Homelessness and dual diagnosis.

Homeless people with co-occurring severe mental illnesses and alcoholuse disorder (AUD) represent a particularly vulnerable subgroup of the homeless with complex service needs (Drake et al. 1991). Although often referred to as dually diagnosed, these people typically are impaired by several additional problems, including abuse of drugs other than alcohol, general medical illnesses, and legal problems. This group also has histories of trauma and behavioral disorders, deficient social and vocational skills, and support networks that include people involved in alcohol and other drug (AOD) abuse or other illegal behavior. Compared with other homeless subgroups, those with co-occurring severe mental illnesses and AUD are more likely to experience harsh living conditions, such as living on the streets rather than in shelters; suffer from psychological distress and demoralization; grant sexual favors for food and money; be picked up by police; become incarcerated; be isolated from their families; and be victimized (Fischer 1990). Much of our current knowledge of homeless adults with dual disorders comes from National Institute on Alcohol Abuse and Alcoholism initiatives funded by the Stewart B. McKinney Act (Huebner et al. 1993). These initiatives include a 3-year, 14-project demonstration to develop, implement, and evaluate interventions for homeless adults with AOD-related problems. Two of the projects specifically have targeted homeless people with cooccurring severe mental illnesses and AOD-use disorders. Prevalence and Etiology In a comprehensive review, Fischer (1990) found that between 3.6 and 26 percent of homeless adults suffered from both a mental disorder and AUD. The rates of co-occurring mental and AOD-use disorders ranged from 8 to 31 percent. Other recent reviews also have determined that the rates of dual diagnoses among the homeless range from 10 to 20 percent (Drake et al. 1991). Many studies investigating the causes (i.e., etiology) of homelessness and dual diagnoses have suggested that people with co-occurring mental and AOD-use disorders are particularly prone to losing family supports and stable housing and becoming homeless (Drake et al. 1991). One reason for this increased risk appears to be that dually diagnosed clients often are excluded from housing and treatment programs designated specifically for people with single disorders (Drake et al. 1991). Management of Homeless People With Dual Diagnoses Several consistent themes have emerged in the literature on interventions for homeless people with dual disorders. Most important, interventions should focus primarily on meeting the clients' basic needs related to subsistence and safety. Moreover, appropriate interventions should provide needed structure, support, and protection. Specific treatment recommendations include the following (Drake et al. 1991): Integration of mental health and substance abuse interventionsfor example, through intensive case management and group interventions Provision of services to families as well as to individual clients Development of culturally relevant services Development of long-term, stagewise interventions. Recent studies have examined the integration of mental health, AOD abuse, and housing interventions in various configurations. These studies show that both engaging and retaining dually diagnosed homeless people in treatment programs are extremely difficult, especially in short-term or residential programs (Blankertz and Cnaan 1994; Burnam et al. 1995; Rahav et al. 1995). Furthermore, any gains that the clients make during shortterm or residential treatment tend to erode rapidly following discharge. Several observations may help explain these findings. For example, behaviors that may represent common adaptations to homeless living, such as intimidating or threatening other people, often are incompatible with participation in treatment and recovery programs (Weinberg and Koegel 1995). …