Substance Use Disorders: Assessment and Treatment, 2nd Edition _ ___________________________________
with 6 months of participant observer activity with two ser- vices providing temporary shelter and treatment to homeless individuals in a large metropolitan area in the United States. The researchers identified distinct themes related to increased vulnerability to substance abuse in a homeless population. Addressing these themes in treatment would seem to provide the best hope of bringing about positive change. The central reality the researchers identified was alienation. This sense of alienation potentiates other factors and is in turn reinforced by them. Alienation expresses itself as a lack of any sense of belonging to any specific community, a deep- seated sense of inferiority, disconnection from and mistrust of any social institutions, and social isolation. Trauma and abandonment are often the underlying causes of this sense of alienation. However, mental health problems such as schizo- phrenia and depressive and anxiety disorders can produce a similar outcome. In fact, trauma/abandonment and mental health problems often coexist in this and other groups. Flowing from alienation and in turn reinforcing it are four fac- tors: trauma and pain, negative social capital, limited material access, and behavioral and chemical exposure to substances (Flanagan & Briggs, 2015). Trauma arises from histories of physical, emotional, or sexual abuse as well as abandonment, along with current victimiza- tions. Pain is physical, emotional, and spiritual and can be both acute and chronic. Pain also includes social, financial, psychological, and existential suffering. In a homeless popula- tion, most of this pain goes untreated, and its often-chronic nature can easily give rise to substance use as a means of lessening suffering. It is not difficult to understand that a state of chronic pain and/or a history of trauma would reinforce a sense of alienation and isolation. Negative social capital relates primarily to the reality that many homeless individuals no longer have any ties with family or kin. This lack of ties makes it very difficult for homeless individu- als to access care for medical, emotional, or substance-related problems. It is especially problematic for those with emotional disorders because a stable family is a core support that is essen- tial for anyone experiencing a mental illness, especially if it is combined with a SUD. This leaves many homeless individuals with no alternative but to seek support from a substance-using population and to participate in a substance-using economy. For some, this population and economy may provide some material support in the form of extra food, blankets, and access to a living space. However, in many cases, substance- using groups on the street serve to humiliate, degrade, and exploit other substance users. The social environment of most homeless individuals with a dual diagnosis does not provide much upward mobility in society and worsens mental health problems and substance use by making abuse and, in many instances, trauma the norm. In addition, treatment is less likely to be sought because of the normalization of substance abuse by the social group.
Limited access to material goods simply means that most indi- viduals who are homeless lack adequate food, clothing, and certainly shelter. Shelter is a special problem for those with SUDs because most shelters require individuals to be abstinent. Lacking consistent access to these basic goods takes a serious toll on physical and mental health. The potential for infectious diseases, lung disorders, and dental problems can be linked to a weakened immune system, worsened by a chronic stress response to the environment. The pain and stress caused by unstable material conditions can worsen substance use and reduce chances for recovery. Substance use becomes a means to mitigate pain. Unfortunately, substance use increases the likelihood of trauma and revictimization because of decreased awareness of danger cues in the environment. Behavioral and chemical exposure to substances can start early in life for individuals who grew up in a family in which heavy use of substances was normative or for those developing in a substance-using peer culture. This mixture of availability and acceptability of substance use is especially potent in situations in which there is stress resulting from a chaotic or violent home environment. However, whether this is the case or not, indi- viduals who are homeless find themselves most frequently in environments where access to substances and use of substances are more the norm than the exception. Environments that are highly stressful and painful and in which substances are readily available promote substance use and make abstinence very difficult. Many homeless individuals find themselves in highly stressful and painful situations that increase their willingness to take risks and seek immediate and short-term gratification. The presence and availability of psychoactive substances offer the promise of decreased pain and stress and an opportunity to make everyday life more interesting or at least more tolerable. Consequently, in the treatment of SUDs in a homeless popula- tion, the provision of adequate and safe housing is an essential first step. The likelihood that individuals will attend to their use of substances while still on the street or in shelter housing is remote. Once a stable living arrangement can be established, the individual will be more able and willing to think about and perhaps change the pattern of substance use. Addition- ally, it is especially important with this population to relate in a respectful and empathetic way so as to begin to establish a therapeutic alliance and increase the sense of self-efficacy. People who have spent time being homeless are used to being dismissed and treated as if they were at best a nuisance and at worst invisible. Clinicians must exercise patience and skill in establishing a working alliance with homeless individuals. Use of therapeutic approaches such as motivational interview- ing would seem especially valuable. Finally, in the context of motivational interviewing, a harm reduction approach to treat- ment might be necessary and beneficial for some individuals (Brubaker et al., 2013; Lee & Peterson, 2009).
135
EliteLearning.com/Psychology
Powered by FlippingBook