Alcohol and other drug problems among the homeless: Research, practice, and future directions
Abstract At least 50 percent of America's homeless people have significant current problems with alcohol and other drugs. These problems are important risk factors in the selection of the undomiciled from the larger population of extremely poor people. This paper reviews what is known about homeless people with alcohol and other drug problems; assesses the relationship between such individual problems and the larger phenomenon of homelessness; and describes selected aspects of projects funded through the National Institute on Alcohol Abuse and Alcoholism/National Institute on Drug Abuse Demonstration Program for Homeless Persons with Alcohol and Other Drug Problems. It concludes with observations about future directions for research and practice.
Rethinking the Prevention of Homelessness
The General Accounting Office's 1990 conclusion about the prevention of homelessness still holds: It remains "too early to tell" what works best. Eviction prevention programs show some promise but have not been rigorously evaluated and tend to exclude people at highest risk of homelessness. Several studies suggest that individuals with severe mental illness can be supported in the community, but the mixture of housing and supportive services necessary remains unclear. There is even less evidence for the usefulness of planning discharges from institutions or of programs to ameliorate domestic conflicts. However, even if expanded to reach 100 percent of their target populations and even if 100 percent successful, all of these programs together would reach only a minority of the people who become homeless each year, and targeting efforts would yield many false alarms for each future case of homelessness correctly identified. Based on evidence that subsidized housing, with or without supportive services, is sufficient to end homelessness for most families, and given the important role of subsidized housing (everywhere it has been examined) in ending homelessness among people with serious mental illnesses, we propose a shift to selected strategies of prevention, such as providing housing subsidies to those with worst—case housing needs, supporting employment and transitional assistance to poor, young people setting up households for the first time, and focusing efforts on communities from which large proportions of homeless people originate. Lessons for Practitioners, Policy Makers, and Researchers Practitioners and policy makers should keep their goals clearly in mind. More specifically, they should remember that preventing homelessness is not identical with ending poverty, curing mental illness, promoting economic self-sufficiency, or making needy people healthy, wealthy, and wise. These are worthy goals, to be sure, but we believe that when attached to the objective of preventing homelessness or rehousing homeless people, these diffuse goals take on lives of their own and raise troubling questions of equity in the distribution of resources available to poor people. Every study that has looked has found that affordable, usually subsidized housing, prevents homelessness more effectively than anything else. This is true for all groups of poor people, including those with persistent and severe mental illness and/or substance abuse. Serious mental illness, while problematic in its own right, need not compromise an individual's ability to maintain housing; evidence regarding substance abuse is more mixed. Although social services are valuable for other reasons, it is not clear how much they contribute to preventing homelessness once access to subsidized housing is controlled. Studies of services that do not examine housing subsidies suggest that services are useful; studies that control for housing subsidies suggest that the intensity of services is unrelated to housing stability. Income supports are also related to housing stability, probably because the affordability of housing is a joint function of income and housing costs. Advocacy for entitlement income may be a key ingredient in case management. Some eviction prevention programs seem promising, but none have been studied rigorously. We need more research with long-term follow-up. Consumer choice in housing is associated with residential stability for people with mental illness and/or substance abuse problems. This suggests that a range of living options is valuable, with different degrees of social control and expectations for behavior. There is no evidence linking brief discharge planning efforts with reduced homelessness, although they may be useful as part of broader, more enduring services, including the provision of housing. Because homeless people in some cities come mainly from a few areas of highly concentrated poverty, it makes sense to test strategies of community development that combine housing development and subsidy, market-based economic development, supported work, public employment, and social services. http://aspe.hhs.gov/progsys/homeless/symposium/13-Preven.HTM The 1998 National Symposium on Homelessness Research 2 of 28 Because there is little research with long-term follow-up, it is impossible to know whether short-term interventions are sufficient to prevent homelessness. In contrast to the prevailing philosophy of time-limited benefits, in our view, it is likely that the shortcomings of the housing and labor markets require indefinite and expanded intervention by the state in both individual cases and in the aggregate. Tax expenditures on home mortgages, which benefit the well-to-do disproportionately, represent a long-term public investment in home ownership that dwarfs housing subsidies for the poor.
The Washingtonian movement.
Certain similarities between the Washingtonian movement of the nineteenth century and the present day fellowship of Alcoholics Anonymous have been commented upon by a number of observers. In view of this resemblance there is more than historical interest in an account of the first movement in the United States which brought about a large-scale rehabilitation of alcoholics. The phenomenal rise and spread of the Washingtonian movement throughout the land in the early 1940’s was the occasion of much discussion, exciting a deep interest. The cause of its equally rapid decline have been a subject of much speculation and are still of concern to the members of Alcoholics Anonymous who may wonder whether or not their movement is destined to a similar fate. This article, therefore, will present not merely a description and history of the movement but also an analysis of the similarities and differences between the Washingtonians and Alcoholics Anonymous.