Introduction
“Addiction treatment providers are
continually challenged to improve services. Often, these challenges occur in a
fiscal growth environment that is not only flat, but in most instances,
declining. Over the past decade, there has been an increased awareness of the
common presentation of persons with co-occurring psychiatric disorders in
routine addiction settings. National and state initiatives have been
significant, and have stimulated considerable interest in providing better
services for co-occurring disorders. Although clearly interested in doing so,
addiction treatment providers have lacked pragmatic guidance on how to improve
existing services (The Dual Diagnosis Capability in Addiction Treatment (DDCAT)
Index, 2006, p.4;
http://www.adp.ca.gov/COD/pdf/ddcat_toolkit.pdf
).” A state survey report (Department of Human Services, 2008) asserted that
individuals with co-occurring disorders are 20 times more likely to be
hospitalized and use emergency services, show increased rates of homelessness,
are vulnerable to housing instability, are susceptible to premature death, and
are more likely to be incarcerated.
Project Excell was a response to this need for services for the homeless
males with co-occurring disorders in Fulton county, GA.
Project Excell
The
greater metropolitan area of Atlanta, Georgia has a population of 3.5 million individuals. Included in this
population are richly diverse communities of color, ethnicity and class
distinction. About 20 percent of the
area’s population has no health insurance.
One-half of those with insurance are African- American and 39 percent are
between the ages of 25 to 44 years old.
Overall, 54% of Fulton County’s
residents are African American, 41% are European American, and three 3% are
Hispanic. According to US Census Data, Georgia ranks 13th in the
nation with people below the national poverty level. Georgia
has a rate of 12.3 % as compared with the rate of 20 % for Fulton County
residents. According to the Atlanta
Regional Commission, 34% of individuals who are homeless are also mentally ill,
often with a co-occurring diagnosis.
Project Excell was a program initiated by Fulton County Department of
Behavioral Health and Developmental Disorders (Oct.2008 – Dec. 2009).
Individuals targeted for this project were those who experiencing co-occurring
substance abuse and mental health disorders. These individuals were homeless
and found residence with Fulton
County, Georgia. Project Excell engaged 60 homeless males
suffering form co-occurring substance abuse and mental health disorders in
intensive outpatient treatment.
Best
Practices Model
DDCAT identifies
the service types provided to individuals with co-occurring disorders, and that
they range from consultation, collaborative, to integrative. The consultation end involves an occasional
communication between the client treatment providers about the clients’ status
and progress, whereas the integrative end involves the provision of substance
abuse and mental health services in the same treatment plan. Project Excell was based on the ‘best
practices model’ and provided integrative services to their homeless clients
with co-occurring disorders.
Another set of
‘best practices’ identified by the Substance Abuse and Mental Health
Administration report (SAMHSA, 2003) was the staff training and utilization of
motivational interviewing. Motivational
interviewing is a counseling style designed to help clients change their
behavior by exploring and resolving their ambivalence about that behavior. Project
Excell staff were trained in this technique.
Futhermore, process and outcome evaluations of Project Excell were
conducted to evaluate client outcomes after each quarter over a one year
period.
Trans-theoretical
Stages of Change ModelThe Trans-theoretical Model of Change, has
been the basis for developing effective interventions to promote changes in
health behaviors. The Transtheoretical Model (Prochaska & DiClemente, 1983;
Prochaska, DiClemente, & Norcross, 1992; Prochaska & Velicer, 1997) is
a model of behavior change which integrates constructs from other theories. The
central organizing construct of the model is the ‘stages of change’ which
encompasses the model of intentional change. Intentional change involves
decision making by the individual and also involves emotions, cognitions, and
behavior. External influences such as social and physical environments are also
considered as impacting through the individual. The model involves a reliance
on self-report.
The trans-theoretical model construes
change as a process involving progress through a series of five stages. The
five stages are: Pre-contemplation, contemplation, preparation, action, maintenance.
Pre-contemplation is the stage in which people are not intending to take action
in the near future (6-months) because they are uninformed about the consequences
of their behavior. Contemplation is the stage in which people are intending to
change in the next 6-months. This is considered the procrastination stage. Preparation is the stage in which people are
intending to take action in the immediate future (in a month). Action is the
stage in which people have made specific overt modifications in their
life-styles within the past 6-months. The action stage is also the stage where
vigilance against relapse is critical. Maintenance is the stage in which people
are working to prevent relapse. They are
more confident that they can continue their change. The Trans-theoretical Model can provide
sensitive measures of progress and
a set of outcome measures that are sensitive to a full range of cognitive,
emotional, and behavioral changes and recognize and reinforce smaller steps
than traditional action-oriented approaches.
Project Excell recognized that addiction treatment was not an all or
none event, but a process which ebbed and flowed. The clinicians assessed the clients’ stage of
change and matched reinforcements and services to help the client move to the
next level.
Treatment
programs for homeless consumers
An overview of homeless programs and detoxification facilities indicates
that the programs and facilities have different goals and provide varied
services. For example, programs have been geared toward treating drunk drivers,
homeless clients with mental health problems, homeless clients with poly-drug
abuse, homeless clients with a history of alcohol abuse, or substance abuse
treatment centers for any homeless clients. Services vary from basic
detoxification, to detoxification followed by a short-term treatment program,
or short-term treatment program followed by a long-term treatment program, residential
programs or non-residential programs (Talpade, 2003)
Leon, Sacks, Staines, McKendrick (2000) identified successful outcomes
in terms of longterm stability of a therapeutic community treatment program for
treating mentally ill chemical abusing homeless clients. Dickey (2000)
estimated that 25% of the homeless population was mentally ill and that this
population was qualitatively different from those who are only mentally
ill. Similarly, Kertesz et al. (2007)
report findings of the national survey data, among
homeless persons with a drug abuse history (58% of the total), 17% reported
receipt of inpatient or residential treatment within the past year, projecting
up to 1/2 million inpatient treatment episodes per year among homeless persons.
Only a minority of participants achieved favorable employment or housing
outcomes at one year. The authors
acknowledge that this treatment, although resource intensive, was insufficient
to help many participants with both homelessness and high levels of psychological
distress. Thus, the need to acknowledge multiple needs and match the consumer
profile with treatment services is imminent.
Dickey (2000) summarized the need for such disparity research by the
following words:
Doing
research, of course, is not the same as improving the lives of those
who are mentally ill and homeless. However, as society becomes
more attentive to evidence-based policy, the link between research and
public support for policy initiatives grows stronger.
Professionals and advocates can collaborate in a way that honors
individual rights and contributes to the social good (p.8).
Project Excell was geared toward matching the client needs with
services. Thus, it was predicted that Project Excell would
improve the bio-psycho-social status of the clients in the program, the
homeless males with co-occurring disorders, over a period of 6-months.
Specifically it was expected that: (1) Alcohol and Drug use reports
would decline, (2) Housing status, education, employment, and income
would improve, (3) Crime and criminal justice status would improve, (4)
Mental and physical health outcomes would improve, (5) risky behaviors
would decline, (6) Social connectedness would improve.
MethodDesign and ParticipantsParticipants.
Consumers in Project Excell were all males, with 75% Black, 12% white,
2% Hispanic, and 11% reporting ‘other’ as their racial
category. The age range of these males is 19 to 67 years, with a
median age of 44 years. The majority (50%) range between the ages
of 35-54 years. Archival data reports the following incidence of
the consumers with co-occurring disorders (66%, n=40) in the
program. Sixty-seven percent (n=41) had mental health needs, 100%
(n=60) needed substance abuse treatment. Additionally, 90% of the
clients were not enrolled in any training, 38% who were the
majority, had 12 years of school, 76% were unemployed, 21% had
been arrested, 41% reported poor to fair health; 15% had sought
inpatient help for alcohol/drug problems and mental health needs; 10%
had sought outpatient help for physical needs, 26% sought outpatient
help for drug/alcohol abuse problems and mental health needs.
Fifteen percent of the clients sought emergency room (ER) treatment for
physical problems, 10% for mental problems, and 2% went to the ER for
alcohol/drug problems. Twenty-six percent of the clients reported
being depressed in the past 30 days, 21% of the clients reported being
anxious in the past 30 days, 13% of the clients reported experiencing
hallucinations in the past 30 days; 5% reported suicidal tendencies in
the past 30 days. Thus, the clients of Project Excell had
significant substance abuse, mental health, physical health, and
housing challenges.
MaterialsThe
assessment protocol of Project Excell included a Family Assessment
Questionnaire (FAQ), Addiction Severity Index (ASI), Multipurpose
Information Consumer Profile (MICP), record of the Georgia Performance
Reporting Act (GPRA) data.
The FAQ was administered to all
consumers at the Center for Behavioral Health and Addictive Diseases to
assess why the consumers came to the center. The ASI, is a
self-report measure which taps into the mental health and
biopsychosocial needs of the consumers. This measure is based on
the clear assumption that individuals entering treatment have a
co-occurring psychiatric disorder. The MICP is a record of the
consumers biopsychosocial and criminal history over one’s lifetime,
whereas the GPRA is a record of the consumers’ biopsychosocial history
over the past 6-months. The MICP tracks the participant’s
biopsychosocial history, many which are not reflected in the
GPRA. For example, evidence of suicide attempts, spirituality,
family support, family history of mental health and chemical
dependence, and leisure activities are recorded and can be used by the
counselor or case manager to facilitate treatment.
ProcedureConsumers
of Project Excell came from the Fulton county homeless shelters,
transitional houses, Mental health jail diversion services, and the
Georgia Crisis Line. After the FAQ was administered,
consumers were provided with informed consent and their signature was
acquired on a SAMHSA approved consent form. Screening and
assessment were conducted at intake, with the GPRA data collected at
the same time. A psychiatric evaluation, nursing (medical)
evaluation, urine test results were assessed and documented. The
MICP and ASI were administered to the clients to determine current
client needs and record the past biopsychosocial history.
Counselors
kept track of individual attendance for group therapy. The
clients had to attend 8-12 sessions, three hours per day for three days
per week. Consecutive attendance was encouraged, however, if the
participant missed any session, they had to complete the 8-12
recommended sessions. If participants missed three sessions
consecutively, their file was deemed closed and ineligible for services.
The
program manager and six staff members provided treatment services to
the participants. This included three Licensed Professional
Counselors, one licensed Addiction Professional Counselor, one M.S. in
Human Services. Additionally two psychiatrists, a nurse clinician
evaluated the mental and physical health needs of the clients.
Medical needs of participants were met by service providers of Fulton
county.
Services
Clients in the Excell
program were provided with intensive outpatient services with group
counseling sessions held during the day at the Center for Health and
Rehabilitation. More intensive individual counseling was provided
for those needing such counseling, and Treatment planning was provided
to all clients.
Screening and Assessment was conducted at
intake, with the GPRA data collected at the same time. The Family
Assessment Questionnaire was administered to all clients at the Center
for Health and Rehabilitation to assess why the client came to the
center. The MICP and ASI were administered to the clients to determine
current client needs and record the past biopsychosocial history.
Aftercare services were provided to clients who did not have such
services at the place of referral. Sites with consistent follow
up client services were identified for client placement.
Clients
were provided with intensive outpatient day treatment, individual and
group counseling and recovery support. Cooccurring treatment and
recovery support were provided to those who needed such support.
HIV/AIDS counseling was also provided. Case management services
provided to the clients included family services, employment coaching,
services. Medical services included alcohol/drug testing,
HIV/AIDS services. Aftercare services included continues care,
relapse prevention, recovery coaching. Educational services
included substance abuse education and HIV AIDS education. The
recovery support services included peer coaching and drug free
socials. The cost per client was $722.
ResultsData
from 60 homeless males with co-occurring/ substance abuse/mental health
challenges were analyzed using the SPSS. A follow-up of 49
clients was conducted and the intake and follow-up data were compared
to evaluate if the predicted outcomes were obtained. The follow-up rate
for Project Excell was 94.2% compared to 67.7% for other grantees.
Alcohol/Drug Use in the past 30 days: Intake Versus at 6-months after intake
Data
of 49 clients at intake and after 6-months was compared. Repeated
measures MANOVA revealed significant decline over time on the measures
of : Alcohol intake over the past 30 days, F (1,13)= 15.36, p = .002
Use of Illegal Drugs over the past 30 days, F (1,13)= 5.44, p = .036,
Use of Alcohol and Drugs over the past 30 days, F (1,13)= 17.04, p =
.001, use of Cocaine over the past 30 days; F (1,13)= 9.52, p =
.009. See Table 1 for descriptive statistics.
Table 1
Alcohol
and Drug Use over the past 30 days: Descriptive Statistics
Interview
|
Used
Alcohol
|
Used Illegal
Drugs
|
Used
Both Alcohol and Drugs
|
Used
Cocaine
|
Intake
Mean
N
SD
6-month
follow-up
Mean
N
SD
|
3.77
57
8.47
1.00
48
3.35
|
5.44
55
10.47
.75
48
2.56
|
14.55
11
12.14
5.67
3
7.23
|
2.44
55
6.97
.31
48
2.02
|
Housing Status, Education, Employment, Income: Intake Versus at 6-months after intake
Nonparametric
and parametric statistics were computed on the client reports.
Chi square analyses of client reports at intake and after 6-months on
housing and employment status revealed non significant
improvements. Changes in housing status, with more clients in
shelters, fewer on the streets and institutions, more residing in
own apartments, were reported. Also, although non significant,
more clients reported working part time after 6-months than at
intake. Repeated measures MANOVA did not reveal significant
differences on the variables of Income and Education.
Crime and Criminal Justice Status: Intake Versus at 6-months after intake
Improvements
in criminal status (no arrests, drug related arrests), number of days
confined, number of crimes, number of arrests, parole status, were
noted 6-months after intake. Chi-square tests revealed
significant differences/decline in drug related arrests, χ2 (1, 19) =
4.05, p = .044. Although chi square analyses revealed non
significant differences, there were positive changes in the number of
clients awaiting trial and those who were on parole/probation.
Pairwise comparisons on the number of arrests, number of days confined,
and the number of crimes revealed non significant differences.
Mental and Physical Health Problems and Treatment: Intake Versus at 6-months after intake
Positive
changes in perceived impact of alcohol/drugs on brain function were
found, F (1, 31) = 4.26, p = .047. Significant increases in
stress, F (1, 31) = 24.24, p = .000; and emotions, F (1, 31) =
40.53, p = .000; were evidenced after 6-months.
Treatment for Alcohol/Drug related problems, Mental health, Physical health
Results
indicate statistically significant reduction in reports of clients
seeking Inpatient treatment for Mental problems, , χ2 (1, N
= 107) = 3.85, p = .050 (likelihood ratio); from 5% at intake to none
after 6 –months, Emergency Room (ER) treatment for Physical problems,
, χ2 (1, N = 107) = 3.85, p =.050 (likelihood ratio); from 10% at
intake to 1% after 6 –months, ER treatment for Mental problems,
χ2 (1, N = 106) = 5.06, p =.022, from 10% at intake to 1% after 6
–months.
Sexual Behaviors : Intake Versus at 6-months after intake
Sexual
behaviors were evaluated by responses to questions regarding the number
of sexual contacts in the past 30 days whereas risky sexual behaviors
were evaluated as responses to questions such as engaging in sex
without using condoms, sex with a HIV positive partner, sex with a
partner when high on alcohol/drugs. Results indicated that
although pairwise comparisons and chi square analyses did not reveal
statistically significant differences, risky sexual behaviors reduced
after 6-months.
Social Connectedness: Intake Versus at 6-months after Intake
Chi
square tests and repeated measures ANOVA revealed non significant
differences in social connectedness. Social connectedness
behaviors were defined by attendance of organizations supporting
recovery, attendance of self help groups, religious groups,
interactions with family and friends, and the number of family members
that clients could turn to when in trouble. Although non significant,
clients reported having people such as clergy, family, friends, and
sponsor to turn to when in need.
Age Group X Interview Type x Educational Attainment
A
MANOVA conducted on target psychological variables such as reports of
stress, educational level, depression, anxiety, hallucinations, brain
function, violent behaviors, health status, and psychotropic
medications as a function of Age Group (Younger versus Older) and
Interview type, revealed significant interactions between the
Educational level as a function of Age and Interview type; F (1,42) =
4.79, p = .035. Thus, educational level of older participants
increased over time whereas the educational level of younger
participants decreased over the 6 month period. See Table 2 for
descriptive statistics.
Table 2
Education
level as a function of Age and Interview type: Descriptive Statistics
|
Interview
|
Age
group
|
Educational
Level
|
Descriptives
|
|
Intake
|
18-44 years
45-65+ years
|
Mean
SD
N
Mean
SD
N
|
11.94
1.85
17
11.45
3.67
11
|
|
6 month follow up
|
18-44 years
45-65+ years
|
Mean
SD
N
Mean
SD
N
|
10.88
1.36
8
14.00
2.53
6
|
Employment Status X Interview Type x Stress level
A
MANOVA conducted on target psychological variables such as reports of
stress, educational level, depression, anxiety, hallucinations, brain
function, violent behaviors, health status, and psychotropic
medications as a function of Employment Status and Interview type,
revealed significant interactions between the Employment Status
(fulltime versus part time) as a function of Age and Interview
type; F (1,39) = 6.91, p = .013. Thus, stress level of part time
participants decreased over time (from Mean = 2.93, SD = 1.16 to Mean =
2.33, SD = 1.75) whereas the stress level of full time participants
increased (from Mean = 2.33, SD = 1.30 to Mean = 4.14, SD = 1.46) over
the 6-month period.
Use of Inpatient Services for Mental Problems X Interview Type x Psychological Problems
A
Kruskall-Wallis analyses conducted on target psychological variables
such as reports of stress, educational level, depression, anxiety,
hallucinations, brain function, violent behaviors, health status, and
psychotropic medications as a function of the use of Inpatient services
for Mental problems and Interview type, revealed significant
effects between the Use of Inpatient Services (yes versus
no) Interview type, and Depression, Stress, Anxiety, Suicide, and
Psychotropic Medications. Thus, the use of inpatient services for
mental problems were significantly related to the experience of stress,
χ2 (2, N = 48) = 6.15, p = .046, depression, χ2 (3, N = 99) =
8.29, p = .040, anxiety, χ2 (3, N = 102) = 9.57, p = .023,
suicide, χ2 (3, N = 101) = 20.87, p = .000, and the use of psychotropic
medications, χ2 (3, N = 102) = 16.67, p = .001. A comparison of the
Mean Ranks (see Table 3) revealed that reports of depression,
suicide, and the use of psychotropic medications at intake, was a
predictor for the use of inpatient treatment for mental problems.
Stress however was not a good predictor for the use of inpatient
treatment for mental problems.
Use of Inpatient Services for Physical Problems X Interview Type x Psychological Problems
Table 3
Use
of Inpatient Services for Mental Problems X Interview Type x Psychological
Problems
|
Variables
|
Interview
|
Response
|
N
|
Mean
Rank
|
|
Stress
|
Intake
|
Yes
|
8
|
30
|
|
|
Intake
|
No
|
27
|
21
|
|
|
6-months
|
No
|
14
|
31
|
|
Depression
|
Intake
|
Yes
|
8
|
72
|
|
|
Intake
|
No
|
45
|
48
|
|
|
6-months
|
No
|
46
|
50
64
|
|
Anxiety
|
Intake
|
Yes
|
8
|
65
|
|
|
Intake
|
No
|
46
|
46
|
|
|
6-months
|
No
|
46
2
|
53
85
|
|
Suicidal behavior
|
Intake
|
Yes
|
9
|
61
|
|
|
Intake
|
No
|
45
|
51
|
|
|
6-months
|
No
|
46
2
|
51
51
|
Psychotropic
Medications
|
Intake
|
Yes
|
9
|
75
|
|
|
Intake
|
No
|
45
|
45
|
|
|
6-months
|
No
|
46
2
|
53
84
|
A Kruskall-Wallis analyses conducted on target psychological
variables such as reports of stress, educational level, depression,
anxiety, hallucinations, brain function, violent behaviors, health
status, and psychotropic medications as a function of the use of
Inpatient services for Physical problems and Interview type, revealed
significant effects between the Use of Inpatient Services
(yes versus no) Interview type, and number of violent acts in the
past 30 days, χ2 (3, N = 103) = 12.15, p = .007. The Mean Ranks
revealed that the number of violent acts in the past 30 days predicted
the use of inpatient services for physical problems (see Table 4).
Table 4
Use of Inpatient Services for Physical Problems X
Interview Type X Psychological Problems
|
Variables
|
Interview
|
Response
|
N
|
Mean
Rank
|
|
Violent Acts
|
Intake
|
Yes
|
1
|
102
|
|
|
Intake
|
No
|
54
|
53
|
|
|
6-months
6-months
|
Yes
No
|
1
47
|
90
49
|
Use of Inpatient Services for Alcohol/Drug related Problems X Interview Type X Psychological Problems
A
Kruskall-Wallis analyses conducted on target psychological variables
such as reports of stress, educational level, depression, anxiety,
hallucinations, brain function, violent behaviors, health status, and
psychotropic medications as a function of the use of Inpatient services
for Alcohol/drug use problems and Interview type, revealed significant
effects of the use of Inpatient Services (yes versus no)
Interview type, on stress, χ2 (3, N = 49) = 9.30, p = .026, and
education level, χ2 (3, N = 107) = 11.06, p = .011. A higher
level of education and stress predicted the use of inpatient services
for alcohol/drug problems (see Table 5).
Table 5
Use of Inpatient Services for Alcohol/Drug related
Problems X Interview Type X Psychological Problems
|
Variables
|
Interview
|
Response
|
N
|
Mean
Rank
|
|
Stress
|
Intake
|
Yes
|
5
|
28
|
|
|
Intake
|
No
|
30
|
22
|
|
|
6-months
6-months
|
Yes
No
|
3
11
|
46
26
|
|
Education
|
Intake
|
Yes
|
8
|
83
|
|
|
Intake
|
No
|
51
|
48
|
|
|
6-months
6-months
|
Yes
No
|
8
40
|
65
54
|
Use of Emergency Room Services for Mental Problems X Interview Type X Psychological Problems
A
Kruskall-Wallis analyses conducted on target psychological variables
such as reports of stress, educational level, depression, anxiety,
hallucinations, brain function, violent behaviors, health status, and
psychotropic medications as a function of the use of ER services for
Mental problems and Interview type, revealed significant
effects between the Use of ER Services (yes versus no)
Interview type, and experiencing Stress, χ2 (2, N = 48) = 8.26, p =
.016; Hallucinations, χ2 (2, N = 99) = 8.64, p = .013; Violent acts, χ2
(2, N = 102) = 6.48, p = .039; Suicide, χ2 (2, N = 101) = 31.98, p =
.000; and Psychotropic medications, χ2 (2, N = 102) =
14.48, p = .001; in the past 30 days. Thus, the presence of
stress, hallucinations, violent acts, suicide, and use of psychotropic
medications at intake predicted the use of ER services for mental
problems. See Table 6 for Mean Ranks.
Table 6
Use
of ER Services for Mental Problems X Interview Type X Psychological Problems
|
Variables
|
Interview
|
Response
|
N
|
Mean
Rank
|
|
Stress
|
Intake
|
Yes
|
6
|
33
|
|
|
Intake
|
No
|
28
|
20
|
|
|
6-months
|
No
|
14
|
30
|
|
Hallucinations
|
Intake
|
Yes
|
5
|
71
|
|
|
Intake
|
No
|
46
|
47
|
|
|
6-months
|
No
|
48
|
50
|
|
Violent Acts
|
Intake
|
Yes
|
6
|
70
|
|
|
Intake
|
No
|
48
|
51
|
|
|
6-months
|
No
|
48
|
50
|
|
Suicidal behavior
|
Intake
|
Yes
|
6
|
67
|
|
|
Intake
|
No
|
47
|
50
|
|
|
6-months
|
No
|
48
|
50
|
Psychotropic
Medications
|
Intake
|
Yes
|
6
|
83
|
|
|
Intake
|
No
|
48
|
46
|
|
|
6-months
|
No
|
48
|
53
|
Use of Emergency Room Services for Alcohol/Drug use Problems X Interview Type X Psychological Problems
A
Kruskall-Wallis analyses conducted on target psychological variables
such as reports of stress, educational level, depression, anxiety,
hallucinations, brain function, violent behaviors, health status, and
psychotropic medications as a function of the use of ER services for
Physical problems and Interview type, revealed significant effects
between the use of ER Services (yes versus no) Interview type,
and experience of Anxiety, , χ2 (2, N = 102) = 6.22, p = .045 ;
and Violent acts, , χ2 (2, N = 103) = 7.58, p = .023. Thus,
anxiety and violent acts at intake predicted the use of ER services for
alcohol and drug problems. See Table 7.
Table 7
Use of ER Services for Alcohol/Drug use Problems X
Interview Type X Psychological Problems
|
Variables
|
Interview
|
Response
|
N
|
Mean
Rank
|
|
Anxiety
|
Intake
|
Yes
|
1
|
100
|
|
|
Intake
|
No
|
53
|
48
|
|
|
6-months
|
No
|
48
|
54
|
|
Violent Acts
|
Intake
|
Yes
|
1
|
102
|
|
|
Intake
|
No
|
54
|
53
|
|
|
6-months
|
No
|
48
|
50
|
DiscussionProject Excell resulted in a
substantial number of changes in the status of the clients.
Project Excell improved the biopsychosocialstatus of the clients in the
program. These findings are corroborated by reflections of the staff in
direct contact with the clients of Project Excell who agreed that the
program made a positive impact on the clients related to their
addiction, mental health, employability, recovery/rehabilitation.
Similar results have been evidenced by other treatment programs for
clients with co-occurring disorders where receipt of professional
service delivered superior outcomes (Gonzales & Rosenheck, 2002).
They also indicated that short –term improvements were found across the
board, and long-term improvements were deemed to persist with ongoing
support systems.
Although improvements were not
evidenced on all the measures, there were substantial changes toward
the positive in client status over the short period of treatment and
follow up time. Specifically, more clients were working
part-time; these findings are positive considering the current
employment conditions. This may explain the results related to stress
where full time workers were more stressed (may have fear of losing
their jobs) in comparison to part-time workers (who may just be
thankful for finding a job). Drug-related arrests declined
significantly over the period of 6-months (from n = 6 to n = 0).
The use of ER services for Mental and Physical health purposes, and
inpatient mental health services declined over time. More clients
sought ER services at intake for varied problems and is attributed to
the lack of insurance, lack of health care, lack of resources.
Use of ER services reduced over time probably indicating an increase in
support systems and coping strategies. Unlike what was found at intake,
poor mental health status was associated with attendance of recovery
groups, suggesting that the clients had probably learnt coping skills
to aid their recovery.
Despite these positive outcomes, it is
acknowledged that some of the findings were not as positive. That
is more clients were housed in shelters after 6-months or were
theoretically, homeless. These findings are attributed to the
resources available at the shelters; food, shelter, treatment,
vocational rehabilitation. In the absence of any financial
resources, the shelters were thus the best available option.
Also, as a clinician pointed out, shelters provide a sense of community
instead of an apartment where they would feel isolated. Reports of
stress and emotions increased with time. It is postulated that
the encounter with outside environmental stressors and the lack of the
controlled supportive environment may have caused these outcomes.
Age was negatively correlated mental health problems and with
sexual activity. It is postulated that because of this
relationship, older clients were more likely to keep up their
psychotropic medication regimen, rather than younger clients who,
according to the counselors, discontinued their medications due to a
negative impact on sexual activity. This relationship may also
explain why older clients continued to increase their educational level
in contrast to the younger clients. This relationship between
lack of education and homelessness has been corroborated by other
researchers (Calsyn & Roades, 1994). Thus, as some of these
findings indicate, this program had better outcomes for the older
clients.
Future implications and improvements for programs
such as this are derived from staff reflections. Staff made
recommendations to enhance treatment outcomes. They were,
incorporating a pretreatment component to educate clients about
expected outcomes and benefit of program completion; transportation and
meals continued for a longer period of time 6-12 months after discharge
from program; healthcare on a sliding fee ; case management
continued from nine months to one year based on the needs of the
client, because clients with co-occurring disorders are the most
difficult to rehabilitate and need more intensive case management and
support. For clients with mental health issues, clients needed
semi independent housing with ongoing support. Relapse is a part
of recovery (85%) therefore the staff argued, enough time was important
to rehabilitate the client. Also, motivation increased when the clients
had fewer needs.
Staff also ascertained that one element
ubiquitous for recovery, in addition to support systems available after
leaving the program, was motivation of the client. To provide
both, it was recommended that the follow up be continued in the
community, with affordable housing, which is supervised by mental
health professionals who could monitor and control negative client
outcomes. Providing such a therapeutic community has delivered
significantly positive outcomes especially among those with mental
health issues (Leon et al., 2000). Improved outcomes for
those with stable housing as a part of the treatment have been
corroborated by others (Kertesz, 2007).
Thus, future
interventions geared toward the homeless will benefit from the
treatment model used by Project Excell and will reap long term benefits
if the staff recommendations of extended treatment, follow-up, and
support services are initiated. In summary, the brief
intervention Project Excell improved client outcomes on several
biopsychosocial measures and provided hope and healing for the homeless
males in Fulton county, Georgia.
