior to other approaches for reducing alcohol and drug use, homelessness, and the severity of mental symptoms among people with co-occurring disorders (Carey, 1996; Drake et al., 1998).

The use of medications within specific parameters is an evidence-based practice for people with serious mental illnesses. Guidelines for the use of medication are being established and evaluated, but there are a number of promising practices that can, and should, be adapted to individuals with serious mental illnesses, including those who are homeless. For example, many people with serious mental illnesses have benefited from a new generation of antipsychotic medications, sometimes called "atypical" drugs. Because these new drugs generally produce fewer side effects, individuals are more likely to continue to take them (HHS, 1999).

Concern about cost and treatment approaches that require patients to "fail" on older medications first may keep some individuals from receiving these potentially beneficial drugs. In response, some states, such as Massachusetts and Texas, have issued guidelines about the use of the new generation medications. The Texas Medication Algorithm Project (TMAP) recommends the use of all of the atypical or novel antipsychotics, other than clozapine, for the initial treatment of schizophrenia (Mellman et al., 2001).

Treatment for people with mental illnesses and/or co-occurring substance use disorders is complicated by the interactive effects of psychoactive medications and illicit drugs or alcohol, as well as by the effects of prescribed psychoactive medications on people who have substance use disorders (SAMHSA, 2002b). In addition, clinicians need to be aware that different racial and ethnic groups, as well as women and men, respond differently to psychiatric medications. For example, many Asians and Hispanics with schizophrenia may require lower doses of antipsychotics than Caucasians to achieve the same blood levels (HHS, 1999).

Psychosocial Rehabilitation

The terms "psychosocial rehabilitation" and "psychiatric rehabilitation" often are used synonymously and interchangeably. Typically, psychosocial rehabilitation refers to a range of services, exclusive of clinical treatment, designed to help individuals with serious mental illnesses recover functioning and integrate or re-integrate into their communities. Psychosocial rehabilitation programs may or may not include the specific technology of psychiatric rehabilitation (P. Kramer, personal communication, December 3, 2001).

Psychiatric rehabilitation, as defined and developed by the Boston Center for Psychiatric Rehabilitation, is a specific, well-tested approach to helping people with serious mental illnesses function with success and satisfaction in environments of their choice with the least amount of professional intervention possible (Anthony et al., 1990). According to the philosophy of psychiatric rehabilitation, recovering is what people with psychiatric disabilities do; psychiatric rehabilitation is what helpers do to encourage the recovery process (Anthony, 1993).

Because psychiatric rehabilitation is an approach and not a program model, it can be applied in a variety of settings or programs, including case management and vocational programs that serve people who are homeless. Typically, such programs focus on independent living and social skills training, psychological support for individuals and their families, housing, vocational rehabilitation, social support, and access to leisure activities. Psychiatric rehabilitation programs that serve people who are homeless may have an added emphasis on outreach and on building trusting relationships that will allow individuals to explore their choices and learn the skills they need to succeed.

Randomized clinical trials have shown that participants in psychiatric rehabilitation programs have fewer and shorter hospital stays and are more likely to be employed (HHS, 1999). The emphasis on choice, on individual potential, and on real-world settings may be especially attractive to people with serious mental illnesses who are homeless and who have had prior negative experiences with professionally directed treatment programs. Indeed, studies of the use of psychiatric rehabilitation with people who are homeless indicate this approach successfully engages disaffiliated individuals, expands their use of human services, and improves their housing conditions, mental health status, and quality of life (Shern et al., 2000).

Income Support and Entitlement Assistance

People who are homeless need adequate income to help them secure and maintain housing. With limited work histories, they frequently must rely on Federal income and entitlement programs, including SSI. But many are not enrolled. Outreach to people with serious mental illnesses, especially those who are homeless, is essential to help them negotiate the benefits application, eligibility, and appeals process. The goals of outreach include (Bianco and Milstrey-Wells, 2001):

• Providing accurate information about disability benefits and work incentive programs;
• Helping individuals gather the required personal, financial, and medical documentation or referring them to programs that provide this assistance; and
• Helping individuals file an application and mount an appeal, if necessary.

In response to the need for knowledgeable advocates to help individuals navigate complex program requirements, the Social Security Administration (SSA) established the Benefits Planning, Assistance, and Outreach program, authorized to fund community-based outreach projects in every State. Outreach providers, trained by SSA, are knowledgeable about other Federal benefit programs, as well, such as the TANF, Medicaid, and HUD programs.

Knowledgeable case managers (including peer case managers) and clinicians can make an enormous difference in their clients’ ability to obtain and maintain disability benefits. With the client’s approval, case managers may request duplicate copies of SSA mailings, especially helpful for individuals who have difficulty understanding their responsibilities and responding in a timely manner.

Case managers also may serve as representative payees for clients who need help managing their benefit checks, or who fear that checks sent to shelter addresses will be stolen. About 25 percent of individuals who receive SSI have a representative payee.

Employment, Education, and Training

People with serious mental illnesses and substance use disorders, including those with histories of homelessness, want and need to work. For many, work helps them recover from their disabilities. Further, income from work may help individuals regain and maintain residential stability (Shaheen et al., 2001). Adequate standards of living and employment are associated with better clinical outcomes.

The same factors that place people with serious mental illnesses at increased risk of homelessness are challenges to obtaining and retaining employment (Lezak and Edgar, 1998). These include symptoms of their illness, lack of housing, stigma and discrimination, and co-occurring substance use disorders. Likewise, people with substance use disorders exhibit behaviors that often interfere with job success.

Therefore, people who are homeless need more services and support than traditional job training programs offer. Successful job training programs for people who are homeless include comprehensive assessment, ongoing case management, housing, supportive services, job training, job placement services, and followup (Northern Illinois University, 1991).

Employment program models effective for people with serious mental illnesses, including transitional employment, supported employment (an evidence-based practice), and individual placement and support, must be flexible in how they define success and be prepared to work with individuals who are homeless over the long-term. A "work-first approach," as opposed to extensive pre-vocational training, can motivate a person who is homeless to address other problems in his or her life. Thus, employment programs must strike a balance between requiring complete abstinence or freedom from symptoms and tolerating some substance use-related behaviors or symptoms of mental illnesses on the job (Shaheen et al, 2001).

Because mental illnesses often emerge in late adolescence or early adulthood, education and career plans may be interrupted. Individuals re-entering school have similar support needs to people adjusting to a competitive work environment, including a full range of housing, health and mental health, and support services (Shaheen et al, 2001).

Services for Women

Gender-specific programs have been shown to improve retention and outcomes for women in substance abuse treatment (Zerger, 2002). For example, a Los Angeles study that examined women treated in publicly funded residential drug treatment programs found that participants in women-only programs had more problems at program outset, but they spent more time in treatment and were twice as likely to complete treatment compared to women in mixed-gender programs (Grella, 1999).

Too often, however, treatment is geared to men and conducted with scant attention to women’s needs. For instance, women often dislike the confrontational approach common to substance abuse treatment. Further, the specific needs of mothers with children often are not met in existing treatment programs. In particular, research on homeless mothers with substance use disorders indicates that the lack of childcare is a significant barrier for many women seeking treatment (Zerger, 2002).

Because physical and sexual abuse are so common among women who are homeless and those who have mental illnesses and substance use disorders, programs designed for women must include an active program of trauma recovery (Harris, 1996). Women who have become homeless after fleeing a dangerous household need specialized residential assistance.

Low-Demand Services

As noted elsewhere in this report, individuals with serious mental illnesses and/or co-occurring substance use disorders who are homeless initially may be reluctant to engage in services. They may have had negative experiences with the behavioral health care system, lack the motivation to begin treatment, or be more concerned about their immediate needs for food, shelter, and income.

Experience has shown that flexible, low-demand services may accommodate individuals who initially are unwilling to commit to more extended care. The ultimate goal of such services is to increase an individual’s motivation for treatment and engage them in more intensive services (Zerger, 2002; McMurray-Avila, 2001). The need for such services was a major finding of the NIAAA Cooperative Agreement Program (NIAAA, 1992).

HUD recognized the need for low-demand services when it established its Safe Havens program for people who are homeless and have serious mental illnesses. Safe Havens are a type of supportive housing that serve individuals who, perhaps because of their illness, have refused help or have been denied or removed from other programs serving people who are homeless. Individuals are not required to participate in treatment but, as they are ready, are expected to re-engage in services and move to permanent housing with supports.

For individuals with substance use disorders, a sobering station is a low-demand setting that accepts people who are intoxicated and serves as a first point of contact with the human services system (Baumohl and Huebner, 1991). Likewise, the presence of chemical dependency staff in a shelter or drop-in center may introduce individuals to the availability of substance abuse treatment (Zerger, 2002).

Crisis Care Services

People with serious mental illnesses are in danger of becoming homeless when a crisis occurs, including exacerbation of symptoms, other medical emergencies, family stress, or the loss of a benefit check or employment. This is especially true for people with co-occurring substance use disorders. Providers must recognize the importance of being able to respond quickly to people in crisis, help them on-site if needed, and provide short-term crisis facilities to avoid unnecessary hospitalization and homelessness. Interdisciplinary, mobile crisis teams provide immediate assistance and may link individuals to community-based respite care (HHS, 1999).

Family Self-Help and Advocacy

As a result of their symptoms and behaviors, people with serious mental illnesses and/or co-occurring substance use disorders often strain the resources of their families to help and may become homeless as a result. Helping families cope with the difficult aspects of living with and providing ongoing assistance to their family members with serious mental illnesses may prevent these individuals from becoming homeless (Lezak and Edgar, 1998).

If family members understand issues such as the cyclic nature of mental illnesses, possible side effects of medication, and what to do when symptoms flare, they often are able to help their relatives maintain residential stability. In some cultures, the family is considered critical to a person’s recovery from mental illnesses and substance use disorders, and family members should be involved in treatment, as appropriate.

Respite services give families a much-needed break to the stressful responsibility of providing a home to a family member with a serious mental illness. In addition to their vital role as caretakers, family members can be successful advocates for improved treatment, increased funding, and ongoing research and education designed to improve the lives of all people with serious mental illnesses and/or co-occurring substance use disorders.

Culturally Competent Services

As noted previously, racial, ethnic, and cultural differences can determine how individuals define their problems, how they express them, whether or not they seek help, from whom they will accept help, and the treatment strategies they prefer (HHS, 2001). Practitioners, too, perceive clients through their own cultural lenses.

The basic tenets of cultural competence—accepting differences, recognizing strengths, and respecting choices—are critical to providing appropriate services to people who are homeless, especially those who have serious mental illnesses and/or co-occurring substance use disorders. While homeless people do not represent a separate culture per se, they have made adaptations to their circumstances that may affect the choices they make (Milstrey, 1994). For example, behavior that may appear dysfunctional to the clinician may be adaptive for life on the streets.

Agencies that offer culturally adapted services share common strategies. They match clients with providers who have the same language and culture; provide services in minority communities; offer flexible hours and walk-in services; include families in treatment, where appropriate; and allow clergy and traditional healers to participate in the treatment process if the client desires (Flaskerud, 1986; Dana et al., 1992).

Criminal Justice System Initiatives

People with serious mental illnesses and/or co-occurring substance use disorders who are homeless have frequent contact with the legal system, both as offenders and as victims. There are a number of points at which the mental health, substance abuse, and criminal justice systems can work together more effectively to address the multiple needs of people with serious mental illnesses and/or co-occurring substance use disorders in the criminal justice system.

For example, the Sequential Intercept Model, developed by Steadman et al. (The National GAINS Center, unpublished paper) is based on the idea that people move through the criminal justice system in reasonably predictable ways. The five points of interception are: (1) law enforcement/emergency services; (2) initial detention/initial hearings; (3) jails, courts, forensic evaluations, and hospitalization; (4) re-entry; and (5) community corrections and community support. Use of the model helps communities visualize how the local mental health, substance abuse, and criminal justice systems intersect as they serve individuals with mental illnesses and substance use disorders. Interventions at several of these points are described below.

Diversion

Individuals with serious mental illnesses or co-occurring disorders who are homeless can be diverted from the criminal justice system either before or after charges have been filed (pre-booking and post-booking, respectively). Drug, mental health, and homeless courts—sometimes referred to as problem-solving or collaborative justice courts—are one model of diversion that shows increasing promise for keeping nonviolent offenders with serious mental illnesses and/or co-occurring substance use disorders from cycling in and out of jails and prisons.

Drug courts combine treatment with intensive judicial supervision, mandatory drug testing, and escalating sanctions to help people break the cycle of addiction and the crime that often accompanies it. Individuals also receive such necessary services as education or job skills training.

Research shows that drug courts have an impact on both drug use and recidivism. A National Institute of Justice evaluation of the Nation’s first drug court in Miami showed a 33 percent reduction for re-arrests for drug court graduates, compared to other offenders with substance use disorders. Fifty to 65 percent of drug court graduates stopped using drugs (Curie, 2002).

Jurisdictions with drug courts also report savings in jail/prison costs as a result of drug court programs. In 2001, the Drug Court Clearinghouse reported that the average annual number of jail/prison days saved per drug court program was 10,113, for a per program cost savings of $667,694 (DOJ, 2001).

Mental health courts based on this model are being developed to divert people with serious mental illnesses into treatment. An evaluation of the first two years of the Seattle Mental Health Court found that the target population experienced a decrease in criminal justice involvement and an increase in mental health treatment engagement (Haimowitz, 2002).

More recently, communities have begun to adapt this model to help homeless people resolve misdemeanor cases, with the added twist that the court goes to the defendant. "The Homeless Court program brings the law to the streets, the court to the shelters, and the homeless back into society," notes the American Bar Association (Binder, 2002). Participation is voluntary, and "sentences" include life-skills training, 12-step meetings, computer training or literacy classes, job training, counseling, or volunteer work.

The homeless court program began in San Diego in the late 1980s as part of a "stand down" to provide multiple services to homeless veterans. In 1999, the San Diego Public Defender’s Office began holding a monthly homeless court at local shelters, which removes barriers to participation for individuals whose days are spent looking for shelter, income, and food. In addition, helping homeless people resolve outstanding warrants and criminal misdemeanor cases paves the way for receipt of such vital services as housing, mental health and/or substance abuse treatment, public benefits, and job training and employment (Binder, 2002).

Comprehensive Services

Diversion programs cannot exist in isolation. They must be part of a comprehensive array of other jail services—including screening, evaluation, short-term treatment, and discharge planning—and must be integrated with community-based mental health and substance abuse treatment, housing, and social services (CMHS, 1995). So-called "boundary spanners" can bridge the two systems and serve as a liaison among mental health and drug courts, local police, and treatment providers (Steadman, 1992).

Treatment for people in jails and prisons improves justice operations and increases the likelihood that individuals will make a successful return to the community. In her review of effective treatment programs for people with co-occurring mental illnesses and substance use disorders in the justice system, Hills defines a set of program principles for successful outcomes:

• Services for people with co-occurring disorders must focus on the integration of treatment programming;
• Both disorders should be treated as primary;
• Services should be individualized and address symptom severity and skill deficits;
• Psychopharmacological interventions should be used when appropriate;
• Phases of intervention must be tailored to the setting;
• The treatment continuum must extend into the community; and
• Support and self-help groups are critical in successful reintegration to the community (2000).

Re-Entry Planning

Jail stays are frequently short, and some individuals cycle through jails dozen or even hundreds of times without ever being connected to community services. Re-entry planning must begin at admission; otherwise a person with a mental or substance use disorder who enters jail in a state of crisis may leave before the crisis can be addressed. This places individuals at risk of relapse, re-arrest, homelessness, and suicide.

Numerous multisite studies of jail mental health programs suggest best practices for people with co-occurring mental illnesses and substance use disorders who are released from jail. Osher et al. (2002) propose one such model called APIC, which includes the following components:

• Assess the inmate’s clinical and social needs and public safety risks;
• Plan for the treatment and services required to address the inmate’s needs;
• Identify required community and correctional programs responsible for post-release services; and
• Coordinate the transition plan to ensure implementation and avoid gaps in care with community-based services.

Jails legally are required to screen and identify inmates with co-occurring disorders and provide crisis intervention and psychiatric stabilization. Successful transition to community services can occur only if the justice, mental health, and substance abuse systems have a capacity and a commitment to work together on behalf of the individuals they serve (Osher et al., 2002).

Supportive housing may be an appropriate adjunct to re-entry planning, according to the Corporation for Supportive Housing, which has prepared a guide to re-entry supportive housing for former inmates (CSH, 2002b). Many of the individuals who leave jails and prisons are the very same individuals served by supportive housing, including those who face persistent mental health, substance use, and other chronic health challenges, and are at risk of homelessness, the CSH report notes. Again, such an approach requires collaboration and commitment among the housing, health care, social services, and justice systems.

SAMHSA’s Leadership in Evidence-Based Practices

SAMHSA has been a leader in the development of evidence-based practices for people with serious mental illnesses and substance use disorders, including those who are homeless. SAMHSA develops technical assistance materials to help providers adapt and adopt evidence-based practices and sponsors grant programs that develop and evaluate science-based interventions for people with mental illnesses and substance use disorders. Some of these programs were described in Chapter 1. Information on additional resources follows. More information on these programs and services is available on the SAMHSA web site at www.samhsa.gov.

The Evidence-Based Practices Project

SAMHSA is a sponsor of the Implementing Evidence-Based Practices for Severe Mental Illness Project, a joint effort of SAMHSA and the Robert Wood Johnson Foundation, The National Alliance on Mental Illness (NAMI), and state and local mental health organizations in New Hampshire, Maryland, and Ohio. The project’s goal is to develop implementation toolkits to promote the delivery of effective practices for people with serious mental illnesses and/or co-occurring substance use disorders, including those who are homeless.

Each toolkit includes specific information for funders, administrators, clinicians, consumers and recovering persons, and their families. Current toolkit topics include medication management, family psychoeducation, ACT, co-occurring disorders, supported employment, and illness management and recovery.

Community Action Grants for Service System Change

The Community Action Grant for Service System Change program, administered by SAMHSA’s CMHS, supports the adoption and implementation of exemplary practices for children with serious emotional disturbances or adults with serious mental illnesses, including those with co-occurring substance use disorders. Phase I grants support consensus-building among key stakeholders to adopt an exemplary practice in their community or state. Phase II grants support implementation of the practice with funds for training and other nondirect services. Both phases of the program include process evaluations.

SAMHSA’s CSAT Targeted Capacity Expansion Program

CSAT’s Targeted Capacity Expansion (TCE) program helps communities address gaps in treatment capacity. The TCE program supports rapid and strategic responses to demands for substance abuse treatment, including alcohol and drug use services. Grantees may include communities with serious, emerging drug problems, as well as communities with innovative solutions to unmet needs.

Addiction Technology Transfer Centers (ATTCs) and Centers for the Application of Prevention Technology (CAPTs)

SAMHSA uses regionally based centers to help communities adopt evidence-based practices in the prevention and treatment fields. Addiction Technology Transfer Centers (ATTCs) are a nationwide, multidisciplinary resource that transmits the latest knowledge, skills, and attitudes of professional addiction treatment practice. Launched by CSAT in 1993, the ATTC network comprises 14 regional centers and a national office that help treatment systems adopt or adapt evidence-based practices for people with substance use disorders, including those with co-occurring mental illnesses. CAPTs are structured similarly and perform the same function for evidence-based substance use prevention strategies.

Treatment Improvement Protocols (TIPS)

SAMHSA’s Treatment Improvement Protocol (TIP) series for substance abuse treatment professionals translates evidence-based research findings in substance abuse treatment to the clinical setting. Each TIP focuses on a specific age group (e.g., adolescents, older adults), a group with special needs (e.g., people with co-occurring disorders, individuals impacted by domestic violence), or a particular clinical practice (e.g., motivational enhancement, brief interventions). TIPs are available at www.SAMHSA.gov/centers/CSAT2002

Developing Services That Will Last

Programs that use evidence-based and promising practices can produce positive outcomes for people with serious mental illnesses or co-occurring disorders who are homeless. The ability to show that these services produce measurable results will help sustain programs that are competing for limited funds, often in a managed care environment.

The final two chapters of this report comprise Section IV: Sustain Services. Chapter 7 examines the types of outcomes that can and should be measured and the use of management information systems to track client data. Chapter 8 looks at ways to improve the availability and accessibility of mainstream resources for people with serious mental illnesses and/or co-occurring substance use disorders who are homeless.

Table 6.1. Essential Service System Components

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