____________________________________ Substance Use Disorders: Assessment and Treatment, 2nd Edition
finding decent housing and building a healthy and supportive social network. Any therapy done with ex-offenders requires a certain amount of case management to address those needs. HOMELESSNESS According to the U.S. Department of Housing and Urban Development’s (2020) yearly point-in-time estimate of home- lessness, approximately 580,466 people in America experience homelessness on any given evening. It is important to under- stand that “homelessness” is not a uniform reality. Differences come from varying degrees of homelessness and the way in which researchers define “homelessness.” Among people who are homeless are those who are literally homeless or marginally housed and the poorly housed. Being literally homeless may mean that individuals have no stable residence and live on the street, or it can mean that an individual has spent at least one night in the past 30 days in a shelter. The marginally housed have no home of their own but live with relatives or friends or in multiple occupancy situations. The housed poor have a house or apartment, but their income is so low that they are at constant risk of losing the housing they have. Of the three groups, the literally homeless have the highest incidence of substance use problems, spend the largest proportion of their income on substances, and have the highest incidence of mental health problems and the lowest level of social support. Interestingly, the poorest group is not the literally homeless but the housed poor (Deck & Platt, 2015). Determining the prevalence of substance use in the homeless population is notoriously difficult. Because of the nature of homelessness, no matter how it is defined, standard epide- miologic methods are difficult or impossible to apply. The best estimates available are not current but come from the work of Burt and colleagues (1999) and set the prevalence of substance use problems at the lifetime estimate of 62% and past-year estimates at around 40% to 45% for the homeless. These percentages are certainly higher than for the population as a whole. Most researchers who have studied this population agree that substance use is a highly significant factor in creat- ing and sustaining homelessness. Homeless individuals with substance abuse problems generally have experienced a more severe and prolonged homeless history, including more physi- cal and sexual abuse and trauma than others in the homeless population (Deck & Platt, 2015). Substance abuse increases the complexities of personal problems, including mental health disorders, and decreases the likelihood of a long-term exit from homelessness. Very few homeless individuals are properly assessed for their vulnerability to substance misuse and consequently do not receive adequate resources for either prevention or treatment (Deck & Platt, 2015). Chronic homelessness applies to approximately 14% of the homeless population in the United States on any given day (National Alliance to End Homelessness, 2016). The word chronic involves either long-term or repeated bouts of homeless- ness, coupled with some sort of physical or mental disability. It is estimated that 30% of chronically homeless individuals have
a concurrent mental illness and addictive disorder (Flanagan & Briggs, 2015). Clinically, it is important to understand that isolation and deep-seated mistrust of others do not come from homeless- ness; rather, they precede it. Isolation and mistrust are often based in early traumatic experiences. Kim, Ford, Howard, and Bradford (2010) explored the association between homeless men with trauma histories of child abuse and victimization and the onset of homelessness. They reported that homeless men encounter a myriad of stressful experiences while home- less, but that trauma histories were most often associated with their mental health problems and their homeless condition. The aftereffects of trauma often give rise to substance use as a means of coping. In this context, substance use increases isola- tion and social mistrust, thus contributing to the condition of homelessness (Deck & Platt, 2015).
Self-Assessment Question
4. In the treatment of homeless individuals with a substance use disorder, the first step is: A) a 12-step program. B) securing adequate and safe housing. C) a referral to a food bank. D) resolving isolation and suspicion. In other studies, TBI was identified as occurring with greater frequency among homeless individuals than in the population as a whole. About 50% of homeless individuals had a positive screening for TBI. Furthermore, among this population, TBI was significantly associated with a lifetime history of mental illness and familial history of substance abuse. One study found that physical assault was a significant cause of TBI among people experiencing homelessness. Initial injury generally occurred before the onset of homelessness, and most people experiencing homelessness with TBI experienced their first injury in childhood (Topolovec-Vranic et al., 2014). Many researchers have argued that substance abuse provides positive and protective effects in the short term for those who are homeless, serving as a buffer against physical and emotional pain that might otherwise be incapacitating. In addition, substance use can relieve some of the tedium and stress of living on the streets, making the day slightly more tolerable and interesting. However, data clearly suggest that protracted substance abuse leads to negative health outcomes, including mood destabilization, physical exhaustion, infection, and death (Ibabe et al., 2014). Perhaps the most clinically useful exploration of substance use in a homeless population comes from the work of Flanagan and Briggs (2015), who did qualitative research with a sample consisting of clinicians who treated homeless individuals with SUDs, formerly homeless individuals recovering from SUDs, physicians who provided medical treatment to homeless individuals, and key members of advocacy groups concerned with homelessness. These interviews were supplemented
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