انگیزه برای تغییر و پریشانی روانی در مصرف کنندگان مواد مخدر بی خانمان

This study explores the treatment needs of homeless individuals participating in a large urban day shelter program. Alcohol and drug use, psychological distress, and stage of change were assessed in 100 participants presenting for services. The associations among substance use, risk perception, and readiness to change were examined for alcohol and drugs separately. Participants had high levels of psychological distress compared to “non-patient” samples. Eighty percent had used alcohol in the past 6 months, with 65% of those drinking at higher-risk levels; 60% had used drugs, with 82% in the higher-risk levels. While the majority felt that they drank and/or used drugs “too much”, most were in precontemplation or contemplation stages of change. Intervention efforts for this population should focus on motivation, facilitation through the stages, and the associations between psychiatric symptoms and substance use.

Homelessness is a significant social problem that continues to exist despite repeated attempts at local, state and national levels to respond to the many and varied needs of this population. The substance-abusing homeless represent a special subset of the population that may be underserved by public treatment programs (Dixon & Osher, 1995). Although substance abuse treatment for this group is a major need, few treatment programs exist specifically for the homeless and most programs lack the resources to adequately address addictive disorders Burt et al., 1999 and Cousineau, 1995. The National Coalition for the Homeless (NCH, 1998) includes long waiting lists, lack of transportation, and lack of supportive services among the barriers to treatment and recovery opportunities. While it is difficult to determine prevalence of substance abuse disorders among the homeless due to regional differences and methodological issues, researchers and service providers agree that substance abuse among the homeless is a major public health concern (Fischer & Breakey, 1991). While accurate estimates of mental disorders among the homeless are also hard to determine, recent studies indicate that as many as 50% of the total homeless population have some form of mental illness with 70–80% having a lifetime diagnoses (Scott, 1993). It is uncertain whether these disorders are a cause or a consequence of homelessness (or a combination of both), but it does seem clear that mental illness tends to worsen as one's homelessness continues (Lamb & Lamb, 1990). The dearth of substance abuse services for this group is further complicated by the fact that any program developed specifically for the homeless must also take into account clients' levels of psychological distress and the relation of this distress to their substance use. This study explores the issues of alcohol, other drug use, motivation for change, and psychological distress among the homeless; presents data on these variables from a sample of homeless day shelter clients in a large urban city; and offers insight into the need for specialized treatment programs. 1.1. Substance abuse and the homeless Many studies have identified alcoholism and other substance abuses as the most pervasive health problem for the homeless. Prevalence estimates of alcohol dependence and abuse among this population range from 59% to 68%. According to Fischer and Breakey (1991), the magnitude of alcohol problems among the homeless can best be appreciated through comparison with rates described for the general population, where 10% of men and 3% of women develop pervasive and persistent alcohol problems. That means that prevalence rates among homeless populations are six to seven times greater than what would be expected in the general population. Alcoholism has a major impact on the physical health of the homeless. Studies indicate that among patients receiving health care in programs for the homeless, alcohol abusers tend to be much sicker than other patients. They are more likely to engage in high-risk life-endangering behaviors, experience serious trauma, and suffer from serious health problems such as liver disease, nutritional deficiencies, hypertension, chronic obstructive pulmonary disease, gastrointestinal disorders, and arterial disease Harris et al., 1994 and Stine et al., 1988. Patterns of the homeless' abuse of drugs other than alcohol have been studied less intensively, yet it is clear that use of illicit drugs is also widespread. It is estimated that from 25% to 50% of homeless people use illicit drugs and that rates of use exceed those reported for the general population. Drug use increases the likelihood of arrests and incarcerations, and homeless individuals who use drugs are more likely to engage in prostitution, increasing their risk for contracting sexually transmitted diseases — particularly HIV (Fischer & Breakey, 1991). 1.2. The “dually diagnosed” homeless A particular source of increasing public health concern is the homeless mentally ill. Although estimates vary, evidence indicates that substantial numbers of the homeless suffer from severe and chronic mental illness (Belcher, 1989). It has also been estimated that a quarter to a third or more have multiple diagnoses of mental illness or disability and substance abuse (Lomas, 1992). These individuals have often become homeless due to their inability to hold jobs, poor social skills, and inability to cope with everyday events. Most often, they have no social support systems, high rates of contact with the criminal justice system, and no established relationship with service systems. The dually diagnosed often fall between the cracks of the public health care system. When these individuals present for care, they are often shuttled back and forth between services. Substance abuse care providers frequently exclude the mentally ill because they are difficult to deal with, and mental health professionals often refuse to treat dually diagnosed clients until they achieve sobriety Farriello & Scheidt, 1989 and Velasquez et al., 1999. While there have been some recent attempts to develop “hybrid” programs in which mental health and substance abuse treatments are integrated, how to accomplish this integration most effectively is still a matter of debate Kofoed et al., 1986, Minkoff, 1989, Ridgely et al., 1990 and Velasquez et al., 1999. Add the problem of homelessness to this already complex situation and it is easy to understand why the homeless dually diagnosed are often left untreated. 1.3. Treatment programs for substance-abusing homeless Due to the complexity of their problems and needs, homeless substance abusers pose special challenges for treatment providers. They have multiple needs in addition to treatment, and they are generally not well served by traditional treatment programs. This is evidenced by extremely high dropout rates, lower compliance, and lower success rates Caton et al., 1994 and O'Brien et al., 1989. It is likely that homeless individuals' immediate needs for security, food and shelter often prevail over their need for treatment of substance abuse problems. A degree of bias may also exist within some traditional treatment programs with treatment providers seeing the homeless as being less deserving of services Goldberg & Simpson, 1995 and Stahler & Cohen, 1995. A few agencies that serve the homeless have attempted to implement substance abuse programs. While these programs are well intended, and while there is obviously a high degree of need for this type of service, their effectiveness may be limited by the fact that service providers most often do not know the type or extent of the clients' substance use, or their degree of motivation for change. When substance abuse treatment service is incorporated into the services offered by homeless shelters and resource centers, participation rates in these types of programs tend to be low unless they are a requirement for obtaining services. Twelve-Step groups, which are often effective for domiciled individuals, are typically not well attended by the homeless (Schutt & Garrett, 1992). Another problem is one that is common to many substance abuse treatment programs — they are “action-oriented”; i.e., most substance abuse programs are geared toward individuals who are ready to change, with the focus being on relapse prevention rather than on increasing and sustaining motivation for change. 1.4. Study goals The impetus for the present study was to learn about the substance abuse treatment needs of homeless clients participating in a large urban day shelter program. We explored the prevalence of alcohol and other drug use among the shelter participants, and assessed their stage of readiness to change these behaviors. We also examined the associations among participants' alcohol and drug use, mental illness, and readiness to address the various problems.