Helping homeless individuals with co-occurring disorders: the four components.
Abstract: Homeless individuals with co-occurring disorders (CODs) of severe mental illness and substance use disorder are one of the most vulnerable populations. This article provides practitioners 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 homeless, impoverished, or at risk of homelessness; (2) increasing the resources of homeless individuals with CODs by helping them apply for government entitlements or supported employment (3) linking homeless individuals to supportive housing, including housing first 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
Article Type: Report
Subject: Homeless persons (Psychological aspects)
Homeless persons (Health aspects)
Social service (Analysis)
Mental illness (Contracts)
Substance abuse (Care and treatment)
Substance abuse (Analysis)
Author: Sun, An-Pyng
Pub Date: 01/01/2012
Publication: Name: Social Work Publisher: Oxford University Press Audience: Academic Format: Magazine/Journal Subject: Sociology and social work Copyright: COPYRIGHT 2012 Oxford University Press ISSN: 0037-8046
Issue: Date: Jan, 2012 Source Volume: 57 Source Issue: 1
Topic: Event Code: 490 Contracts & orders let; 610 Contracts & orders received Computer Subject: Contract agreement
Product: Product Code: 9105130 Social Service Support Programs; 8000143 Alcohol & Drug Abuse Programs NAICS Code: 92313 Administration of Human Resource Programs (except Education, Public Health, and Veterans' Affairs Programs); 62142 Outpatient Mental Health and Substance Abuse Centers SIC Code: 8093 Specialty outpatient clinics, not elsewhere classified
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 294900192
Full Text: Helping vulnerable client 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 client populations. Compared with homeless individuals without CODs, SMI, or SUD, who often are just transitionally homeless, individuals with CODs are more likely to experience chronic homelessness (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 child social work; 22 percent were in public 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 public health and medical field and the mental health and substance abuse field, are likely 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 literature review. Relevant articles were located via database searches of PubMed, PsycINFO, and Social Work Abstracts, using the key words "homeless individuals," "homelessness," "housing," "co-occurring disorders," "dual diagnosis," "mental disorders," "schizophrenia," "bipolar," "substance abuse," "substance dependence," "substance use disorders," and "treatment," plus the reference lists of located articles. Because research on the homeless population with CODs and SMI using randomized controlled trials (RCTs) is still 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-experimental designs; observational studies; qualitative studies; the 'consensus of expert clinicians,' in a few sources in which research evidence was combined with consistent expert opinion (Burt et al., 2004; Caton et al., 2007; Center for Substance Abuse Treatment [CSAT], 2005; Ziedonis et al., 2005)--were adopted. Rog (cited in Caton 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 findings: (1) ensuring effective transition, (2) increasing resources via government 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 released from institutions (for example, psychiatric hospitals, substance abuse treatment programs, correctional facilities, foster care) into the community without receiving proper transitional services is critical to reducing homelessness among individuals with CODs (Burt et al., 2004). The literature contains six strategies for more 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 responsibility of the institution 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, & Rossler (2006) suggested that institutions develop a discharge plan for a homeless client with CODs immediately after his or her admission to an inpatient setting. A thorough discharge plan provides a projected discharge date, gathers medical records, arranges postrelease housing, coordinates medical and mental health care, and brings together other community services (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 first months after discharge, when a client's relationship with people in the community may be fragile, 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 appointments 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 empirical studies also showed that CTI recipients tend to do better with respect to housing, alcohol and other drug (AOD) use, and psychiatric symptoms (Kasprow & Rosenheck, 2007, a nonrandomized two-cohort comparison study) and negative psychiatric symptoms (Herman et al., 2000, a randomized two-group design). Psychiatric symptoms may include positive and negative symptoms. Positive symptoms may include delusions, hallucinations, grossly disorganized/catatonic 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 homeless nights at a lower expense compared with the usual care approach (Jones et al., 2003).

Providing Motivational Interviewing before Discharging Clients

Research suggests that a motivational interviewing (MI) session prior to hospital discharge may increase the likelihood 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 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 beginning 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 accepted or admitted to the treatment program or for actually starting the treatment), providing orientation, engaging clients early (to build a trust relationship or alliance with clients 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 (Karniel-Lauer et al., 2000 [N = 751).

Allocating Funds

Providing funds for rent, deposits, and utility payments to homeless clients with CODs before they secure employment or government benefits can help them transition from institutions to the community (Foote, Tucker, & Millspaugh, 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 participants 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 disability (Tsemberis & Eisenberg, 2000). Compton et al. (2003) found that whether individuals with SMI have "sufficient income for housing" was one factor predicting homelessness. Linking individuals to government entitlements and connecting them with SE are two strategies to increase their income.

Applying for Government Entitlements

Many homeless people, although eligible for government entitlements, do not receive, apply for, or maintain such benefits (Long, Rio, & Rosen, 2007; Page & Nooe, 2002; Zuvekas & Hill, 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 preceding month predicted women's nonhomelessness (p = .001). Some individuals may exit from the original Temporary Assistance for Needy Families (TANF) rolls because they were sanctioned; others may be removed from TANF rolls 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 puzzling, 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 from seeking services.

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

In addition, lack of verifying identity or other documentation and permanent address often prevents homeless individuals from successfully completing the application process. Furthermore, many homeless individuals lost their Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) under the 1997 policy change that eliminated AOD addiction as a legitimate disability. Despite this, statistics showed that only 11 percent of homeless individuals surveyed were getting SSI and only 8 percent of homeless individuals were getting SSDI, whereas it is estimated that 46 percent of homeless individuals had physical disabilities and 39 percent of homeless individuals had mental health problems (cited in Long et al., 2007).

Practitioners should be equipped with knowledge 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 Outreach, 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 applications was only 10 percent to 15 percent prior to SOAR, whereas it dramatically increased in states that participated 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 duration of homelessness.

However, individuals with CODs face obstacles in seeking and maintaining employment. One hindrance is the fear that employment may jeopardize 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, individuals 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 counseling to clients with CODs and their families to empower them to make informed decisions regarding employment (Biegel, Ronis, & Boyle, 2008). Although various attempts have been made to address the issue of SSI and SSDI being disincentives for benefits 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 individuals' 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 disorders 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, 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 prevocational training and sheltered jobs before being linked 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 individualized and longterm support after they obtain employment so as to prolong job tenure, and works collaboratively with other team members (Becker et al., 2005).

More SE studies, however, have been done on individuals with mental disorders than on individuals with CODs (Biegel et al., 2008). Biegel et al's study revealed that although the competitive employment rates of clients with CODs who received SE were lower than those in SE clinical 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' employment. Both findings facilitated the inference that SE can be effective with clients with CODs (Biegel et al., 2008). Becker et al. (2005) suggested three guidelines for applying SE to help individuals with CODs:

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

2. Employment specialists 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 link 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 will not be used to purchase 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 successfully treat the COD problems of homeless clients, practitioners must help them obtain and maintain housing. The literature has consistently 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 literature.

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-dwelling homeless person's life;

* organizing various agencies under one central unit so that the operation can be more efficient and each client's data can be more complete;

* ensuring that the outreach team has direct access to supportive and "low-demanding" housing and full support from the city's mental health, AOD treatment, and health treatment programs, as an outreach would be futile 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 community to engage homeless individuals; and

* targeting the areas where chronically homeless individuals cluster.

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

Triaging and Linking Clients with Proper Permanent Housing

Nelson, Aubry, and Lafrance's (2007) review of 16 controlled studies showed that supported and permanent housing have a positive effect in combating 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 public housing (for example, Section 8) and their finding steady independent living arrangements. Clark and Rich (2003) found that a comprehensive housing program that ensures both housing and case management, as opposed to a program with only case management, appears 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 appears to be successful for combating chronic homelessness, it may be easier for clients with SMI than for clients with SUD or CODs to obtain and maintain public housing. Individuals with SUD or SUD histories may face more difficulty in applying for public housing than do others because of their AOD problems and the frequent connection between AOD use and criminal behaviors. Both the official and unofficial housing policies 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 applicant and his or her family members when determining eligibility for or eviction from federally subsidized housing (Dickson-Gomez et al., 2007). The Quality Housing and Work Responsibility Act of 1998 (P.L. 105-276) (QHWRA) also requires Section 8 and public housing agencies to exclude any applicant who was "evicted from public, federally assisted, or Section 8 housing because of drug-related criminal activity," and that ban may last for three years after the applicant'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 favorable toward individuals with SUD or SUD histories, and the ultimate eligibility 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 users in a disadvantageous 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 qualitative study revealed that housing caseworkers can exercise much discretion in the final say regarding housing applications, and they may favor applicants without an AOD problem or history due to their higher likelihood of maintaining 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 clients with CODs. Other barriers may include frequently long waiting lists and the recent shortfall of federal funding. For example, the Las Vegas Housing Authority (LVHA) has currently closed its housing application process, and it is not expected to reopen for three or more years when federal funds become available (personal communication, LVHA, August 2009).

Considering Housing First as Opposed to Treatment First Practice

Unlike the traditional treatment first (TF) approach, 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 clients, but also results in similar AOD treatment outcomes (Padgett, Gulcur, & Tsemberis, 2006 [RCT {N=225}] Tsemberis & Eisenberg, 2000 [quasi-experimental {N = 1,842}] Tsemberis, Gulcur, & Nakae, 2004 [RCT {N = 225.}]) Lipton et al. (2000 [quasiexperimental {N = 2,937}]) also found that individuals with CODs residing in highly structured housing programs may have a lower level of residential stability than their counterparts residing in housing programs flexible regarding AOD issues. Homeless individuals who have "failed" 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 client autonomy (for example, "no curfew") and privacy (for example, "a room with a key") (Lincoln, Plachta-Elliott, & Espejo, 2009 [qualitative study {N = 16}]).

An HF program is not completely unconditional; 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 drags on the premises (Burt et al., 2004). Some HF programs only require tenants to comply 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' ability 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 focusing 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 policies that "housing or services would not be denied to a person coming off the streets after many years who feels mistrustful about agreeing to money management" (Tsemberis & 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 nonpayment 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 essential to make treatment attractive to them. A modified assertive community 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 friends with clients, and creating social activities (for example, holding birthday parties) (Burt et al., 2004). Burt et al. emphasized that the best referrals actually come from 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 still limited regarding effective techniques that produce change among individuals with CODs (Bellack, Bennett, Gearon, Brown, & Yang, 2006; Cleary, Hunt, Matheson, & Walter, 2009). Nonetheless, the literature stressed three elements: (1) an integration of psychiatric and AOD treatments, (2) treatment as a long-term process, and (3) harm reduction (Bellack et al., 2006). Drake et al. (2001) also suggested four stages: (1) engaging individuals with CODs by using outreach techniques, linking them with practical assistance, and establishing a trusting relationship; (2) motivating them to get involved in COD treatment and offering individual counseling and groups (persuasion); (3) equipping them with the skills and support (groups or family) to manage illnesses 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 linear. A client may enter treatment 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 involved in the elements and stages of COD treatment.

Assertive Community Treatment

To engage homeless individuals with CODs, a more intense and proactive intervention may be necessary (DiClemente, Nidecker, & Bellack, 2008). Assertive community treatment (ACT)--an approach that emphasizes outreach, community tenure, practical and intensive case management, small caseloads (usually a client-worker ratio of 10 to 1), 24-hour service, and interdisciplinary 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, Maim, & Rossler, 2001). The inconsistency could be related to differing 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, clinical 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 clinical case management approach for clients with CODs and antisocial personality disorder (ASPD), whereas ACT and the clinical case management approach created similar treatment outcomes for dually disordered clients without ASPD. More research is needed regarding successfully matching clients with ACT, step-down programs, and regular chnical case management.

Modified Motivational Interviewing/ Motivational Enhancement Therapy

Motivational interviewing (MI)/motivational enhancement therapy (MET) produces some evidence 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, mostly with a randomized design). For example, Graeber, Moyers, Griffith, Guajardo, & Tonigan's (2003 [N=30]) RCT found that, compared with an educational treatment 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 intervention may help clients with CODs of schizophrenia and substance use disorders (Barrowclough et al., 2001 [N = 36]) and that combining MI, contingency management, and social skills training resulted in better treatment outcomes than did the control condition ("a supportive group discussion") among clients with CODs (Bellack et al., 2006 [N = 175]).

MI/MET facilitates change and helps a client move from a more initial stage (for example, precontemplation) to a more advanced stage (for example, contemplation, determination, action. Clients compare their baseline AOD use with the normative data, develop discrepancies between where they are and where they want to be, discuss the role of AOD use as a barrier preventing them from being where they want to be and the role of quitting AOD as a facilitator promoting 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 experience a lower motivation to change because of their positive symptoms (for example, delusions, hallucinations) and negative symptoms (for example, anergia, avolition), other cognitive limitations, low self-efficacy, or limited external resources and support systems (Carey, Purnine, Maisto, & Carey, 2001; DiClemente et al., 2008; Horsfall, Cleary, Hunt, & Walter, 2009). Although 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 structure--clients with CODs (including clients with schizophrenia) can reflect on the pros and the cons of their substance-using behavior and be involved 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, DiClemente et al., 2008; Horsfall et al., 2009), and empirical studies (for example, Carey et al,, 2001) suggest the following strategies to modify MI/ MET to help clients with CODs.

Empathy and an Alliance with the Client. clients with CODs, especially those with SMI, are less able than others to tolerate stress, confrontation, 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 (Ziedonis et al., 2005), which can be helped by conveying 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 Compliance. Modified MI/MET should be applied not only to SUD, but also to SMI problems. Psychiatric medication noncompliance is especially prevalent among individuals with CODs with psychosis (CSAT, 2005). Individuals with schizophrenia and co-occurring SUD are less likely to adhere to medication regimens than are individuals with only schizophrenia (Ziedonis et al., 2005). Psychiatric medication noncompliance has a tremendous effect on a person's function and presenting symptoms (CSAT, 2005); individuals with psychotic disorders must take antipsychotic medications to control their psychotic symptoms (Evans & Sullivan, 2001). clients with CODs need to be motivated to manage their psychiatric disorders (including medication comphance) and to understand 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, distrust 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 medications for fear of the alcohol-medication interaction (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). Medication compliance may be facilitated by

* using all appointments to discuss the medications--the purpose, the expected time course 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 pills, depot injections, 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 antipsychotic 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. Theoretically, it would be safer to adopt total abstinence (versus 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, & McGovern, 2005). In reality, however, clients with CODs may experience more difficulty in achieving total abstinence than do clients with SUD because of their impaired cognitive functions and other psychiatric symptoms (Carey et al., 2001, 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 consequences needs to be presented to clients repeatedly, and opportunities need to be offered to practice newly learned skills over and over (Evans & Sullivan, 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 client identify his or her internal triggers (thoughts, feelings, and emotions) and external triggers (events, activities, and incidents) and learn skills to effectively deal with those triggers. RCTs have reported efficacy in MI with CBTs in improving alcohol problems among clients with CODs of depression and AOD disorders (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 outcomes of clients with CODs, including clients with comorbid schizophrenia and AOD disorders. Their review further showed inconsistent support for the application of stand-alone CBT to help individuals with CODs--a 16- to 20-session round of CBT targeting clients with bipolar disorder appeared to be effective, whereas a 6- to 12-session round of CBT working with clients with schizophrenia 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 clients are stabilized (both their SUD and their mental disorders);

* building a working alliance and rapport;

* having clients be active participants, with the clinician being mainly an educator;

* starting low and going slow, with the clinician understanding that it takes trust and time for the clients to change and refraining from pushing clients too soon to address their ingrained habits of thoughts;

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

* helping clients learn specific coping skills to deal with the combined trials of SUD and mental disorder;

* accommodating clients' cognitive limitations and refraining from addressing too many specific 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 client's desirable behaviors by providing incentives and discourages the client's undesirable behaviors by using disincentives (Petry, 2000). Numerous studies have indicated the positive effects of CM in reducing the substance use and other negative behaviors of clients with SUD, at least in the short term (Higgins, Alessi, & Dantona, 2002; Prendergast, Podus, Finney, Greenwell, & Roll, 2006), Contingency management has also recently been found to be efficacious with clients with CODs (Cleary et al.'s, 2009, review of three RCT studies [Drebing et al., 2005; Pies 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; Helmus, Saules, Schoener, & Roll, 2003; Ries et al., 2004; 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 clients.

However, two issues need to be noted. Some researchers believe that both a client'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 rehabilitation 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 reinforcers stopped. Research suggests combining MI/ MET with CM (Bellack et al., 2006; Drebing et al., 2007). The second issue is the cost, as CM necessitates provision of a concrete reward to a client 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 organizations and companies;

* applying CM only to individuals with severe impairments (not all individuals need CM to change); and

* using nonmonetary rewards.

Although CM is considered highly promising in helping clients with CODs, research is still 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 members with CODs because of the stigma attached to having a mental disorder;

* it may stick to the total abstinence orientation, which may influence members with CODs to stop taking prescribed psychiatric medications, despite this not being the official position of the Alcoholics Anonymous or Narcotics Anonymous organizations; and

* its collective insights may not necessarily benefit members 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 allows for open discussion of not only AOD issues, but also issues related to mental disorders, psychiatric medications, medication side effects, psychiatric hospitalizations, and other issues regarding which participants might experience stigma if discussed in mainstream 12-step groups (Bogenschutz, 2005), Magura et al. (2003) of specialized 12-step groups showed that by helping others, an individual reinforces self-learning of valued behaviors and that by sharing recovery experiences, individuals 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 mainstream self-help groups do (Bogenschutz, 2007). A two-year follow-up study of Double Trouble in Recovery (DTR), a specialized 12-step group (N=310), conducted from 1998 to 2000 by Magura and colleagues 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 attendance, 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 recovery, and (4) quality of life.

Most specialized self-help group studies (for example, Magura et al.'s, 1998-2000, study) suffered from a lack of a control group (the same issue applies to the studies of mainstream self-help groups). To improve the research design, Magura et al. (2008) recently conducted a quasi-experimental 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 findings. Because the specialized 12-step group has a relatively shorter history, treatment programs should facilitate linkages between their clients with CODs and such groups. Clients with CODs who are in more advanced recovery should also be encouraged to assume a facilitator's role; both a manual and facilitator training are available from the founders 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 challenging tasks. This article suggests four components in this regard: (1) ensuring effective transition of homeless individuals from institutions into community living; (2) helping them apply for government entitlements and obtain SE; (3) linking them with supported and supportive housing, a task that particularly demands practitioners' creative thinking in the context of the current economic crisis, which has cut housing resources; and (4) applying and combining modified ACT, clinical case management, MI/MET, CBT, CM, and specialized 12-step groups to maximize treatment effects. All four components are consistent with social work values; they help social workers to affirm and empower clients 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 to 60 percent were women, with a few studies being extreme, including 100 percent men, 100 percent women, or only seven percent women in a veterans study). Although this reflects the actual gender distribution in that chronically homeless individuals are more likely to be men, understanding of chronically homeless women with CODs will 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 participants composed a higher percentage than did other ethnic groups. This is consistent with statistical data indicating a higher percentage of African Americans among the homeless population. Also, the research data covered here were mostly collected from major cities in the United States, with only little from rural areas; rural homeless individuals may have different needs than do urban homeless individuals. One other issue is that this article focuses only on individual homeless clients, not homeless families, as it targets chronic homelessness (or homeless clients with CODs), and homeless families are less likely than homeless individuals to be chronically homeless. (Nonetheless, 30 percent of the U.S. homeless population are families with children, and practitioners should prepare themselves to help these families.) Finally, COD treatment methods, although emerging and promising, are still in their infancy, and more studies with rigorous designs are needed.

doi: 10.1093/sw/swr008

Original manuscript received November 24, 2009

Final revision received May 31, 2010

Accepted June 9, 2010

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An-Pyng Sun, PhD, LCSW, is professor, School of Sodal Work, University of Nevada, Las Vegas, 4505 Maryland Parkway, Box 455032, Las Vegas, Nevada, 89154-5032; e-maih an-pyng.sun@unlv.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.
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