Helping Homeless Individuals withCo-occurring Disorders: The Four Components

An-Pyng Sun

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

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

H elping vulnerable cUent populations haslong been a major mission of the socialwork profession (National Association

of Social Workers, 2008). Homeless individualswith co-occurring disorders (CODs) of severemental illness (SMI) and substance use disorder(SUD) are one of the most vulnerable cHent pop-ulations. Compared with homeless individualswithout CODs, SMI, or SUD, who often are justtransitionally homeless, individuals with CODsare more likely to experience chronic homeless-ness (Caton, Wilkins & Anderson, 2007; Kuhn &Culhane, 1998). Compared with individuals withCODs, SMI, or SUD who are not homeless.Homeless individuals with CODs, SMI, or SUDare less likely to engage in treatment and torecover from their diseases. Social workers maycome across chronically homeless clients invarious practice fields. During 2008, among the642,000 positions held by social workers, 46percent were in family, school, and chud socialwork; 22 percent were in pubhc health andmedical social work; 21 percent were in substanceabuse and mental health social work; and 11percent were in other types of social work(Bureau of Labor Statistics, n.d.). Practitioners inall four fields, though particularly the pubhchealth and medical field and the mental health

and substance abuse field, are hkely to encounter,directly or indirectly, homeless clients with CODsand related challenges. It is critical that both socialwork students and practitioners be equippedwith knowledge and skills to help this clientpopulation.

This article discusses strategies for helpinghomeless individuals with CODs on the basis of ahterature review. Relevant articles were locatedvia database searches of PubMed, PsycINFO, andSocial Work Abstracts^ using the key words "home-less individuals," "homelessness," "housing,""co-occurring disorders," "dual diagnosis,""mental disorders," "schizophrenia," "bipolar,""substance abuse," "substance dependence," "sub-stance use disorders," and "treatment," plus thereference hsts of located articles. Because researchon the homeless population with CODs and SMIusing randomized controlled trials (RCTs) is stülvery limited (Caton et al., 2007), all relevantlocated studies on the homeless population withCODs that used various levels of designs— forexample, RCTs; meta-analyses; quasi-experimen-tal designs; observational studies; quahtativestudies; the 'consensus of expert clinicians,' in afew sources in which research evidence was com-bined with consistent expert opinion (Burt et al.,2004; Caton et al., 2007; Center for Substance

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

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

COMPONENT 1: ENSURING EFFECTIVETRANSITION FROM INSTITUTION TOCOMMUNITYReducing the flow of at-risk individuals being re-leased from institutions (for example, psychiatrichospitals, substance abuse treatment programs,correctional facilities, foster care) into the com-munity without receiving proper transitional ser-vices is critical to reducing homelessness amongindividuals with CODs (Burt et al., 2004). Theliterature contains six strategies for niore effectivetransitions, with the enhancement of continuityof care being common feature (Compton et al.,2003).

Establishing Rules Regarding DischargePlanningState and local agencies should establish rules toensure a well-executed discharge plan that linksan institution that discharges an individual withthe community that takes in the individual (Burtet al., 2004). Some states have required dischargeplanning as a formal responsibüity of the institu-tion releasing a person, whereas other states treatit only as an informal responsibility. The lack ofpolicies about discharge may contribute to thedeemphasis on discharge planning, precipitatingdiscontinuity of care (Burt et al., 2004).

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

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

Offering Critical Time InterventionThe institutions that release individuals into thecommunity can offer critical time intervention(CTI) (Susser et al., 1997), an evidence-basedtreatment that goes one step beyond a dischargeplan. During the fint months after discharge,when a client's relationship with people in thecommunity may be frague, CTI strengthens theclient's adjustment to the community by pairingthe client with a social worker who visits theclient's community residence, accompanies theclient to appointments, and helps the clientdevelop relationships with people at the appoint-ments and provides advice in periods of crisis(Susser et al., 1997). Susser et al.'s RCT study (N= 96) found that during the 1.5-year follow-upperiod, the mean number of homeless nights was30 for CTI recipients, whereas it was 91(p = .003) for usual-service recipients. Later em-pirical studies also showed that CTI recipientstend to do better with respect to housing, alcoholand other drug (AOD) use, and psychiatric symp-toms (Kasprow & Rosenheck, 2007, a non-randotnized two-cohort cotnparison study) andnegative psychiatric symptoms (Herman et al.,2000, a randomized two-group design). Psychiat-ric symptoms may include positive and negativesymptoms. Positive symptoms may include delu-sions, hallucinations, grossly disorganized/cataton-ic behavior, and so on. Negative symptoms mayinclude affective flattening, alogia, avolition, andso on. Research shows that CTI not only reducesrecurrent homelessness among people with SMI,but it is also cost-effective in that it reduces home-less nights at a lower expense compared with theusual care approach Qones et al., 2003).

Providing Motivational Interviewingbefore Discharging ClientsResearch suggests that a motivational interviewing(MI) session prior to hospital discharge may in-crease the likehhood of a patient attending aninitial outpatient appointment (CSAT, 2005;Swanson, Pantalon, & Cohen, 1999). The MIsession addresses the differences between hospitaland outpatient treatment regarding the treatmentgoals and methods and engages the client to

24 Social Work VOLUME 57, NUMBER I JANUARY 2012

explore his or her own understanding of his orher clinical condition and commitment totreatment.

Engaging Clients EarlyCommunity agencies that accept clients releasedfrom institutions can play a role in promoting aneffective transition. Data indicate that the begin-ning period of treatment is one of three high-riskperiods for dropout among homeless clients(Orwin, Garrison-Mogren, Jacobs, & Sonnefeld,1999). It is risky because the clients need to adjustto new rules and demands, which may take a tollon 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 includereducing waiting time (for being formally accept-ed or admitted to the treatment program or foractually starting the treatment), providing orienta-tion, engaging clients early (to buud a trust rela-tionship or alliance with chents during the earlystage [for example, when clients initially entertreatment] and therefore motivate clients to stay intreatment) (Orwin et al., 1999), and forming ashort-term reentry group that facilitates outpatienttreatment participation and compliance using apsychoeducational approach (Kamiel-Lauer et al.,2000 [N= 75]).

Allocating FundsProviding funds for rent, deposits, and utility pay-ments to homeless clients with CODs before theysecure employment or government benefits canhelp them transition firom institutions to the com-munity (Foote, Tucker, & MOlspaugh, 2008).Forchuk et al.'s (2008) randomized study (N =14)showed that intervention group participants whoreceived immediate assistance with housing accessand rent on discharges from psychiatric settingsmaintained housing after three and six months,whereas all but one of the control group partici-pants remained homeless (the exception tradedsex to avoid homelessness).

COMPONENT 2: INCREASING THE RESOURCES

OF HOMELESS INDIVIDUALS WITH CODS

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

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

Applying for Government EntitlementsMany homeless people, although eligible for gov-ernment entidements, do not receive, apply for,or maintain such benefits (Long, Rio, & Rosen,2007; Page & Nooe, 2002; Zuvekas & HiH,2000). Wechsberg et al. (2003) found that havingan income below $500 in the preceding monthpredicted women's homelessness {p= .014),whereas receiving welfare income in the preced-ing month predicted women's nonhomelessness(p=.OOl). Some individuals may exit from theoriginal Temporary Assistance for Needy Families(TANF) roUs because they were sanctioned;others may be removed from TANF roUs withoutknowing what they needed to do to comply withthe rules (Page & Nooe). Nwakeze, Magura,Rosenblum, and Joseph (2003) considered thelow use of Medicaid and food stamps by homelesspeople puzzMng, because those two governmententitlements are not affected by the WelfareReform Act (part of the Personal Responsibilityand Work Opportunity^ Reconciliation Act of1996 [P.L. 104-193]). They offered three possibleexplanations:

1. Homeless individuals have a lower sense ofself-efficacy, which leads to deficientservice-seeking behavior.

2. Agency bureaucracy and staff discriminationdiscourage homeless individuals fiomseeking services.

3. Homeless individuals consider their housingneeds the top priority and Medicaid andother entidements secondary and do notpursue the secondary needs.

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

SUN / Helping Homeless Individuals with Co-occurring Disorders: The Four Components 25

disability. Despite this, statistics showed that only11 percent of homeless individuals surveyed weregetting SSI and only 8 percent of homeless indi-viduals were getting SSDI, whereas it is estimatedthat 46 percent of homeless individuals had physi-cal disabüities and 39 percent of homeless individ-uals had mental health problems (cited in Longet al., 2007).

Practitioners should be equipped with knowl-edge of community resources and the skills forlinking a homeless individual with governmententitlements. The Substance Abuse and MentalHealth Services Administration's SSI/SSDI Out-reach, Access and Recovery (SOAR) programprovides technical assistance to case managers andprogram staff in this regard. Data showed that thesuccess rate among SSDI/SSI apphcations wasonly 10 percent to 15 percent prior to SOAR,whereas it dramatically increased in states that par-ticipated in SOAR. For example, the averagesuccess rate in the 32 states involved in SOARwas about 71 percent during spring and summerof 2009 (Policy Research Associates, Inc. [PRA],2009). The application processing times were alsosignificantly reduced after SOAR implementation.For example, the processing time was eightmonths before SOAR training and 4.5 monthsafter SOAR training in Oregon (Long et al.,2007), and the average time to reach a decisionduring spring and summer of 2009 was 89 daysamong the 32 SOAR-participating states (PRA,2009). According to the Substance Abuse andMental Health Services Administration (2011), 37states reported SOAR-assisted 8,978 applicationsfrom 2006 to June 2010, with an approval rate of73 percent and an average time of 91 days fromapplication submission to approval.

Connecting with EmploymentHomeless individuals with SUD consider housingand employment to be two major factors thatkeep them homeless (Governor's Advisory on theHomeless, Oklahoma Department of HumanServices, cited in Foote et al., 2008). Caton et al.'s(2005) study found that being currently employedat time of homeless shelter admission or having aprevious employment history, even if currentlyunemployed, was associated with a shorter dura-tion of homelessness.

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

hindrance is the fear that employment may jeop-ardize their government benefits. Studies showthat receipt of SSI/SSDI benefits may discourageindividuals with mental disorders from pursuingcompetitive employment (Becker, Whitley,Bailey, & Drake, 2007 [N= 38]; Rosenheck et al.,2006 [N= 1,411]). Federal regulations require aperson's disability status to be reviewed on his orher return to work; an SSDI recipient's cashpayment may cease if his or her allowable incomeexceeds the substantial gainful activity level for aparticular number of months. Furthermore, indi-viduals who lose SSDI due to employment maybe at risk of losing other benefits, such as foodstamps, utility supplements, and housing subsidies(Polack & Warner, cited in Cook, Terrell, &Jonikas, 2004). Becker et al. (2007) found thatparticipants seemed to prefer part-time work,owing not only to its lesser demands, but also totheir perception of its allowing them to maintaintheir Social Security and other benefits. It is thuscritical to provide benefits counsehng to chentswith CODs and their families to empower themto make informed decisions regarding employ-ment (Biegel, Ronis, & Boyle, 2008). Althoughvarious attempts have been made to address theissue of SSI and SSDI being disincentives for ben-efits recipients to pursue better financial security,the results seem to be disappointing, and moreefforts are needed in this regard (Cook et al.,2004).

Other barriers to employment are an individu-als' COD symptoms, lack of self-efficacy, agency-level barriers, and society's biases. Becker et al.(2007) found that psychiatric illness is the primaryhurdle and that long-term supports and part-timeemployment are the major facilitators to work. SEhas been recognized as an evidence-based practicefor linking individuals with mental disorders orCODs to competitive employment; clinicalstudies 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 ofwhether they have mental disorden or CODs, toseek competitive employment (that is, work thatpays at least minimum wage and provides a non-segregated work setting) directly and swiftly. Theeligibility for job placement is an individual'schoice rather than his or her job readiness orabstinence from AOD (Becker, Drake, & Naughton,

26 Social Work VOLUME 57, NLIMBER I JANUARY 2012

2005). Studies have found that clients with mentaldisorders may achieve more success in obtainingand maintaining competitive employment if theyare being linked to competitive employment rightfrom the beginning rather than being linkedto prevocationaJ training and sheltered jobs beforebeing hnked to competitive jobs (Drake et al.,1999). One key person in SE is an employmentspecialist, who helps clients seek a competitivejob, provides them with individuaHzed and long-term support after they obtain employment so asto prolong job tenure, and works coUaborativelywith other team members (Becker et al., 2005).

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

1. Employment specialists and other teammemben should ensure optimism about aclient's ability to recover and to work andinstiU hope in the client, as the chent mayhave low self-efficacy.

2. Employment speciahsts and other teammembers should work together with theclient to create a detailed vocational profileand include in it the client's substance abusesituation. The specialist should unk theclient with a job that supports recovery (forexample, not a bartending job) and designan individualized treatment plan, so that, forexample, the client and the treatment teamcan develop a mutually agreeable moneymanagement plan so that the money earnedfrom employment wul not be used to pur-chase AOD.

3. Employment specialists and other teammembers should coordinate systems ofmental health treatment, AOD treatment,and vocational services.

COMPONENT 3: LINKING HOMELESSINDIVIDUALS WITH CODS TO HOUSINGTo successfriUy treat the COD problems of home-less clients, practitioners must help them obtainand maintain housing. The literature has consis-tendy suggested that most homeless clients withCODs or SUD place housing over other needs,such as psychiatric and addiction treatments(Nwakeze et al., 2003; Orwin et al., 1999). Threestrategies to help link COD homeless individualsto housing were addressed in the hterature.

Providing Effective OutreachResearch and consensus of expert clinicians (Burtet al., 2004; Murray, O'Donnell, & Speedling,2005) suggested that effective outreach mayrequire

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

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

• ensuring that the outreach team has directaccess to supportive and "low-demanding"housing and fuU support from the city'smental health, AOD treatment, and healthtreatment programs, as an outreach would befritile if "the other end of the spectrum" isnot ready to provide housing or treatmentwhen a homeless person is initially reached;

• conducting outreach during the day insteadof only at nighttime, as more resources areavailable during the day;

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

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

Some experts suggest involving trained law en-forcement officers who understand the philosophyof the helping professionals, as this may smooththe outreach work and protect the outreachworkers.

SUN / Helping Homeless Individuals with Co-occurring Disorders: The Four Components 27

Triaging and Linking Clients with ProperPermanent HousingNelson, Aubry, and Lafi:ance's (2007) review of16 controlled studies showed that supported andpemianent housing have a positive effect in com-bating chronic homelessness among people withmental disorders. Hurlburt, Wood, and Hough(1996) found a strong positive relationshipbetween individuals with CODs, SMI, or SUDhaving access to pubhc housing (for example.Section 8) and their finding steady independenthving arrangements. Clark and FUch (2003) foundthat a comprehensive housing program thatensures both housing and case management, asopposed to a program with only case manage-ment, appean to be more critical to people withsevere psychiatric symptoms and high substanceuse than it is to their counterparts with onlymedium- or low-level symptoms. For individualswith only medium- or low-level psychiatricsymptoms and a low level of AOD use, a casemanagement-only program can do as well as acomprehensive housing program.

Although offering permanent housing andsupport appean to be successful for combatingchronic homelessness, it may be easier for chentswith SMI than for clients with SUD or CODs toobtain and maintain pubhc housing. Individualswith SUD or SUD histories may face more diffi-culty in applying for public housing than doothers because of their AOD problems and thefrequent connection between AOD use and crim-inal behaviors. Both the official and unofficialhousing pohcies may place individuals with SUDat a disadvantage (Dickson-Gomez, Convey,Hilario, Corbett, & Weeks, 2007).

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

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

Unofficial policy may further exacerbatesubstance-abusing clients' housing applications(Dickson-Gomez et al., 2007). Dickson-Gomezet al.'s quahtative study revealed that housingcaseworkers can exercise much discretion in thefinal say regarding housing apphcations, and theymay favor apphcants without an AOD problem orhistory due to their higher hkehhood of maintain-ing housing tenure. The drug-using participantsin Dickson-Gomez et al.'s study stated thathousing caseworkers often disrespected andimposed bureaucratic red tape on them. It is thuscritical for practitioners to work closely withhousing authorities to advocate for homelesschents with CODs. Other barriers may includefi-equently long waiting hsts and the recent short-fall of federal funding. For example, the Las VegasHousing Authority (LVHA) has currently closedits housing apphcation process, and it is not ex-pected to reopen for three or more years whenfederal funds become available (personal commu-nication, LVHA, August 2009).

Considering Housing First as Opposed toTreatment First PracticeUnlike the traditional treatment fint (TF) ap-proach, which places homeless clients with CODsor SUD first in treatment programs before theyare ready for (permanent) housing, the housingfirst (HF) approach shifts the paradigm and placesthem directly into (permanent) housing withoutfirst requiring treatment or sobriety (Burt et al.,2004; Pathways to Housing, Inc., New York,2005). Studies have shown that compared withTF, HF can not only better retain cHents, but alsoresults in similar AOD treatment outcomes (Padgett,Gulcur, & Tsemberis, 2006 [RCT { J V = 2 2 5 } ]

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

28 Social Work VoLinnE 57, NUMBER I JANUARY 2012

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

An HF program is not completely uncondi-tional; it may impose various minimal demandson tenants. For example, HF programs sponsoredby the U.S. Department of Housing and UrbanDevelopment prohibit tenants from using illegaldrugs on the premises (Burt et al., 2004). SomeHF programs only require tenants to cotnply withthe conditions specified in their lease. Somerequire tenants to participate in a representativepayee program or a money management programto ascertain tenants' abuity to pay rent reliably andto manage their money effectively (Burt et al.,2004; Tsemberis & Eisenberg, 2000). Somerequire clients to meet with program staff at leasttwice each month (Tsemberis & Eisenberg, 2000)and some require tenants to attend sessions focus-ing on skills development and job seeking and tonot have too many visitors (Pratt, 2008). SomeHF programs may be "applied flexibly to alltenants" and have pohcies that "housing or servic-es would not be denied to a person coming offthe streets after many years who feels mistrustfulabout agreeing to money management" (Tsembe-ris & Eisenberg, 2000, p. 489).

Although an HF program does not requiretenants to receive treatment, it is required toprovide treatment. When providing treatment, adivision of labor between property managementand COD treatment is appropriate as it helps toavoid conflicts of interest with respect to nonpay-ment and other lease-related issues (Burt et al.,2004). Second, if most tenants with CODs areclustered, it may be more effective to bring thetreatments to them instead of referring them out

to the agencies, as "the demand that they dealdirectly with service systems may be enough toprevent them from getting the services they need"(Burt et al., 2004, p. 30). Third, because tenantsare not required to receive treatments, it is essen-tial to make treatment attractive to them. A modi-fied assertive commutiity treatment approach(introduced in the next section) that emphasizesconsumers' decision-making power may be usefulin this regard (Tsemberis & Eisenberg, 2000).Other strategies include making oneself availableto clients, making friendj with clients, and creat-ing social activities (for example, holding birthdayparties) (Burt et al., 2004). Burt et al. emphasizedthat the best referrals actually come frotn tenantstalking about the program to their friends andneighbors, who then come into the programthemselves.

COMPONENT 4: OFFERING COD TREATMENT

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

SUN / Helping Homeless Individuals with Co-occurring Disorders: The Four Components 29

Assertive Community TreatmentTo engage homeless individuals with CODs, amore intense and proactive intervention may benecessary (DiClemente, Nidecker, & BeUack,2008). Assertive community treatment (ACT)—an approach that emphasizes outreach, communi-ty tenure, practical and intensive case manage-ment, small caseloads (usually a client-workerratio of 10 to 1), 24-hour service, and interdisci-plinary teamwork (Drake et al., 1998)—may fulfillthe goal. ACT is an evidence-based approachproven by some studies to reduce hospital days(for example. Bond et al., 1990), increase time inhousing or decrease homeless rates, and improvepsychiatric symptoms (Coldwell & Bender, 2007).The ACT outcomes findings, however, are notcompletely consistent; findings in the UnitedStates are more consistent in generating a positiveeffect than are those in the European studies(Bums, Fioritti, Holloway, Malm, & Rössler,2001). The inconsistency could be related to dif-fering operational definitions for the variables(Coldwell & Bender, 2007), lack of model fidelity,and "treatment quality" improvement of thecontrol group (Verhaegh, Bongers, Kroon, &Garretsen, 2009).

Although ACT has been criticized for beingexpensive and lacking a recovery orientation,recent studies have shown that ACT does nothave to be time unlimited, and some clients cantransition from ACT to less intensive communitymental health services or step-down programs(Hackman & Stowell, 2009; Rosenheck, Neale, &Mohamed, 2010). Recent studies also found thatnot all clients with CODs need ACT and thatACT may be necessary only for clients with moresevere problems. For example, Essock et al. (2006[N= 198]) found that, compared with ACT, clin-ical case management (a less intensive form thanACT [for example, with a client-worker ratiobeing 25 to 1 instead of 10 to 1]) created similartreatment outcomes among homeless or unstablyhoused clients with CODs. However, Frismanet al. (2009 [N= 124]) found that ACT appearedto be more effective than the cHnical case man-agement approach for clients with CODs and an-tisocial personality disorder (ASPD), whereasACT and the clinical case management approachcreated similar treatment outcomes for dually dis-ordered clients without ASPD. More research isneeded regarding successfully matching clients

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

Modified Motivational Interviewing/Motivational Enhancement TherapyModvational interviewing (MI)/motivational en-hancement therapy (MET) produces some evi-dence of decreasing substance use and psychiatricsymptoms and increasing treatment engagementduring the short term among individuals withCODs (see Cleary et al.'s, 2009, review of nineempirical studies, mosdy with a randomizeddesign). For example, Graeber, Moyers, Griffith,Guajardo, & Tonigan's (2003 [A/=30]) RCTfound that, compared with an educational treat-ment intervention, MI was more likely to reducedrinking days and increase abstinence rates amongschizophrenic 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 attendedmore aftercare sessions and drank less. OtherRCTs also suggest that combining MI withcognitive—behavioral therapy (CBT) and familyintervendon may help clients with CODs ofschizophrenia and substance use disorders (Bar-rowclough et al., 2001 [N=36]) and that com-bining MI, contingency management, and socialskills training resulted in better treatment out-comes than did the control condition ("a suppor-tive group discussion") among clients with CODs(BeUack et al., 2006 [N= 175]).

MI/MET facilitates change and helps a clientmove from a more initial stage (for example, pre-contemplation) to a more advanced stage (forexample, contemplation, determination, action.CUents compare their baseline AOD use with thenormadve data, develop discrepancies betweenwhere they are and where they want to be,discuss the role of AOD use as a barrier preventingthem fiom being where they want to be and therole of quitdng AOD as a facilitator promodngtheir well-being, explore ambivalence related tochanging AOD use, tip the decisional balancetoward change, and develop goals and actionplans (Miller & Rollnick, 2002). Individuals withCODs, particularly those with an SMI, may expe-rience a lower motivation to change because oftheir positive symptoms (for example, delusions,hallucinations) and negative symptoms (forexample, anergia, avolidon), other cognitive

30 Social Work VOLUME 57, NUMBER I JANUARY 2012

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

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

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

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

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

• using all appointments to discuss the medica-tions—the purpose, the expected time couneand results, side effects, and AOD-psychiatricmedication interaction effects and to promotehope and realistic expectations to increasemedication adherence;

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

• discontinuing medications with side effectsthat lead to nonadherence;

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

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

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

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

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

Structure, Concreteness, Repetitiveness, andDegree of Alertness. Group sessions with a topicalfocus are better than process groups; in-sessionrole playing and in-session homework can alsoenhance session structure (Carey et al., 2001;Evans & Sullivan, 2001). Providing written cueswith respect to daily activity checklists and usingwritten worksheets to guide each session may behelpful to individuals with schizophrenia as theymay have difficulty with auditory materials (Careyet al, 2001; Evans & Sullivan, 2001; Ziedoniset al., 2005). Information related to CODs andthe link between AOD and negative consequenc-es needs to be presented to clients repeatedly, andopportunities need to be offered to practice newlylearned skills over and over (Evans & Suüivan,2001; Ziedonis et al., 2005). Ziedonis et al.further suggested adapting interventions accordingto a patient's level of alertness.

Modified CBTCBT helps a chent identify- his or her internaltriggers (thoughts, feelings, and emotions) and ex-ternal triggers (events, acti'ities, and incidents)and learn skills to effectively deal with those trig-gers. RCTs have reported efficacy in MI withCBTs in improving alcohol problems amongchents with CODs of depression and AOD disor-den (Baker et al., 2010) and in CBTs and CBTplus contingency management reducing substanceuse and posttraumatic stress disorder (PTSD) andother psychiatric symptoms among clients withCODs 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 thata combination of MI and CBT over a longer termimproves substance abuse and mental health out-comes of clients with CODs, including chentswith comorbid schizophrenia and AOD disorden.Their revie^v further showed inconsistent supportfor the application of stand-alone CBT to help in-dividuals with CODs—a 16- to 20-session roundof CBT targeting clients with bipolar disorder ap-peared to be effective, whereas a 6- to 12-session

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

Research evidence and the consensus of expertclinicians argue for the following modifications toCBT to accommodate clients with CODs:

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

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

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

cian undentanding that it takes trust and timefor the clients to change and refraining frompushing clients too soon to address their in-grained habits of thoughts;

• using concrete methods (for example, roleplaying) and arranging highly structured,small-group sessions, if a group modality isadopted;

• helping chents leam specific coping skills todeal with the combined trials of SUD andmental disorder;

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

• enhancing clients' self-efficacy by reinforcingtheir early successes (CSAT, 2005; Ziedoniset al., 2005).

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

32 Social Work VOLUME 57, NUMBER I JANUARY 2012

Sigmon et al., 2000]). Drake et al. (2008), citingLedgerwood and Petry, stated that "improvementsrelated to contingency management are probablyunrelated to motivation and other cognitivefactors" (p. 134); they suggested that this may bean advantage for dual-diagnosis chents.

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

• considering a prize-based CM (drawing todetermine receiving a prize or not and thevalue of a prize), as it is less expensive than avoucher-based CM;

• seeking donations from community organiza-tions and companies;

• applying CM only to individuals with severeimpairments (not aU individuals need CM tochange); and

• using nonmonetary rewards.

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

Dual-Focus Mutual-Aid GroupsMainstream 12-step group involvement appears tobe associated with better outcomes with respectto AOD abuse, self-efficacy, motivation, andcoping skills (Kownacki & Shadish, 1999; McKay,2001), but a mainstream 12-step group may notbe appropriate for individuals with CODs,because

• it may be prejudicial toward meniben withCODs because of the stigma attached tohaving a mental disorder;

• it may stick to the total abstinence orienta-tion, vhich may influence members withCODs to stop taking prescribed psychiatricmedications, despite this not being the officialposition of the Alcohohcs Anonymous orNarcotics Anonymous organizations; and

• its coUective insights may not necessarilybenefit memben with CODs, as memberswith SUD may have very different needs forrecovery than do members with CODs(CSAT, 2005;Magura, 2008).

A specialized 12-step group allo^vs for open dis-cussion of not only AOD issues, but also issuesrelated to mental disorders, psychiatric medica-tions, medication side effects, psychiatric hospitah-zations, and other issues regarding whichparticipants might expedence stigma if discussedin mainstream 12-step groups (Bogenschutz,2005). Magura et al. (2003) of specialized 12-stepgroups showed that by helping othen, an individ-ual reinforces self-learning of valued behaviorsand that by sharing recovery experiences, individ-uals learn from each other. Although few studieshave researched the outcomes of specialized12-step groups, they suggest that such groupsbenefit individuals with CODs more than main-stream self-help groups do (Bogenschutz, 2007). Atwo-year foUow-up study of Double Trouble inRecovery (DTR), a speciahzed 12-step group(A/=310), conducted firom 1998 to 2000 byMagura and coUeagues produced 13 articles.Based on this 1998-2000 study, Laudet et al.(2004) reported that continuing DTR attendancewas related to a higher likelihood of abstinence,and Magura, Laudet, Mahmood, Rosenblum, andKnight (2002) observed that weekly DTR atten-dance, not attendance at mainstream self-helpgroups, was associated with psychiatric medicationadherence. Magura's (2008) solo review of this1998-2000 study suggested DTR's effectivenessin four areas: (1) AOD abstinence, (2) psychiatricmedication adherence, (3) self-efficacy for recov-ery, and (4) quality of Hfe.

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

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

groups). To improve the research design, Maguraet al. (2008) recently conducted a quasi-experi-mental study and found that a cohort with DTRexposure had significantly fewer days of AOD usethan did a cohort without DTR exposure, afinding consistent with the team's previous find-ings. Because the speciaUzed 12-step group has arelatively shorter history, treatment programsshould faciUtate Unkages between their cUentswith CODs and such groups. CUents with CODswho are in more advanced recovery should alsobe encouraged to assume a facilitator's role; both amanual and facüitator training are available fromthe founden of some dual-focus 12-step self-helpgroups (Magura et al., 2003).

CONCLUSION

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

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

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

REFERENCESBaker, A. L., Kavanagh, 0 . J., Kay-Lambkin, F., Hunt, S.,

Lewin, T., Carr, V., et al. (2010). Randomized con-trolled trial of cognitive-behavioral therapy for coex-isting depression and alcohol problems: Short-termoutcome. Addiction, 105, 87-99.

Barrowclough, C , Haddock, G., Tarder, N., Lewis, S.,Moring, J., O'Brien, R., et al. (2001). Randomizedcontrolled trial of motivational interviewing, cogni-tive behavior therapy, and family intervention for pa-tients with comorbid schizophrenia and substance usedisorders. American Journal of Psychiatry, 158,1706-1713.

Becker, D., Bond, G., McCarthy, D., Thompson, D., Xie,H., McHugo, G., et al. (2001). Converting day treat-ment centers to supported employment programs inRhode Island. Psychiatric Services, 52, 351-357.

Becker, D., Drake, R. E., & Naughton, W. J. (2005). Sup-ported employment for people with co-occurringdisorders. Psychiatric Rehabilitation Journal, 28,332-338.

Becker, D., Whitley, R., Bailey, E., & Drake, R. (2007).Long-term employment trajectories among partici-pants with severe mental illness in supported employ-ment. Psychiatric Services, 58, 922-928.

Bellack, A. S., Bennett, M. E., Gearon, J. S., Brown, C.H., & Yang, Y. (2006). A randomized clinical trial ofa new behavioral treatment for drug abuse in peoplewith severe and persistent mental illness. Archives ofGeneral Psychiatry, 63, 426-432.

Biegel, D. E., Ronis, R. J., & Boyle, P. E. (2008). Theimpact of supported employment for consumers withco-occurring mental and substance use disorders. Retrievedfrom http://www.centerforebp.case.edu/research/employmentstudy.html.

34 Social Work VOLUME 57, NUMBER 1 JANUARY 2012

Bogenschutz, M. P. (2005). Specialized 12-step programsand 12-step facilitation for the dually diagnosed. Com-munity Mental Health Journal, 41, 7-20.

Bogenschutz, M. P. (2007). 12-step approaches for thedually diagnosed: Mechanisms of change. Alcoholism:Clinical and Experimental Research, 3i(Suppl. 3),64S-66S.

Bond, G. R., Witheddge, T. F., Dincin, J., Wasmer, D.,Webb,]., & De Graaf-Kaser, R. (1990). Assertivecommunity treatment for frequent users of psychiatrichospitals in a large city: A controlled study. AmericanJournal of Community Psychology, 18, 865—891.

Bureau of Labor Statistics, (n.d.). Occupational outlook hand-book, 2010-11 edition. Retrieved from http://www.bls.gov/oco/ocos060.htm

Bums, T., Fioritti, A., Holloway, F., Malm, U., & Rössler,W. (2001). Case management and assertive commu-nity treatment in Europe. Psychiatric Services, 52,631-636.

Butt, M. R., Hedderson,J., Zweig, J., Ortiz, M. J., Aron-Tumham, L., & Johnson, S. M. (2004). Strategies forreducing chronic street homelessness. Retrieved fromhttp://www.huduser.org/Publications/PDF/ChronicStrtHomeless.pdf

Carey, K. B., Pumine, D. M., Maisto, S. A., & Carey, M.P. (2001). Enhancing readiness-to-change substanceabuse in petsons with schizophrenia: A four-sessionmotivation-based intervention. Behavior Modification,25, 331-384.

Caton, C , Dominguez, B., Schanzer, B., Hasin, D.,Shrout, P., Felix, A., et al. (2005). Risk factots forlong-term homelessness: Findings from a longitudinalstudy of first-time homeless single adults. AmericanJournal of Public Health, 95, 1753-1759.

Caton, C , Wilkins, C , & Andenon, J. (2007). People whoexperience long-term homelessness: Characteristics and inter-ventions. Retrieved from http://aspe.hhs.gov/hsp/homelessness/symposium07/caton/report.pdf

Center for Substance Abuse Treatment. (2005). Substanceabuse treatment for persons with co- occurring disorders(TIP Series 42, DHHS Publication No. [SMA]08-3992). Rockville, MD: Substance Abuse andMental Health Services Administration.

Center for Substance Abuse Treatment, (n.d.). Know yourrights. Retrieved from http://store.samhsa.gov/shin/content//PHD1091/PHD1091.pdf

Clark, C , & Rich, A. R. (2003). Outcomes of homelessadults with mental illness in a housing program andin case management only. Psychiatric Services, 54,78-83.

Cleary, M., Hunt, G., Matheson, S., & Walter, G. (2009).Psychosocial treatments for people with co-occurringsevere mental illness and substance misuse: Systematicreview. Journal of Advanced Nursing, 65, 238—258.

Coldwell, C , & Bender, W. (2007). The effectiveness ofassertive community treatment for homeless popula-tions with severe mental illness: A meta-analysis.American Journal of Psychiatry, 164, 393-399.

Compton, S., Swanson, J., Wagner, H., Swartz, M.,Bums, B., & Elbogen, E. (2003). Involuntaryoutparient commitment and homelessness in petsonswith severe mental illness. Mental Health ServicesResearch, 5, 27-38.

Cook,J. A., Terrell, S., &Jonikas,J. A. (2004). Promotingself-determination for individuals with psychiatric disabilitiesthrough self-directed services: A look at federal, state, andpublic systems as sources of cash-outs and other fiscal expan-sion opportunities. Retrieved from http://wvw.psych.uic.edu/uicnrtc/sdsamhsaconfsentver3.pdf

Dickson-Gomez, J., Convey, M., Hilario, H., Corbett,A. M., & Weeks, M. (2007). Unofficial policy:

Access to housing, housing information and socialservices among homeless drug usets in Hartford,Connecticut. Substance Abuse Treatment, Prevention,and Policy, 2(8). doi: 10.1186/1747-597X-2-8. Re-trieved from http://www.substanceabusepolicy.com/content/2/1/8.

DiClemente, C. C , Nidecker, M., & Bellack, A. S.(2008). Motivation and the stages of change amongindividuals with severe mental illness and substanceabuse disorders. Jowma/ of Substance Abuse Treatment,34, 25-35.

Drake, R. E., Essock, S. M., Shaner, A., Carey, K. B.,Minkoff, K., Kola, L., et al. (2001). Implementingdual diagnosis services for clients with severe mentalillness. Psychiatric Services, 52, 469-476.

Drake, R. E., McHugo, G. J., Bebout, R. R., Becker, D.R., Harris, M., Bond, G. R., et al. (1999). A ran-domized clinical trial of supported employment forinner-city padents with severe mental disordets. Ar-chives of General Psychiatry, 56, 627—633.

Drake, R. E., McHugo, G. J., Clark, R. E., Teague, G.B., Xie, H., Miles, K., et al. (1998). Assertive com-munity treatment for patients with co-occurringsevere mental illness and substance use disorders: Aclinical trial. American Journal of Orthopsychiatry, 68,201-215.

Drake, R. E., O'Neal, E. L., & Wallach, M. A. (2008). Asystematic review of psychosocial research on psycho-social interventions for people with co-occurringsevere mental and substance use disorders. Jowma/ ofSubstance Abuse Treatment, 34, 123-138.

Dtake, R., Wallach, M., & McGovem, M. (2005). Futuredirecdons in prevendng relapse to substance abuseamong clients with severe mental illnesses. PsychiatricServices, 56, 1297-1302.

Drebing, C , Van Ormer, E., Krebs, C , Rosenheck, R.,Rounsaville, B., Herz, L., & Penk, W. (2005).The impact of enhanced incendves on vocadonalrehabilitation outcomes for dually diagnosed veterans.Journal of Applied Behavior Analysis, 38, 359-372.

Drebing, C , Van Ormer, E., Mueller, L., Hebert, M.,Penk, W., Petry, N., et al. (2007). Adding condn-gency management intervendon to vocational reha-bilitation: Outcomes for dually diagnosed veterans.Journal of Rehabilitation Research & Development, 44,851-865.

Essock, S., Mueser, K., Drake, R., Covell, N., McHugo,G., Frisman, L., et al. (2006). Comparison of ACTand standard case management for delivering integrat-ed treatment for co-occurring disordets. PsychiatricServices, 57, 185-196.

Evans, K., & Sullivan, J. M. (2001). Dual diagnosis: Counsel-ing the mentally ill substance abuser. New York: GuilfordPress.

Foote, E., Tucker, P., & MiHspaugh, J. (2008). Reachingtoward hope: The state of homelessness and substanceuse disorders in Oklahoma. Joumn/ of Oklahoma StateMedical Association, 101, 338-342.

Forchuk, C , Macclure, S. K., Van Beers, M., Smith, C ,Csiemik, R., Hoch, J., et al. (2008). Developing andtesdng an intervention to prevent homelessnessamong individuals discharged from psychiatric wardsto shelters and "no fixed address." JoMma/ of Psychiatricand Mental Health Nursing, 15, 569-575.

Frisman, L., Mueser, K., Covell, N., Lin, HJ., Crocker,A., Drake, R., et al. (2009). Use of integrated dualdisorder treatment via assertive community treatmentvetsus clinical case management for persons withco-occurring disorders and andsocial personality dis-order. Jowma/ of Nervous and Mental Disease, 197,822-828.

SUN / Helping Homeless Individuals with Co-occurring Disorders: The Four Components 35

Graeber, D., Moyers, T., Griffith, G., Guajardo, E., &Tonigan, S. (2003). A pilot study comparing motiva-tional interviewing and an educational interventionin patients with schizophrenia and alcohol use disor-ders. Community Mental Health Journal, 39, 189-202.

Hackman, A. L., & Stowell, K. R. (2009). Transitioningclients from assertive community treatment to tradi-tional mental health services. Community MentalHealth Journal, 45, 1-5.

Helmus, T, Saules, K., Schoener, E., & Roll, J. (2003).Reinforcement of counseling attendance and alcoholabstinence in a community-based dual-diagnosistreatment program: A feasibility study. Psychology ofAddictive Behaviors, 17, 249-251.

Herman, D., Opler, L., Felix, A., Valencia, E., Wyatt, R.,& Susser, E. (2000). A critical time intervention withmentally ill homeless men: Impact on psychiatricsymptoms. JoHma/ of Nervous and Mental Disease, 188,135-140.

Hien, D., Cohen, L., Miele, G., Litt, L., & Capstick, C.(2004). Promising treatments for women with co-morbid PTSD and substance use disorders. AmericanJournal of Psychiatry, 161, 1426-1432.

Higgins, S., Alessi, S., & Dantona, R. (2002). Voucher-based incentives: A substance abuse treatment innova-tion. Addictive Behaviors, 27, 887-910.

HorsfaU, J., Cleary, M., Hunt, G. E., & Walter, G. (2009).Psychosocial treatments for people with co-occurringsevere mental illnesses and substance use disorders(dual diagnosis): A review of empirical evidence.Harvard Review of Psychiatry, 17, 24-34.

Hurlburt, M., Wood, P., & Hough, R. (1996). Providingindependent housing for the homeless mentally ill: Anovel approach to evaluating long-term longitudinalhousing patterns. Joumfl/ of Community Psychology, 24,291-310.

Jones, K., Colson, P. W., Holter, M. C , Lin, S., Valencia,E., Susser, E., et al. (2003). Cost-effectiveness of criti-cal time intervention to reduce homelessness amongpersons with mental illness. Psychiatric Services, 54,884-890.

Kamiel-Lauer, E., Szor, H., Livne, S., Melamed, Y., Spiro,S., & Elizur, A. (2000). The "re-entry group"—Atransitional therapeutic framework for mentally ill pa-tients discharged from the hospital to communityclinics. Canadian Journal of Psychiatry, 45, 837—839.

Kasprow, W. J., & Rosenheck, R. A. (2007). Outcomes ofcritical time intervention case management of home-less veterans after psychiatric hospitalization. PsychiatricServices, 58, 929-935.

Kownacki, R. J., & Shadish, W. R. (1999). Does Alcohol-ics Anonymous work? The results from a meta-analysis of controlled experiments. Substance Use andMisuse, 34, 1897-1916.

Kuhn, R., & Culhane, D. P. (1993). Applying cluster anal-ysis to test a typology of homelessness by pattern ofshelter utilization: Results from the analysis of admin-istrative data. American Journal of Community Psychology,26, 207-232.

Lauber, C , Lay, B., & Rössler, W. (2006). Homelesspeople at disadvantage in mental health services. Eu-ropean Archives of Psychiatry and Clinical Neuroscience,256, 138-145.

Laudet, A., Magura, S., Cleland, C , Vogel, H., Knight,E., & Rosenblum, A. (2004). The effect of 12-stepbased fellowship participation on abstinence amongdually diagnosed persons: A two-year longitudinalstudy. Jowraa/ of Psychoactive Drugs, 36, 207-216.

Lester, K., Milby, J., Schumacher, J., Vuchinich, R.,Person, S., & Clay, O. (2007). Impact of behavioralcontingency management intervention on coping

behaviors and PTSD symptom reduction incocaine-addicted homeless. Journal of Traumatic Stress,20, 565-575.

Lincoln, A. K., Plachta-EUiott, S., & Espejo, D. (2009).Coniing in: An examination of people withco-occurring substance use and serious mental illnessexiting chronic homelessness. American Journal ofOr-thopsychiatry, 19, 236-243.

Lipton, F., Siegel, C , Hannigan, A., Samuels, J., & Baker,S. (2000). Tenure in supportive housing for homelesspersons with severe mental illness. Psychiatric Services,51, 479-486.

Long, D., Rio, J., & Rosen, J. (2007). Employment andincome supports for homeless people. Retrieved fî omhttp://aspe.hhs.gov/hsp/homelessness/symposium07/long/report.pdf

Magura, S. (2008). Effectiveness of dual focus mutual aidfor co-occurring substance use and mental health dis-orders: A review and synthesis of the "DoubleTrouble" in recovery evaluation. Substance Use &Misuse, 43, 1904-1926.

Magura, S., Laudet, A., Mahmood, D., Rosenblum, A., &Knight, E. (2002). Adherence to medication regimensand participation in dual-focus self-help groups. Psy-chiatric Services, 53, 310—316.

Magtira, S., Laudet, A. B., Mahmood, D., Rosenblum, A.,Vogel, H. S., & Knight, E. L. (2003). Role of self-help processes in achieving abstinence among duallydiagnosed persons. Addictive Behaviors, 28, 399—413.

Magura, S., Rosenblum, A., Villano, C , Vogel, H., Fong,C , & Betzler, T. (2008). Dual-focus mutual aid forco-occurring disorders: A quasi-experimentaloutcome evaluation study. American Journal of Drugand Alcohol Abuse, 34, 61-74.

McKay, J. (2001). Effectiveness of continuing care inter-ventions for substance abusers: Implications for thestudy of long-term treatment effects. EvaluationReview, 25,211-232.

Miller, W. R., & Rollnick, S. (2002). Motivational interview-ing. New York: Guilford Press.

Moos, R. H. (2007). Theory-based active ingredients ofeffective treatments for substance use disorders. Drugand Alcohol Dependence, 88, 109-121.

Murray, T , O'Donnell, G., & Speedling, E. (2005). Ttieoutreach coordination center: A collaboration between ProjectH.O.M.E & the City of Philadelphia. Retrieved fromhttp://wvrw.oneneighborhood.org/fdes/OCC%20HISTORY%202005_0.doc

National Association of Social Workers. (2008). Code ofethics of the National Association of Social Workers. Re-trieved from http://www.naswdc.org/pubs/code/code.asp

Nelson, G., Aubry, T , & Lafrance, A. (2007). A review ofthe literature on the effectiveness of housing andsupport, assertive community treatment, and intensivecase management interventions for persons withmental illness who have been homeless. AmericanJournal of Orthopsychiatry, 77, 350—361.

Nwakeze, P. C , Magura, S., Rosenblum, A., &Joseph, H.(2003). Homelessness, substance misuse, and access topublic entitlements in a soup kitchen population.Substance Use and Misuse, 38, 645—668.

O'Brien, A., Fahmy, R., & Singh, S. P. (2009). Disengage-ment from mental health services. Social PsychiatryPsychiatric Epidemiology, 44, 558—568.

Orwin, R. G., Garrison-Mogren, R., Jacobs, M. L., &Sonnefeld, J. (1999). Retention of homeless clients insubstance abuse treatment. Jowma/ of Substance AbuseTreatment, 17, 45-66.

Padgett, D., Gulcur, L., & Tsemberis, S. (2006). Housingfirst services for people who are homeless with

36 Social Work VOLUME 57, NUMBER I JANUARY 2012

co-occurring serious mental illness and substanceabuse. Research on Social Work Practice, 16, 74—83.

Page, T., & Nooe, R. M. (2002). Life experiences and vul-nerabilities of homeless women: A comparison ofwomen unaccompanied versus accompanied byminor children, and correlates with children's emo-tional distress. JoMma/ of Social Distress and the Homeless,7 7,215-231.

Pathways to Housing, Inc., New York. (2005). Providinghousing first and recovery services for homeless adultswith severe mental illness. Psychiatric Services, 56,1303-1305.

Personal Responsibility and Work Opportunity Reconcili-ation Act of 1996, P.L. 104-193, 110 Stat. 2105(1996).

Petry, N. M. (2000). A comprehensive guide to the apph-cation of contingency management procedures inclinical settings. Drw? and Alcohol Dependence, 58,9-25.

Policy Research Associates Inc. (2009). National SOAR out-comes—spring/summer 2009. Delmar, NY: Author.

Pratt, T. (2008, April 22). First Things firît: For homeless,a home. Las Vegas Sun. Retrieved from http://www.lasvegassun.com/news/2008/apr/22/first-thin gs-first-homeless-home/

Prendergast, M., Podus, D., Finney, J., Greenwell, L., &Roll, J. (2006). Contingency management for treat-ment of substance use disorders: A meta-analysis. Ad-diction, 101, 1546-1560.

Quality Housing and Work Responsibility Act of 1998,RL. 105-276, 112 Stat. 2518 (1998).

Ries, R.K., Dyck, D.G., Short, R., Srebnik, D., Fisher,A., & Comtois, K.A. (2004). Outcomes of managingdisability benefits among patients with substance de-pendence and severe mental illness. Psychiatric Services,55, 445-447.

Rosenheck, R., Leslie, D., Keefe, R., McEvoy, J., Swartz,M., Perkins, D., et al. (2006). Barriers to employmentfor people with schizophrenia. American Journal of Psy-chiatry, 163, 411-417.

Rosenheck, R., Neale, M., & Mohamed, S. (2010). Tran-sition to low intensity case management in a VA as-sertive community treatment model program.Psychiatric Rehabilitation fournal, 33, 288-296.

Santa Ana, E., Wulfert, E., & Nietert, P. (2007). Efficacyof group motivational interviewing (GMI) and psy-chiatric inpatients with chemical dependence. Jowma/of Consulting and Clinical Psychology, 75, 816-822.

Sigmon, S., Steingard, S., Badger, G.J., Anthony, S.L., &Higgins, S.T. (2000). Contingent reinforcement ofmarijuana abstinence among individuals with seriousmental illness: A feasibility study. Experimental andClinical Psychopharmacology, 8, 509—517.

Substance Abuse and Mental Health Services Administra-tion (2011, January). 2010 national SOAR outcomes.Retrieved from http://www.prainc.com/SOAR/library/pd6/handouts/2010_SOAROutcomes.pdf.

Susser, E., Valencia, E., Conover, S., Felix, A., Tsai,W. Y., & Wyatt, R. J. (1997). Preventing recurrenthomelessness among mentally ill men: A "criticaltime" intervention after discharge from a shelter.American Journal of Public Health, 87, 256-262.

Swanson, A. J., Pantalon, M. V., & Cohen, K. R. (1999).Motivational interviewing and treatment adherenceamong psychiatric and dually diagnosed patients.Journal of Nervous & Mental Disease, 187, 630—635.

Tracy, K., Babuscio, T , Nich, C , KUuk, B., Carroll, K.M., Petry, N.M., & Rounsaville, B.J. (2007). Contin-gency management Co reduce substance use in indi-viduals who are homeless with co-occurring

psychiatric disorders. American Journal ofDru^ andAlcohol Abuse, 33, 253-258.

Tsemberis, S., & Eisenberg, R. (2000). Pathways tohousing: Supported housing for street-dwellinghomeless individuals with psychiatric disabilities. Psy-chiatric Services, 51, 487-493.

Tsemberis, S., Gulcur, L., & Nakae, M. (2004). Housingfirst, consumer choice, and harm reduction for home-less individuals with a dual diagnosis. American Journalof Public Health, 94, 651-656.

Verhaegh, M., Bongers, I., Kroon, H., & Garretsen, H.(2009). Model fidehty of assertive community treat-ment for clients with first-episode psychosis: A targetgroup-specific application. Community Mental HealthJournal, 45, 12-18.

Wechsberg, W. M., Lam, W. K. K., Zule, W., Hall, G.,Middlesteadt, R., & Edwards,}. (2003). Violence,homelessness, and HIV risk among crack-usingAfrican American women. Substance Use and Misuse,38, 669-700.

Weiss, R. D. (2004). Treating patients with bipolar disor-der and substance dependence: Lessons leamed.Journal of Substance Abuse Treatment, 27, 307-312.

Ziedonis, D., Smelson, D., Rosenthal, R., Batki, S.,Green, A., Henry, R., et al. (2005). Improving thecare of individuals with schizophrenia and substanceuse disorders: Consensus recommendations. Joimw/ ofPsychiatric Practice, 11, 315-339.

Zuvekas, S., & Hill, S. (2000). Income and employmentamong homeless people: The role of mental health,health and substance abuse. JoHma/ of Mental HealthPolicy and Economics, 3, 153—163.

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

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

PRACTICE UPDATES

Are you involved in a program, researchproject, practice innovation, or other

effort that may interest readers? Send yourarticle (six double-spaced pages or fewer) asa Word document through the online portalat http://swj.msubmit.net (initial, one-timeregistration is required).

SUN / Helping Homeless Individuals with Co-occurring Disorders: The Four Components 37

Copyright of Social Work is the property of National Association of Social Workers and its content may not be

copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written

permission. However, users may print, download, or email articles for individual use.