The American Medical Association declared alcoholism a disease in 1956, which lead to medical treatment instead of incarceration for those overtaken by the affects of alcohol in public.  In 1971, the Uniform Alcoholism and Intoxication Treatment Act, also known as the Hughes Act, officially decriminalized public drunkenness and mandated a medical treatment approach.

Homeless people who were alcoholics were sent to publicly funded detoxification programs for some form of treatment rather than being jailed.

Results:

• Studies of detoxification programs for indigent people reveal that few individuals leave with referrals for treatment
• The majority of those who are given referrals do not use them

Conclusion:

• These findings led the researchers to conclude that the Hughes Act had replaced the revolving jail door with a “padded revolving door.”
• Medical treatment is still a mainstay for individuals with substance use disorders
• The approach does, however, have its drawbacks for people who are homeless
• Treatment is expensive
• Residential stays are short, often, no more than 28 days
• Without adequate discharge planning, individuals frequently return to the streets
• People with substance use disorders in day treatment programs may have no place to sleep at night
• The combination of poverty and addiction are significant barriers to adequate housing

A social model emerged in California as an alternative treatment approach in the 1970s for alcoholism and other substance use disorders.  The social model programs are:

• Peer-oriented rather than professionally led

The focus is:

• On the need for behavior change through experimental learning and shared responsibility

Results:

• One study assessed the effectiveness of social-setting detoxification for homeless individuals with severe alcohol dependence and found the approach was as safe and effective as hospital detoxification

Positive aspects of the social model are:

• Less costly than medical treatment

Negative aspects of the social model are:

• Services are rarely deemed reimbursable by third-party insurers
• They struggle to secure funding from public agencies

There is a growing body of research that supports the concept of integrated treatment for individuals who are homeless and also have substance use disorders or serious mental illnesses.  This integrated approach involves treatment for both disorders provided at the same time by the same clinician or team of clinicians in a single setting.  This type of treatment is particularly beneficial in helping individuals recover from substance use.  The problem is that there are few such programs in existence.

Result:

• The significant unmet need for both mental health and substance abuse treatment means that those with the fewest resources are least likely to receive appropriate care.

The Federal response to ending chronic homelessness among people with serious mental illnesses and/or co-occurring substance use disorders is:

• This is an achievable goal
• The Stewart B. McKinney Homeless Assistance Act of 1987, known today as the McKinney-Vento Act – was the first, and to date, the only comprehensive Federal legislation to address homelessness
• The Act included a number of provisions designed specifically to provide health and mental health care to people with serious mental illnesses and substance use disorders who are homeless

There were amendments to the McKinney Act in 1988, 1990, 1992, and 1994.  These amendments have strengthened the provisions and expanded the scope of the original legislation (National Coalition for the Homeless, 1999).

Positive effects of the enactment of the McKinney Act include:

The Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services, and the U.S. Department of Housing and Urban Development, have funded:

• Innovative housing and service programs
• Research and demonstration projects

The goal of SAMHSA is to determine how best to serve people with serious mental illnesses and substance use disorders that are homeless.  These programs served as a catalyst for further development of the evidence-based practices.

In addition, The McKinney Act established:

• The Interagency Council on the Homeless (now the Interagency Council on Homelessness) to provide Federal leadership for activities to help homeless individuals and families

The Interagency Council is comprised of the heads of major Federal departments that manage programs for people who are homeless.  The Council convened the Federal Task Force on Homelessness and Severe Mental Illness in the early 1990s.  The Task Force released its 1992 report, “Outcasts on Main Street,” which provided a national strategy and a comprehensive framework for addressing homelessness among people with serious mental illnesses, many of whom have substance use disorders.

The Task Force recommended:

• Federal agencies help states and local communities develop integrated systems of treatment, housing and support services for people with serious mental illnesses who are homeless
The framework for services outlined in “Outcasts on Main Street,” includes:

• Outreach
• Case management
• A range of housing options

This framework for services has withstood the test of time and rigorous evaluation for people with serious mental illnesses, substance use disorders and co-occurring mental illnesses and substance use disorders.

Results:

• Residential stability is a goal desired by, and attainable for, most people with serious mental illnesses and substance use disorders who become homeless

Continued in Part 3

Source:  Substance Abuse and Mental Health Services Administration.  Blueprint for Change:  Ending Chronic Homelessness for Persons with Serious Mental Illnesses and Co-Occurring Substance Use Disorders.  DHHS Pub. No. SMA-04-3870, Rockville, MD:  Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2003.

Written by:  Connie Limon  Visit http://smalldogs2.com/AboutHumanServices for more information about the responsibilities of human service specialists.  For a variety of FREE reprint articles visit http://www.camelotarticles.com

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