Supporting Persons Experiencing Homelessness (PEHs) in Recovery from Substance Use

Disorders (SUDs)

Amanda Flores, Lexie Geltman, Hassena Gul, Shelby Karraker, Aubrey Skripko

Chapman University

CSP 626: Assessment and Treatment of Substance Abuse for the Professional Counselor

Dr. Amy Jane Griffiths

July 9, 2023
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Introduction

In the United States, the Annual Homeless Assessment Report (AHAR) reported that on a

single night in January 2020, an estimated 580,000 people experienced homelessness (U.S.

Department of Urban Housing and Development, 2020). Homelessness is a complex issue that

manifests as sleeping on the streets, residing in emergency shelters, living in cars, or not having

permanent housing (Carver et al., 2020). Various factors contribute to people experiencing

homelessness (PEH), such as economic hardships, mental health disorders, lack of affordable

housing, and substance use disorders (SUD). Substance use disorder can contribute to and result

from homelessness, with individuals who use drugs or alcohol as a coping mechanism or falling

into a cycle of addiction that leads to homelessness (Carver et al., 2020). The Substance Abuse

and Mental Health Services Administration (SAMHSA) estimated in 2019 that over 60% of

people experiencing homelessness also struggled with substance use disorders. Homelessness

and substance use disorders are interconnected issues. SUDs are often a precursor to

homelessness due to exhaustion of financial resources from drugs and alcohol, barriers to health

care, and co-occurring mental health disorders such as depression, anxiety, post-traumatic stress

disorder (PTSD), and schizophrenia.

A comprehensive approach that combines affordable housing initiatives, social support

systems, mental health services, and substance abuse treatment can address homelessness and

substance use disorders. By understanding the nature of these issues, implementing

evidence-based interventions increases the likelihood of improving the lives of people

experiencing homelessness and substance use disorders (Koegal, 2019). Furthermore, addressing

the patterns and symptoms of PEH and SUDs is crucial to identify gaps and overcome barriers

that individuals may encounter on their path to recovery.

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Substance Use Patterns and Signs/Symptoms

Drug use disorder rates have increased in recent years, indicating increased substance

use. Substance use among the homeless population is much more common than among the

housed population, with PEH using substances up two to three times higher than the general

population (Gomez et al., 2010). Exceptionally, homeless women may be more susceptible to

substance use when they lack social support. However, homeless men are often more isolated

than women, more likely to be psychiatrically impaired, and have post-traumatic stress disorder

(PTSD). Some patterns that often influence pathways to homelessness include social selection,

socioeconomic adversity, and traumatic experiences (Kim et al., 2010). When surrounded by

people who also use substances, homeless adults are less likely to quit substance use (Tucker et

al., 2011).

Risk Factors

Some studies have shown that about 75% of homeless youth who use substances do so to

suppress hunger, keep warm, and cope with their living situations (Bousman et al., 2005).

Attempted suicide, traumatic sexual/physical abuse, parental substance misuse, sexual

orientation, lack of social support, lack of parental monitoring, and being homeless for extended

periods are some indicators of substance use in homeless youth (Bousman et al., 2005; Tyler &

Ray, 2019). Other risk factors can include depressive symptoms, running away frequently,

physical victimization, and sexual trading (Tyler & Ray, 2019). Although it is prominent for

homeless individuals to have social support, some peer 'support' groups may negatively impact

and influence substance use among some homeless individuals (Bender et al., 2007).

Protective Factors
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Although the homeless population is more susceptible to substance use, they are resilient

and can adapt to stressful situations (Rew et al., 2001). Specifically for young homeless adults,

relationships formed with their peers fulfill many social needs, including a sense of connection

and safety when enduring life without shelter. When young homeless adults break from social

institutions (e.g., family, employment, school), homeless peers provide support as a protective

factor (Gomez et al., 2010). Another protective factor includes the homeless individual's position

to be influenced by positive role models. These individuals are more likely to develop healthy

coping styles with supportive guidance in not resorting to coping involving substance use (Tyler

& Ray, 2019).

Barriers to Care

Although persons experiencing homelessness are considerably more likely than average

to have a substance use disorder (SUD), they are often least likely to access support (Adams et

al., 2022). Substance use disorders often interact with homelessness, as SUDs are a risk factor

for homelessness, and homelessness is a risk factor for SUDs (Kertesz et al., 2003). As indicated

by the lack of access to SUD treatment, identification and treatment of SUDs for the PEH

population can be difficult. Barriers to identification and care for substance use disorders are

plentiful for the PEH population, with considerable personal and systemic barriers that one might

face. Personal barriers to care include mental health concerns, prioritization of other needs, and

lack of institutional trust. Structural barriers include difficulty navigating systems of care, lack of

resources, limited space and support, stigma, and disjointed, substandard care.

Personal Barriers to Care

Personal barriers to substance use treatment center around individuals and their

challenges with personally receiving care. These barriers may be a perceived lack of self-efficacy,
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additional problems that take priority, or negative attitudes toward care. A qualitative study on

substance use support among homeless individuals asked participants to describe barriers to

receiving support. One participant commented, "Once you are in that vicious circle, it can be

very hard to access anything; you do not know whom to go to or whom to speak to or whom to

contact; it is just tough to know what to do" (Adams et al., 2022). This remark speaks to both

structural barriers and a lack of self-efficacy.

According to a study of women experiencing homelessness and their perceived barriers to

substance use treatment, the most commonly identified barrier was 'feeling depressed or not up to

treatment' (Upshur et al., 2018). Mental health disorders are among the most common concerns

for people experiencing homelessness (Substance Abuse and Mental Health Services

Administration, 2021). When considering the stresses of homelessness, such as lack of safety,

support, and access to basic needs, it is reasonable for those with SUDs to have difficulty

identifying where to start and finding the motivation and self-belief necessary to get help.

Another common personal barrier to SUD treatment is the interaction and prioritization

of other needs. Experiencing homelessness, having a SUD, and/or having mental health concerns

all come with significant barriers to care, and these concerns may interact cyclically to make

barriers even more significant. People may not know what to prioritize or how; One concern may

exacerbate the other. People experiencing homelessness may also perceive child care,

employment, food, and shelter as higher priorities than receiving treatment for SUDs (Adams et

al., 2022).

Finally, negative attitudes towards care are common in the PEH population. These may

come from personal or cultural beliefs toward care providers or previous negative experiences.

According to a survey of teens experiencing homelessness, teens were more likely to seek advice
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and help from loved ones and friends, often citing negative interactions with care providers as a

reason for distrust (Ensign & Panke, 2002). Further systemic reasons for negative attitudes

toward care are explored below.

Structural Barriers to Care

Structural barriers to SUD identification and treatment involve more systemic challenges

homeless individuals face. These include systems that are difficult to navigate, a lack of

accessibility, limited space and support for recovery, and stigma or substandard care from

providers.

A significant concern for receiving care for SUDs while experiencing homelessness is the

difficulty identifying and accessing resources. Lack of health insurance and permanent address

was a commonly identified barrier in many studies (Adams et al., 2022; Ensign & Panke., 2002;

Upshur et al., 2018). Many clinics require forms of identification and a permanent address to

allow patients to make an appointment and receive care. In the general population, many

substance use disorders are identified through a patient seeking care for another concern, such as

a headache or infection, making healthcare providers a standard first line of screening and

identification (Van Boekel et al., 2013). As many individuals experiencing homelessness cannot

even go to a primary care provider, they are less likely to be identified with a SUD or referred for

treatment.

A lack of accessibility was another identified barrier for SUD treatment. Post-COVID,

many providers switched to online appointments or intakes, which can be a barrier for the PEH

population, who are less likely to be able to access the internet consistently (Adams et al., 2022).

Adams and colleagues also identified challenges with a lack of availability and long waiting lists

for providers that were accessible. Women and teens are even more likely to lack access to
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appropriate treatment resources, as treatment groups are often male-dominated or require

parental consent (Upshur et al., 2018; Kertesz et al., 2003).

Even when people can access treatment, it is more common for homeless individuals to

relapse, a phenomenon referred to by some as the 'revolving door' (Kertesz et al., 2003). People

who can receive care and recover are often forced to transition out of recovery quickly and

without a transition plan. They may lack the space to recover and need to live where substance

abuse is expected and encouraged, causing a high potential for relapse (Adams et al., 2022).

Research has shown that positive peer and social support can significantly improve outcomes for

recovery from SUDs, and continuing to remain around negative influences can slow or halt

recovery (Dobkin et al., 2002). A lack of social support and space to recover are significant

barriers to recovery that must be considered.

Finally, homeless individuals are more likely to face stigma or substandard care from

providers. Researchers found this was a common concern for homeless teens with SUDs, who

reported that healthcare providers often lacked empathy, pressured them to make specific health

choices, and were condescending or treated as ignorant about their health (Ensign & Panke,

2002). Another study found that a common concern was that healthcare providers were

dismissive or judgemental. Participants reported having to retell their stories to many providers

instead of receiving continuous care (Adams et al., 2022).

Despite significant personal and structural barriers to care for those experiencing

homelessness, there are many avenues to pursue recovery from SUDs for the homeless

population. Support may focus on addressing contributing factors to SUDs, removing barriers to
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care, or directly treating the individual with the SUD through treatment programs or therapeutic

interventions.

Evidence-Based Treatments

People experiencing homelessness (PEH) and substance use disorders (SUDs) need

support and intervention. However, there are conflicting opinions regarding the interactions

between homelessness and substance use disorders. Researchers question, does homelessness

cause substance abuse? Or does substance abuse cause homelessness? There are several

evidence-based resources available for individuals experiencing homelessness that have proven

to be effective. Housing First provides a client-centered approach to Housing and focuses on

shelter before sobriety. Meanwhile, Alcoholics Anonymous (A.A.) allows individuals to join free

meetings centered around sobriety, which does not discriminate based on housing status. Another

evidence-based resource is motivational interviewing (MI). This therapy style focuses on a

collaborative relationship between client and practitioner to support changes clients can make

daily.

Housing First

Housing First programs are evidence-based treatment centers for people experiencing

homelessness and substance use disorder (Gulcur et al., 2003). Davidson and colleagues (2014)

found that the Housing First programs had higher retention rates than abstinence-based

programs. In addition, Davidson and colleagues reported lower rates of SUD during the yearly

follow-up with the Housing First residents (2014). The client-centered approach, community

collaborations, and case management of these programs were vital to the success of PEH. In

addition, Housing First programs are unique because they adopted a Healthcare for the Homeless

(HCH) model, which tolerates continued missed appointments and gaps in care due to the nature
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of their housing situation (Carter et al., 2019). Gulcur and colleagues studied the impact of SUD

and Housing First programs by having an experimental group in a Housing First program and a

control group not in the program (2003). They reported lower rates of SUD for the experimental

group in Housing First over 48 months of experimentation. Researchers stated that due to the

resources within the Housing First program (i.e., mental health counseling, social workers, and

medical attention) contributed to the higher rates of sobriety within the experimental group.

Housing First programs are evidence-based treatment centers for people experiencing

homelessness and substance abuse disorder.

Alcoholics Anonymous

When considering treatment for substance abuse disorders, many people turn to

Alcoholics Anonymous (A.A.), a free meeting for the general public, including people

experiencing homelessness. It is essential to note the contradictory research surrounding A.A.

and PEH due to the program's core values and steps.

Rayburn & Wright (2009) studied the effects of A.A. on homeless men in Florida and

sought to understand if A.A. is an excellent avenue to cultivate a robust social support system for

PEH. However, their findings revealed that A.A. is not conducive to people experiencing

homelessness due to the core value of sobriety being an individual's priority (Rayburn & Wright,

2009). This value promotes the idea that substance abuse is the likely cause for an individual

experiencing homelessness, when PEH may use substances to cope with their tribulations. Many

participants felt that "If they can get and stay sober, their housing problems should somehow

resolve themselves. However, clients continue to get and stay sober, but very few successfully

find affordable Housing. If there are places these men can afford to live, then sooner or later, they

must be asking themselves, "What is the point?" Is being clean, sober but still homeless really an
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improvement?" (Rayburn & Wright, 2009, p. 110). Although A.A. can address SUDs effectively

for many, for PEH, Housing, and essential needs must also be met in order for an individual to

prioritize and maintain sobriety.

Motivational Interviewing

Motivational interviewing aims to identify and support a client's motivation for change

through collaborative communication between a client and counselor (Orciari et al., 2022).

Initially used in treating SUDs, motivational interviewing incorporates reflections and questions

based on the client's understanding of their behavior to facilitate their autonomy and evoke

change (Miller et al., 2019). In response to participating in motivational interviewing, persons

identified with SUDs have shown an increased probability of decreasing their behavior at

follow-up meetings up to one year after program completion and share increased motivation for

change for periods post-intervention (Santa Ana et al., 2016; Sayegh et al., 2021). Research

supports the notion that MI techniques, coupled with increasing intrinsic motivation and

supportive community members, increase retention among clients with SUDs. (Sayegh et al.,

2021).

MI-SNI, or Motivation interviewing with network intervention, has been used for persons

experiencing homelessness to support motivation for change while identifying community

members willing to support them in their change (Tucker et al.,2021). In a study by Kennedy et

al., persons experiencing homelessness who enter interim housing or treatment centers identified

a lack of supportive relationships or an understanding of reconnecting with supportive

communities (Kennedy et al., 2022). During sessions, counselors aim to promote conversation

regarding the lack of supportive communities to identify clients' current support system and their

understanding of the impact on their sobriety. Through conversations supporting autonomy for
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the client, statements such as, "The goal of this interview is to give you information so that you

can better understand and make decisions about your social life. What you do with this

information is totally up to you," are used to encourage an increase in the client's self-efficacy

through self-reflection (Tucker et al., 2021, p. 113). Through repeated exposure to supportive

conversations that encourage autonomy, a person experiencing homelessness can begin to look

beyond themselves and identify their role in their behavior and the impact of their community.

MI-SNI Study

One study used MI-SNI and showed positive results in decreasing AOD use and

increasing positive self-efficacy. The study consisted of 41 adults in a residential treatment center

who attended one to four motivational interviewing sessions focusing on supportive

conversations identifying their social environment's role and substance use's effect (Kennedy et

al., 2022). Throughout the sessions, clients construct physical images representing their network

structure, the influence each member provides to use AODS, and the level of support each

member receives using dots that connect people to the client and lines representing community

members' connection to each other, highlighting relationships and commonalities among circles.

(Kennedy et al., 2018). In conjunction with the physical designs, clients reflected and altered

their previous designs to represent how their behavior change influenced their relationships.

Results

At a 3-month follow-up post-intervention meeting, participants' AOD decreased while

client self-efficacy increased (Kennedy et al., 2018). Clients' reflection statements exemplified

their understanding of social networks through conversation, such as "just being able to see it,

just to see it on paper, I think it is more concrete. So I think it would help" (Kennedy et al., 2022,

p. 234). Post-completion of MI-SNI sessions, on average, clients' relationships with

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non-supportive community members decreased by 13%, and only 13% of their original

community members remained in their network (Kennedy et al., 2022). Throughout sessions, the

client's reflection on whether network members were supportive to non-supportive changed by an

average of 42% (Kennedy et al., 2022). Within the change of perception, clients reported feeling

increased motivation and a greater understanding of their social communities (Kennedy et al.,

2022). As a result, AOD use decreased when individuals identified positive social networks and

were provided with their basic needs. Additionally, individuals showed improvement in their

self-efficacy and their motivation to change.

Areas of study/gaps in the research

Additional areas of study that would benefit from exploration or research for individuals

experiencing homelessness with substance use populations mainly relate to intersectionality. As

previously mentioned, PEH with SUDs tend to have difficulties resulting from both homelessness

and substance use, and these issues may have a reciprocal nature. Continued studies on the

unique challenges PEH with SUDs face and evidence-based treatments explicitly developed for

this population are necessary to provide adequate care.

Much of the research on homelessness and substance use treatment appears to be with an

older male population, so continued research with women and adolescents would be beneficial.

Studies conducted on women and adolescents provide limited sample sizes, limiting the

generalizability of the results (Tucker et al., 2011). According to researchers, many treatment

approaches vary in efficacy based on the level of social support and treatment adherence (Miller

et al., 2019). As mentioned in the barriers section, teens and women experiencing homelessness

are less likely to have support groups or treatments tailored to their needs. Research on
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effectively serving homeless women and teens individually and in groups is essential. These

treatments may need to be tailored to specific challenges these populations face, like childcare,

school attendance, and domestic violence. In addition, future research should focus on social

contextual, and traditional individual factors to understand PEH with SUDs access and barriers

to supportive treatment (Tucker et al., 2011).

Furthermore, there needs to be more research on the interaction between Housing First

and SUD, specifically regarding sobriety. Future research should focus on this interaction and

elaborate on today's limited research. Psychologists and society must know how to help the

homeless population struggling with SUD and if the Housing First model is the most appropriate.

Continued research on the interaction between homelessness, mental health needs, and SUDs

would help find new threads for treatment and support for this population.
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Contributions:

Hassena Gul: Scope of the Problem

Amanda Flores: Substance Use Patterns and Symptoms

Shelby Karraker: Barriers to Identification and Treatment

Aubrey Skripko/Lexie Geltman: Evidence-Based Treatment & One Pager Resource

Shelby Karraker/Lexie Geltman/Amanda Flores: Areas of Study/gaps in research