Running head: Phase three

Phase 3 Paper
SW 3810
21 June 2014
Tiera Couch (004322562)
Professor Sharonlyn Harrison Ph.D.
Wayne State University

Running head: Phase three

2
Statement of the problem

Housing homeless persons who suffer from dual disorders without adequate treatment is
providing a disservice to that population. Many service providers are not equipped to treat those
with dual disorders extensively prior to housing them, which can lead to dysfunction and a return
to homelessness. Due to the nature of their conditions these individual are susceptible to
homelessness and are also more likely to remain homeless longer than the rest of that population
(as cited in Drake, Yovetich, Bebout, Harris & Mchugo, 1997, p. 298).
Substance abuse and mental illness are factors contributing to the loss of stable housing
(Bebout, Drake, Xie, Mchugo & Harris, 1997, p. 936). Substance abuse can cause psychiatric
relapses," destroy supportive relationships, lead to disorderly behavior, and cause disruption or
removal from treatment and services (Bebout, Drake, Xie, Mchugo & Harris, 1997, p. 936).
Substance addiction can also lead to the mishandling of finances (Bebout, Drake, Xie, Mchugo
& Harris, 1997, p. 936). When these disturbances result in homelessness, these individuals are in
need of extensive services (as cited in Drake, Yovetich, Bebout, Harris & Mchugo, 1997, p. 298).
Due to the intricate nature of their conditions, dually diagnosed homeless are difficult to
accommodate, general care does not meet their needs (Bebout, Drake, Xie, Mchugo & Harris,
1997, p. 936).
In the event, they are housed; it is often done so without adequate treatment. They are
then expected to pay rent on time (for those that have an income), follow the rules (if any), and
keep appointments. When living in shelters, supportive housing, or transitional housing, they
were subject to structure and provided assistance. The experience of independent living can be
difficult to adapt to, especially for those who are chronically homeless. For people that have been
homeless for an extended period it can be difficult to function in society because they lack social

Running head: Phase three

skills and often do not feel safe. While homeless individuals with co-occurring disorders need
extensive integrated care, the priority is frequently given to housing these individuals. The
efforts and resources used are wasted if the individual cannot function properly. It is not
uncommon for a person battling dual disorders to get overwhelmed and walk away from the
responsibilities, returning to homelessness.
Prior to becoming homeless, these people had difficulty maintaining financial and
housing stability, social relationships and their physical and mental wellbeing. How is it helping
to place them in permanent housing without providing the tools needed for them to function?
Ending homelessness consists of far more than providing low-cost housing. All environmental
factors must be addressed, to decrease homeless recurrence. If homeless adults with co-occurring
severe mental illness and substance abuse problems received Integrated Dual Disorder Treatment
(IDDT) prior to placement in permanent housing, will it decrease the percentage of homelessness
recurrence in that population?
Research design
In the study, Integrated Treatment for Dually Diagnosed Homeless Adults," researchers
used a quasi-experimental (Drake, Yovetich, Bebout, Harris & McHugo, 1997, para. 28)
research design. They tested the effectiveness of integrated treatment (IT) versus standard
treatment (ST) for homeless persons suffering from co-occurring substance abuse and mental
health issues (Drake, Yovetich, Bebout, Harris & McHugo, 1997, para. 1). The study measured
the outcome of IT in comparison to ST for dually diagnosed homeless persons, by compiling two
groups with similar histories and conditions, assigning IT for one-group and ST for the other
group, and analyzing the results of treatment (Drake, Yovetich, Bebout, Harris & McHugo, 1997,
para. 6).

Running head: Phase three

Although attrition was an issue, researchers reported that it was not a threat to external
validity because there were no correspondences between participants who completed the study
and those who dropped out (Drake, Yovetich, Bebout, Harris & McHugo, 1997, para 18). The
study attributed attrition to insufficient accessibility of the standard group (Drake, Yovetich,
Bebout, Harris & McHugo, 1997, para 18), had researchers established tracking methods for
participants attrition could have been minimized (Rubin & Babbie, 2013, p. 199). According to
Drake, Yovetich, Bebout, Harris & McHugo, (1997) many of the participants who left the study
prematurely had the following characteristics; more education, less dependent on substances,
newly homeless, and married prior (para. 18). These characteristics suggest that these persons
conditions were not as severe as their counterparts.
Majority of participants were single, African American women, with minimal education
(Drake, Yovetich, Bebout, Harris & McHugo, 1997, para. 10), women were deliberately overrepresented because of their limited visibility in past studies (Drake, Yovetich, Bebout, Harris &
McHugo, 1997, para. 9). The practice of oversampling women, compiled with the attrition of
Caucasian males, lessened the representativeness of the study. In order to test nonrepresentativeness as a threat to internal validity, researchers examined the effects of baseline
variable inequalities and found no difference in the results (Drake, Yovetich, Bebout, Harris &
Mchugo, 1997, para. 28).
While the study analyzed the effects of non-representativeness among baseline variables,
the participants as a whole are of a small subgroup of the population they are to represent. The
study took place in Washington D.C., where the population is mostly African American, and the
lifestyles of the people and their living conditions are similar to those in most inner city areas
(Drake, Yovetich, Bebout, Harris & Mchugo, 1997, para. 7). The study limited its relevance to a

Running head: Phase three

broader population, by solely concentrating on participants in urban settings (Bebout, Drake,

Xie, McHugo, & Harris, 1997, p. 940). This study is not generalizable to people from different
backgrounds, living spaces, and ethnicities (Rubin & Babbie, 2013, p. 199). The study lacks
diversity, and equal representation among participants, so the results cast a very narrow picture
of the effect of IT compared to ST for dually diagnosed homeless persons.
Results from the study could have been affected by the abundance of resources readily
available to the ST group, which is not normally the case in most inner cities. According to
Drake, Yovetich, Bebout, Harris & McHugo (1997) the D.C. Right to Overnight Shelter law
ensured that the ST had access to multiple services (para. 25). Both the IT group, and ST group,
received comparable services and displayed exceptional progress during the study (Drake,
Yovetich, Bebout, Harris & McHugo, 1997, para. 25). That outcome may have been different
were the study conducted in a city that lacked such a law.
Sampling
The study used judgmental sampling; the researchers hired individuals to screen possible
participants, by visiting from shelters, and other know areas homeless people congregated
(Drake, Yovetich, Bebout, Harris & McHugo, 1997, para. 10). Homeless people are transient,
and it would be difficult for people who are unaware of their patterns to locate them. The
advantage of using a judgmental sampling was the researchers ability to use the knowledge of
persons who worked with the homeless to locate possible participants (Rubin & Babbie, 2013, p.
172). The disadvantage of using judgmental sampling is the findings are limited; in this case
participants were individuals who were obviously homeless, or are already seeking services
(Rubin & Babbie, 2013, p. 172). The homeless are a unique population, so, judgmental sampling
was an appropriate approach, but to expand the scope of participants researchers should have

Running head: Phase three

added snowball sampling (Rubin & Babbie, 2013, p.173.) because participants have knowledge
not available to professionals.
The study is directly related to the client characteristics, intervention being considered,
alternative, intervention and outcome (CIAO) question. Subjects were persons diagnosed with
co-occurring mental health and substance abuse issues, who lived in either a shelter, in an
institution or on the streets (Bebout, Drake, Xie, McHugo, & Harris, 1997, p. 937), which are the
client characteristics for the question. The study tested integrated treatment on dually diagnosed
persons, which is the intervention introduced in the CIAO question. Last, the study reported
success for participants who received integrated treatment; it is safe to infer that persons who
have a decrease in addiction and an increase in mental health and housing stability are less likely
to return to homelessness.
Measurement
The study measured the variables housing status, substance abuse and psychiatric
symptoms. Housing status was measured by the Personal History Form (PHF) (Drake, Yovetich,
Bebout, Harris & McHugo, 1997, para. 13) and defined by the number of days the individual
remained in homeless settings, institutions and stable housing (Drake, Yovetich, Bebout, Harris
& McHugo, 1997, para. 20). Alcohol and drug abuse results were based on scores from the
Alcohol Use Scale (AUS), Drug Use Scale (DUS), Substance Abuse Treatment Scale (SAT)
(Drake, Yovetich, Bebout, Harris & McHugo, 1997, para. 21) and the Addiction Severity Index
(ASI). Substance use was defined by the individual's levels of usage and functioning (Drake,
Yovetich, Bebout, Harris & McHugo, 1997, para. 13). Psychiatric symptoms were measured with
structural clinical interviews, and scores on the Brief Psychiatric Rating Scale (BPRS) and
defined by the severity of symptoms (Drake, Yovetich, Bebout, Harris & McHugo, 1997, para.

Running head: Phase three

13). Had the success of housing status solely been determined by number of days an individual
remained independently in permanent housing the study would have been biased, which is
because participants progress at different rates.
Data collection
Data was collected by conducting face-to-face, hour and a half long interviews, at threemonth intervals (Drake, Yovetich, Bebout, Harris & McHugo, 1997, para. 13). According to
Rubin and Babbie (2013), the advantages of conducting face-to-face interviews include higher
response rates, higher completion rates, the ability to receive clearer answers, increased
clarification, fewer misunderstandings, and the ability to assess non-verbal communication (p.
141-142). Rubin and Babbie (2013), continue with, the interviewer could be a disadvantage to
face-to-face interviews. The interviewer's presence can affect the participant's response, and his
or her appearance, demeanor and level of comparability, can create biases and or affect the
participant's willingness to respond (p. 142). Using a different method would not have been
beneficial to the study. As most of the participants do not have access to computers and
telephones or have an address to collect mail (Rubin & Babbie, 2013, p. 144), it would be very
hard to administer online, phone or mail in survey.
Ethical and cultural considerations
The intervention in the article used the target group dually diagnosed, homeless adults
(Drake, Yovetich, Bebout, Harris & McHugo, 1997, as cited in para. 7), which is the same
population listed in the statement of the problem. While researchers worked directly with the
targeted population, there was no mention of measures taken to accommodate the uniqueness of
the demographic they studied. The study oversampled women (Drake, Yovetich, Bebout, Harris
& McHugo, 1997, para. 9), but there was no mention of whether these women had children and

Running head: Phase three

how they were accommodated if that was the case. The study did not implicate any use of
incentives or reimbursement. Dispersing bus cards and calling cards would have been especially
helpful to the participants receiving ST, and the added mobility and accessibility could have
lessened the amount of dropouts from the program. To address ethical issues, researchers
received written informed consent from participants and refrained from printing identifiable
information (Drake, Yovetich, Bebout, Harris & McHugo, 1997, para. 9). That is the extent of
the available information; this study either omitted its ethical and cultural considerations or
neglected to address the special circumstances of its participants.
Results and implications
Drake, Yovetich, Bebout, Harris & McHugo (1997) suggest that the study findings
support the use of IT, as an effective treatment for dually diagnosed homeless adults (Drake,
Yovetich, Bebout, Harris & McHugo, 1997, para. 32). Drake, Yovetich, Bebout, Harris &
McHugo (1997) stated the following:
The main hypotheses concerning group differences at follow-up were that the subjects
who received IT a) would be more likely to move out of homeless and institutional
settings into stable housing and b) would show greater decreases in substance use.
Secondarily, we predicted that these primary outcomes would lead to greater positive
changes in symptom severity, functional status, and quality of life for the group that
received IT (para. 6).
The intervention includes counseling for substance abuse, treatment for mental health
conditions and service to connect participants with stable housing (Drake, Yovetich, Bebout,
Harris & McHugo, 1997, para. 11). In order to implement the intervention, the agency would
need case managers, substance abuse counselors, and housing support staff (Drake, Yovetich,

Running head: Phase three

Bebout, Harris & McHugo, 1997, para. 11). Integrating services requires the expertise of
multiple professionals, with a vast knowledge of each service area. The biggest barrier to
implementing the intervention will be funding. Currently, most agencies focus on specific
functions and provide referrals for other needs. Building a new program or revamping a current
program will be costly, but making the shift to providing all services in house could be costeffective in the future.

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10
References

Bebout, R. R., Drake, R. E., Xie, H., Mchugo, G., & Harris, M. (1997). Housing status among
formerly homeless dually diagnosed adults. Psychiatric Services, 48(7), 936-41.
Drake, R. E., Yovetich, N. A., Bebout, R. R., Harris, M., & Mchugo, G. J. (1997). Integrated
treatment for dually diagnosed homeless adults. The Journal of Nervous & Mental
Disease, 185(5), 298-305. Retrieved from
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Rubin, A., & Babbie, E. (2013). Essential research methods for social work (3rd ed.). 142-99
Brooks/Cole. Retrieved from
http://ps.psychiatryonline.org/data/Journals/PSS/3471/936.pdf