The International Journal of Psychosocial Rehabilitation

 

Homelessness and Dual Diagnosis

Robert E. Drake
New Hampshire-Dartmouth Psychiatric Research Center
Fred C. Osher
National Institute of Mental Health
Michael A. Wallach
Duke University

Reprinted from:
American Psychologist, November 1991 Vol. 46, No. 11, 1149-1158
© 1991 by the American Psychological Association



This article was supported by U.S. Public Health Service Grants 1-R01-AA-08341-01 from the National Institute on Alcohol Abuse and Alcoholism and 1-R18-MH-46072-01 from the National Institute of Mental Health (NIMH), and NIMH Research Scientist Development Award 1-K02-MH-00839-01. The views presented are those of the authors and do not necessarily reflect the position or policies of the National Institute of Mental Health.

ABSTRACT
People who are dually diagnosed with severe mental illness and substance use disorders constitute 10%-20% of homeless persons. They are a heterogeneous and extremely vulnerable subgroup with complex, poorly understood needs. In this article recent research on the epidemiology, subject characteristics, and service needs of the dually diagnosed homeless population is reviewed. Also, the range of evolving approaches to providing social services, housing, and mental health and substance-abuse treatments; the relevant system issues and legal issues; and problems with current research, as well as future research directions, are discussed. The importance of the distinction between providing appropriate living environments and mental health treatments emerges throughout.


Introduction:

Homeless persons who are dually diagnosed with severe mental illness and substance use disorders constitute a particularly vulnerable subgroup with complex service needs ( Breakey, 1987 ; Fischer, 1990 ). Few studies address their particular characteristics, needs, and treatment specifically. This oversight results from several difficulties.

One problem is definition. Dual diagnosis is defined in different ways, and homeless mentally ill substance abusers are, in reality, multiply impaired, with the impairments having consequences on multiple levels. In addition to mental illness and substance use disorders, many homeless persons have general medical illnesses, legal problems, histories of trauma, behavioral problems, skill deficits, and inadequate or antisocial support systems ( Fischer, 1990 ; Koegel & Burnam, 1988 ; Rosenheck, Gallup, Leda, Thompson, & Errera, 1988 ; Wright & Weber, 1987 ).

Another difficulty is assessment. Because instruments have not been validated for use with homeless or dually diagnosed populations, case ascertainment depends on varied and uncertain procedures ( Lovell & Shern, 1990 ). Research efforts are further hampered by the disorder-specific organization of services. Service systems tend to view clients in corresponding unidimensional terms (i.e., as mentally ill or chemically dependent), despite the complicated realities of co-occurrence ( Ridgely, Goldman, & Willenbring, 1990 ).

A final problem is that dually diagnosed individuals are an extremely heterogeneous population ( Lehman, Myers, & Corty, 1989 ). This heterogeneity includes demographics, pathways to homelessness, type and severity of nonaddictive mental disorder, and type and pattern of substance use disorder(s). All of these problems, and particularly the issue of heterogeneity, make generalizations about the dually diagnosed homeless population difficult.

Substance abuse, as well as housing instability and homelessness, has increased dramatically among people with severe mental illness in the postinstitutional era ( Bachrach, 1984 ; Minkoff, 1987 ). As awareness of the problem of dual diagnosis has grown ( Boyd et al., 1984 ; Galanter, Castaneda, & Ferman, 1988 ; Ridgely, Goldman, & Talbott, 1986 ), models for integrating mental health and substance abuse treatments have begun to emerge ( Minkoff, 1989 ; Osher & Kofoed, 1989 ; Ridgely, Osher, & Talbott, 1987 ; Teague, Schwab, & Drake, 1990 ) but have not been specifically applied to homeless persons. Similarly, models for intervening with the homeless mentally ill population ( Burwell et al., 1989 ) and with homeless substance abusers ( Argeriou & McCarty, 1990 ) are being developed, but these may not be sufficient for the dually diagnosed homeless population.

Addressing dually diagnosed homeless persons forces us to confront clinical issues, service system issues, legal issues, and housing issues. In this review we will briefly address the existing literature in each of these areas, critique the current research, and suggest directions for future clinical and research efforts. One goal is to improve our understanding of distinctions between protected living arrangements and treatment-distinctions that were blurred when patients were institutionalized.
 

Epidemiology

Approximately one third of homeless persons suffer from severe and disabling mental illnesses ( Morrissey & Dennis, 1986 ; Morrissey & Levine, 1987 ; Tessler & Dennis, 1989 ), 30% to 40% have alcohol problems ( Fischer & Breakey, 1987 ; Koegel & Burnam, 1987 ; Wright, Knight, Weber-Burdin, & Lam, 1987 ), and 10% to 20% have problems with other drugs ( Milburn, 1989 ). Approximately 10% to 20% of homeless persons are dually diagnosed with severe mental illness and alcohol or other drug problems ( Tessler & Dennis, 1989 ).

In a recent comprehensive review of the literature on homelessness for the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute of Mental Health (NIMH), Fischer (1990) identified 10 studies that differentiated between individuals with a single diagnosis of alcohol, drug, or mental health problems and those with dual or multiple diagnoses. The rate of mental disorder plus alcohol use disorder ranged from 3.6% to 26% in 7 studies, the rate of mental disorder plus other drug use disorder ranged from 1.7% to 2.5% in 3 studies, and 3 studies reported mental disorders co-occurring with alcohol or drug use disorders in a range of 8% to 31.1%. In a similar review for the National Institute of Mental Health, Tessler and Dennis (1989) reviewed NIMH-funded studies of homelessness and found that mental disorder plus substance abuse (alcohol or other drug use disorder) ranged from 8% to 22% in the 5 studies that reported comorbidity. Four of the 5 studies reported that nearly one half of those persons with mental disorders had co-occurring substance use disorders. Even with the lack of standardization in reporting categories, assessment methods, and sampling, both reviews support the 10% to 20% rate of dual diagnosis for the homeless population.

Few studies have examined the relationship between dual diagnosis and homelessness. Koegel and Burnam (1988) found that the rate of schizophrenia was nine times as high in homeless alcohol-dependent persons compared with the household sample of alcohol-dependent persons in the Epidemiologic Catchment Area study. Similarly, bipolar disorder was seven times as prevalent in homeless alcohol-dependent individuals as in their housed counterparts.

Reports from clinical samples indicate that dually diagnosed individuals are particularly vulnerable to housing instability and homelessness. Drake, Wallach, and Hoffman (1989) found that 27% of an urban state hospital aftercare sample had unstable housing and were at least temporarily homeless over a six-month evaluation period. Both alcohol use and other drug use were strongly correlated with homelessness, and more than one half of the dually diagnosed subgroup experienced homelessness during this interval ( Drake & Wallach, 1989 ). In a prospective study, Belcher (1989) found that 36% of the mentally ill patients discharged from a state hospital became homeless, at least temporarily, within six months of their discharge. Use of alcohol and other drugs strongly predicted homelessness, so the rate of homelessness among dually diagnosed individuals was considerably higher than 36%. Drake, Wallach, et al. (1991) found that even in a rural area with extensive family supports and available low-cost housing, dual diagnosis was strongly correlated with housing instability: More than one half of the schizophrenic patients with alcohol problems experienced housing instability during a six-month period.
 

Subject Characteristics of Dually Diagnosed Homeless Persons

Fischer (1990) reviewed characteristics of dually diagnosed homeless persons in 10 federally funded epidemiologic studies of homelessness that identified them as a separate subgroup, albeit using several different definitions of dual diagnosis. Compared with homeless persons who had single or no diagnoses, dually diagnosed individuals were more likely to be older and male and were less likely to be working. Along with alcoholics, dually diagnosed individuals were more likely to be local residents and to have longer durations of homelessness than were other subgroups. In one study ( Fischer & Breakey, 1990 ), dually diagnosed individuals were more likely to experience extremely harsh living conditions, such as living on the streets rather than in shelters. Various health status indicators show that dually diagnosed individuals have greater difficulties and receive more services than other subgroups ( Fischer, 1990 ). Koegel and Burnam (1987) found that dually diagnosed individuals (defined as those suffering from severe mental illness and chronic alcoholism) were more likely than other homeless groups to suffer from psychological distress and demoralization, to grant sexual favors for food and money, and to be picked up by the police and to become incarcerated. They were less likely to have contacts with and receive help from their families, and like primary alcoholics, they were highly prone to victimization. According to Blankertz, Cnaan, White, Fox, & Messinger (1990) , dually diagnosed homeless persons are particularly prone to isolation, mistrust of people and institutions, and resistance to accepting help.

Several critical correlates of dual diagnosis such as risk of homelessness, prognosis for recovery, and response to specific interventions were not studied in the first generation of NIMH-funded research. Koegel and Burnam (1987) did find that a majority of dually diagnosed homeless persons reported that their first alcoholic symptoms preceded their homelessness by at least five years. Clinical studies suggest that dually diagnosed individuals are strongly predisposed to homelessness because their substance abuse and treatment noncompliance lead to disruptive behaviors, loss of social supports, and housing instability ( Belcher, 1989 ; Benda & Dattalo, 1988 ; Drake, Osher, & Wallach, 1989 ; Drake & Wallach, 1989 ; Drake, Wallach, & Hoffman, 1989 ; Drake, Wallach, et al., 1991 ). Interviews with families and third parties confirm this view ( Lamb & Lamb, 1990 ).
 

Service Needs

Programs for the dually diagnosed homeless population generally offer an amalgam of service elements adopted from mental health or substance abuse treatment programs for homeless people ( National Resource Center on Homelessness and Mental Illness, 1990 ). In recognition of the difficulty in attracting and rehabilitating these individuals, programs generally accept the need for a lengthy engagement process that emphasizes outreach, help with basic needs, and slowly building a trusting relationship. Common program elements include comprehensive assessment, intensive case management, supported housing, peer groups for support and therapy, training in independent living skills, and mental health and substance abuse treatment. Program philosophy includes acceptance and tolerance of relapses, an emphasis on structured approaches, clear expectations within residential programs, and a commitment to long-term care.

As more programs for dually diagnosed homeless people evolve, these basic service elements are being developed in a variety of settings ( National Resource Center on Homelessness and Mental Illness, 1990 ). Examples of well-described programs include the Salvation Army Clitheroe Center Shelter in Anchorage, Alaska ( Dexter, 1990 ), the Phoenix Drop-in Center in Somerville, Massachusetts ( Wittman & Madden, 1988 ), and residential services in several areas ( Blankertz & White, 1990 ; J. Kline, Bebout, Harris, & Drake, 1991 ; Wittman & Madden, 1988 ).

Despite their extensive treatment needs, as perceived by others, dually diagnosed homeless persons are unlikely to have received recent treatment for either mental illness or substance abuse ( Koegel & Burnam, 1987 ). Dual diagnosis is underidentified ( Helzer & Pryzbeck, 1988 ), but even when identification occurs, other formidable reasons prevent care.
 

Barriers to Care

Barriers to care for homeless mentally ill people and for homeless substance abusers have been detailed in previous articles in this section of the special issue of the American Psychologist. Because clinicians, programs, institutions, and funding mechanisms have developed over time within disability-specific categories, barriers between these categorical services have arisen ( Ridgely et al., 1990 ) and add to the accumulated burden of multiple disabilities ( Bachrach, 1987 ). Even stably housed clients with co-occurring disorders are often refused admission to or prematurely discharged from categorical programs ( Galanter et al., 1988 ).

Alcohol and drug treatment developed outside the traditional medical care system and, to a significant extent, in reaction to the perception that the medical community, and particularly mental health providers, viewed substance abuse as a moral or characterological problem ( Vaillant, 1983 ). Not until the 1950s did the American Medical Association and the World Health Organization recognize alcoholism as a disease. Despite the recent push of alcohol- and drug-treatment providers to relocate services within hospitals for purposes of reimbursement, historical barriers remain largely unaffected ( Ridgely et al., 1990 ).

On the federal level, the administration of alcohol, drug abuse, and mental health research and treatment is organized into three separate institutes-the National Institute of Mental Health, the National Institute on Alcohol Abuse and Alcoholism, and the National Institute on Drug Abuse-and two newly created offices-the Office of Treatment Improvement and the Office of Substance Abuse Prevention. This fragmentation mirrors and reinforces administrative structures in most states, which are separated into at least two categories without a single authority to oversee, coordinate, develop, and fund integrated services for clients who need them ( Ridgely et al., 1990 ). At the program level, categorical administration and funding, particularly in times of limited or shrinking financial resources and increasing demand, promote the identification of single disorders, for the purpose of either treatment or shunting to another system, and thereby institutionalize the denial of dual disorders. Differences in treatment philosophy, training, and credentialing of clinicians reinforce these barriers.

Funding barriers are particularly problematic. Alcohol and drug programs are now profitable enterprises in general hospitals, and like mental health units, they may exclude the indigent, unmotivated, or complicated client in order to protect the homogeneity or profit margin of the program ( Ridgely et al., 1990 ). In the recent past, people with severe mental illness have had difficulty obtaining entitlements ( Goldman & Gattozzi, 1988 ). Those with alcohol and drug problems now face similar barriers to obtaining benefits. The Social Security Administration currently provides benefits only if a substance abuser is in treatment and has a protective payee, both of which are in short supply. Many insurance programs still fail to provide for treatment of alcohol and drug problems. Current trends toward prospective payment also complicate the treatment of those with dual disorders because they tend to underpay for complicated cases ( Scherl, English, & Sharfstein, 1988 ). The current emphasis on funding according to diagnosis-related groups encourages short hospital stays, which may be ineffective for complicated cases.

Similar comments can be made regarding housing. Because of the dramatic decrease in low-cost housing, anyone with uncertain income, rental payment, or behavior may be unable to secure housing ( Hopper, 1989 ). Illness exacerbation and disruptive behavior related to substance abuse make dually diagnosed individuals particularly visible and difficult tenants who are especially subject to community resistance described as the not-in-my-backyard syndrome ( Robert Wood Johnson Foundation, 1990 ). Those with dual disorders encounter more than double jeopardy because of the combination of their problems and the categorical nature of supported housing arrangements. Housing programs for mentally ill persons often exclude substance abusers, and those for substance abusers often exclude severely mentally ill individuals. Asking housing personnel to cooperate with more than one treatment system may be impossible in practical terms. Special housing programs that utilize new housing regulations, funding streams, and administrative oversight may need to be created. The protective functions that institutions traditionally offered may need to be more seriously addressed on the outside.

Another barrier to service utilization is the mismatch between available resources and individual client preferences. Homeless persons, even those with psychiatric and addictive impairments, want help with basic amenities like food, clothing, shelter, and jobs, but may have little interest in mental health treatment ( Mulkern & Bradley, 1986 ). Even those who seek hospitalization are typically interested in the basic comforts of food and shelter rather than treatment ( Drake, Wallach, & Hoffman, 1989 ; M. V. Kline, Bacon, Chinkin, & Manov, 1987 ). As Mulkern and Bradley (1986) observed, the problem is often acceptability rather than accessibility. The realities of what clients want may need to be taken more into account in what professionals offer.
 

Housing

Adequate housing is the cornerstone, and perhaps the sine qua non, of care for homeless persons, and particularly for those with multiple impairments such as dually diagnosed individuals ( Hopper, 1989 ). Homeless people with either mental illness or substance abuse problems are more likely to return to institutional care if they are not provided with adequate housing ( M. V. Kline et al., 1987 ; Lipton, Nutt, & Sabatini, 1988 ; Wittman, 1989 ). For those with alcohol and drug problems, including those dually diagnosed, maintaining sobriety may be impossible practically without adequate housing ( Teague et al., 1990 ; Wittman, 1989 ).

Clinicians and researchers who work with dually diagnosed individuals advocate both a range and a continuum of housing options to meet needs that vary across individuals and over time. Blankertz and White (1990) suggested that individual characteristics of dually diagnosed persons such as acceptance of restrictive environments, desire for self-determination, tolerance of high expectations in several areas simultaneously, and willingness to strive for abstinence determine their housing preferences at any time.

A continuum of housing can be conceptualized in terms of either the level of expectation for program participation or phases of treatment (defined later as engagement, persuasion, active treatment, and relapse prevention). Living on the streets or in shelters presents a complicated set of demands for survival rather than treatment. Shelters may provide an opportunity for screening and assessment, but they often fail to offer basic security and cleanliness that would allow engagement to take place ( Dockett, 1989 ; Martin, 1989 ). In addition, long-term placement in shelters tends to socialize clients into dependency on nontherapeutic, institutional care ( Grunberg & Eagle, 1990 ). More adequate alternatives should provide safety, individual space, cleanliness, and dignity.

Engagement is more likely to take place in supported housing or "low-demand" residences, although clients will sometimes need hospitalization or detoxification to make the transition to housing. Although the concept of wet housing is controversial within traditional chemical dependency settings, proponents argue that all clients have a right to decent and safe housing and that treatment should be a second-order consideration ( Hopper, 1989 ). As Baumohl (1989) expressed it, we must explore "the limits of toleration without making it a euphemism for neglect" (p. 294). Low-demand settings may at least reduce morbidity and permit the development of trusting relationships (i.e., engagement) so that residents can be persuaded to participate in treatment and to pursue abstinence. The low-demand approach for the dually diagnosed population is currently being tried in group-home settings ( Blankertz & White, 1990 ) and has been proposed as an intervention in single-room-occupancy settings ( Coalition of Voluntary Mental Health, Mental Retardation and Alcoholism Agencies, 1989 ). Our experience suggests that the housing system must be maximally flexible during this phase of treatment; clients often leave housing precipitously if too much pressure is placed on them, and they are often extruded by landlords. The tolerance of a housing system (e.g., allowing shifts from one housing situation to another) may be helpful in the long-term process of preventing homelessness and promoting stabilization ( J. Kline et al., 1991 ).

For those dually diagnosed clients who become committed to abstinence, alcohol and drug-free living alternatives are essential. New York City has developed the concept of transitional living communities-specialized transitional care settings analogous to halfway houses, in which clients receive integrated treatment to facilitate abstinence, develop sober living skills, make connections to self-help providers in the community, establish medication compliance, and develop realistic goals ( Hannigan & White, 1990 ). New Hampshire uses specialized halfway houses for dually diagnosed clients at this stage ( Drake, Antosca, Noordsy, Bartels, & Osher, 1991 ). Community Connections in Washington, DC, uses highly supervised apartments staffed by housing personnel with substance-abuse-treatment backgrounds and guarded by security officers ( J. Kline et al., 1991 ).

The next step might be alcohol and drug-free living settings with less structure and more independence. Attendance at self-help groups would be required, and the use of alcohol and other drugs off-site would not be tolerated. Ultimately, the success of transitional facilities depends on the availability of permanent housing. Numerous mechanisms for the development of permanent housing, discussed elsewhere in this issue, although not specific to the dually diagnosed, are clearly essential for this vulnerable population.

At least two controversies need to be addressed as we develop housing programs for the dually diagnosed population. First is linking treatment to housing. Given the complex clinical problems of dually diagnosed individuals, providing housing and clinical services without treatment can be seen as naive by clinicians ( Drake & Adler, 1984 ); requiring participation in treatment can be construed as essential. On the other hand, treatment and support are separate issues, and acceptance of treatment may have more to do with the values of professionals than of clients. Many feel that all people have a right to decent housing, regardless of their problems and willingness to participate in treatment. Clearly, many dually diagnosed clients seek hospitals, shelters, and other institutional settings for their basic amenities rather than for treatment ( Drake & Wallach, 1988 ; M. V. Kline et al., 1987 ). Moreover, decent housing may be a necessary first step in engaging clients and persuading them to participate in treatment. Research data on the use of low-demand housing for dually diagnosed clients are not available.

Another controversy with relevance for the dually diagnosed population concerns the use of permanent versus transitional housing. Some ( Blanch & Carling, 1988 ; Carling, 1990 ) have advocated normal permanent housing (with necessary supports) rather than transitional housing, which requires moves that may themselves be stressful. Others, as described earlier, have developed programs with transitions according to clinical status and needs ( National Resource Center on Homelessness and Mental Illness, 1990 ). Despite strong opinions on this issue, solid research evidence is again lacking.
 

Mental Health and Substance Abuse Treatment

Few programs have developed services designed specifically for homeless dually diagnosed clients. A small number of homeless demonstration programs funded by NIMH or NIAAA focus on those with dual disorders ( Argeriou & McCarty, 1990 ; Burwell et al., 1989 ). Emerging programs reflect two currents of developing clinical experience: services for homeless persons with a single categorical disorder and services for dually diagnosed individuals.

As to categorical services, mental health services for homeless mentally ill persons and substance-abuse services for homeless substance abusers have been reviewed in previous articles in this section. Within each category, outreach and access to a full and continuous range of categorical services have been emphasized. Those who are dually diagnosed must be brought in touch with alcohol, drug, and mental health services that in turn are linked together.

We next turn to services for the dually diagnosed population. On the basis of the Alcohol, Drug Abuse, and Mental Health Administration's review of dual-diagnosis programs ( Ridgely et al., 1987 ), our review of the 13 demonstration programs for young adults with co-occurring disorders funded by NIMH in 1987 ( Teague et al., 1990 ), the dual-diagnosis programs funded by NIMH in 1989 ( NIMH, 1989 ), and our New Hampshire dual-diagnosis program ( Drake, Teague, & Warren, 1990 ; Teague & Drake, 1990 ), several principles have emerged. The convergence of opinion by experienced clinicians and administrators can be summarized as follows:

1 Integrated treatment.
Treatment for co-occurring severe mental illness and substance-abuse problems should be concurrent and carefully coordinated ( Lehman et al., 1989 ; Minkoff, 1989 ; Osher & Kofoed, 1989 ; Ridgely et al., 1987 ). Many clinicians and administrators advocate integrating treatment within one system or setting, rather than linking services in separate settings by two systems. Proponents of the integrated treatment model argue that integration must occur at all levels: increasing individual clinicians' capacities to treat severe mental illnesses and addictive disorders; consolidating alcohol, drug, and mental health treatment at the local level under one roof and supervisory authority; and coordinating administration, monitoring, funding, and other aspects of intersection at the state level. Exactly how to modify existing clinical systems is the subject of several current studies. Traditional methods of parallel or sequential treatments (i.e., linkage) may be less effective because they place too much of the burden of integration on the client. However, the linkage model has the distinct advantage of making use of an extensive self-help system that is free and in place. Several current studies are examining the issue of integrated versus linked treatment for dual diagnosis ( NIMH, 1989 ).

2. Intensive case management.
Coordination of care by clinicians with small caseloads and an orientation toward assertive outreach and providing treatment in the community has been termed intensive case management. Because dually diagnosed clients are difficult to engage and retain in treatment, regardless of their housing status, even programs that do not focus on homeless persons usually prescribe intensive case management as the central treatment vehicle ( Teague et al., 1990 ). Intensive case managers engage clients through outreach, crisis intervention, and practical assistance; they are able to access for clients the entire community support services model ( Stroul, 1989 ); they are in a unique position to assess dual disorders ( Drake, Osher, et al., 1990 ); and they are able to steer and support clients through the stages of addiction treatment (defined later). Several current studies are examining aspects of intensive case management for the dually diagnosed population and for the homeless population ( NIMH, 1989 ).

3. Group treatment.
The assertive case-management approach, by itself, may not be a sufficient treatment for chemical dependency ( Bond, McDonel, Miller, & Pensec, in press ). Clinicians across a wide variety of programs agree that dual-diagnosis groups of some type are essential treatment components. This view is supported by open clinical trials ( Hellerstein & Meehan, 1987 ; Kofoed, Kania, Walsh, & Atkinson, 1986 ; Kofoed & Keys, 1988 ). Different types of groups may be effective. They range from purely educational to interactive to behavioral skill-building to the Alcoholics Anonymous/Narcotics Anonymous social program model, but all are peer-oriented and integrated into a comprehensive dual-diagnosis program.

4. Phases of treatment.
Many of the controversies about treatment of dual diagnosis, such as when to insist on abstinence, can be resolved by conceptualizing treatment as a process with different phases ( Osher & Kofoed, 1989 ). We have proposed four phases: engagement, persuasion, active treatment, and relapse prevention. During engagement, the emphasis is on developing a trusting, collaborative relationship with the client. The clinician (or clinical team) accomplishes this through providing practical help as well as companionship. Crisis intervention and detoxification may occur during this phase. Few demands for compliance or participation are made.

Once the client is engaged, the clinician attempts to persuade the client to participate in programs and treatment, and particularly to consider abstinence-oriented treatment. Persuasion is accomplished in the context of providing for basic needs, gradual stabilization, and increasing awareness, often in peer groups, of the relationship between substance use and problems in living.

For clients who are persuaded that abstinence is a goal, active treatment concentrates on attaining the skills, supports, and life-style changes that promote abstinence. Peer group treatment is also a key aspect of this phase. The active treatment phase has higher expectations, and external supports such as laboratory monitoring and alcohol and drug-free living settings are frequently helpful. Clients who have attained and maintained sobriety for six months to a year graduate to a relapse prevention phase, in which they continue to monitor risk factors and participate in some aspect of maintenance treatment such as group, self-help group, or case management.

5.Substitute activities.
Clinicians from a variety of programs agree that dually diagnosed clients, like other substance abusers, must develop substitute activities and relationships. These vary greatly across programs but typically emphasize skill-building, group-identity formation, self-esteem enhancement, and focusing on an abstinent life-style ( Teague et al., 1990 ).

6. Cultural relevance.
Minorities are overrepresented among the dually diagnosed homeless population ( Koegel & Burnam, 1987 ). Cultural relevance is frequently cited as one critical aspect of programs that serve ethnic and racial minorities. These programs attempt to incorporate the values, styles, language, and other characteristics of local groups. Hiring staff from the same cultural group clearly facilitates this process, as does emphasis on larger proportions of nonprofessionals in the staff. Some programs also hire former consumers to participate in outreach and engagement ( Teague et al., 1990 ).

7. Training.
Because there are few clinicians well trained in both mental health and substance-abuse treatment, current programs are dependent on their own internal training mechanisms. Training should be longitudinal rather than episodic; outside speakers raise interest and enthusiasm but not skills. Clinicians must instead struggle daily with dually diagnosed clients in the context of regular supervision with other clinicians who will question their assumptions, provide information and perspective from another discipline, and encourage them to try new approaches. To benefit from longitudinal training, clinicians must be flexible, willing to try new approaches, and of course interested in the overlap of severe mental illness and addictive disorders.

8.Families.
Dually diagnosed homeless persons are often significantly estranged from their families. When families can be accessed, they need education about substance abuse as well as mental illness and should be referred to Al-Anon, as well as the Alliance for the Mentally Ill ( Osher & Kofoed, 1989 ). Experience indicates that these families are often reluctant to participate with the mental health system and may need considerable outreach and assistance ( Lehman, Herron, & Schwartz, 1991 ).
 

Legislative and Legal Issues

Dually diagnosed homeless persons are, with respect to legal issues, affected by legislation that targets the homeless population, the mentally ill population, or substance abusers. Key legislative issues regarding access to entitlements, housing, or treatment for any of these three groups will influence them. For example, they have been excluded at times from entitlements because of their status as homeless, mentally ill, or substance abusing.

The Fair Housing Amendment of 1988 extended protections of federal fair housing legislation to people with disabilities. Although it forbids discriminatory intent or effects of regulations concerning housing for mentally ill individuals, dually diagnosed individuals may still be vulnerable because the language does not cover people who are currently using unlawful controlled substances unless they are participating in drug-treatment programs ( Mental Health Law Project, 1989 ). In addition, involvement with illicit drugs raises issues of liability that dissuade many potential landlords.

As reviewed in previous articles in this section, mental health, public assistance, or adult protective service legislation in some states has been effective in securing shelter for homeless persons. Nevertheless, a national strategy for assuring shelter has not developed. Langdon and Kass (1985) proposed comprehensive federal legislation that would create a nationwide shelter system and centers for those with specific needs, among them dually diagnosed individuals.

The movement to abridge rights of self-determination of homeless persons will strongly affect those dually diagnosed, inasmuch as they are prone to disruptive behaviors ( Drake & Wallach, 1989 ) and particularly likely to be involved in illegal activities and to have contacts with the police ( Koegel & Burnam, 1987 ). A variety of states have proposed or instituted legislation to broaden the criteria of involuntary hospitalization, to provide outpatient commitment, to permit transportation to hospital or shelter, or to impose limited guardianship ( Parry & Beck, 1990 ). Such legislation may protect dually diagnosed individuals from inappropriate shunting into jails and prisons, and hospitalization (voluntary or involuntary) may provide an opportunity for engagement with the community treatment team ( Bennett, Gudeman, Jenkins, brown, & Bennett, 1988 ). The necessity of involuntary measures is, however, unclear. Because many of the dually diagnosed population may themselves want protective living, even as they reject mental health treatment ( Drake, Wallach, & Hoffman, 1989 ), it seems important to sort out carefully what can be voluntary, before expanding involuntary measures.
 

Current Research Issues

A number of research foci can be identified for further work.

1. Assessment validity.
Many of the issues highlighted in previous articles are relevant as well to the dually diagnosed homeless population. The issue of valid assessment, for example, is critical for this group. Standardized instruments have not been validated for use with them; more work needs to be done to validate the assessment of severe mental illness ( Susser & Struening, 1990 ), substance abuse ( Drake, Osher, et al., 1990 ), and other key dimensions. Not the least of these is living preference-a complex attitude not easily assessed by simple, face-valid questions ( Drake & Wallach, 1979 , 1988 ). Validity can be increased by aggregating observations over time and situation ( Drake, Osher, et al., 1990 ), by collecting information from collaterals ( Drake, Wallach, & Hoffman, 1989 ; Lamb & Lamb, 1990 ) and by modifying standard instruments so that they assess behavioral dimensions that are relevant for this population ( Drake, Osher, et al., 1990 ).

2.Qualitative methods.
In some areas, our understanding of key issues is so inchoate that qualitative approaches are essential. Koegel (in press ; Koegel & Overbo, 1990) has argued persuasively for ethnographic approaches-proceeding in context, over time, from the insider's perspective-in studying homelessness. For example, intensive participant observation with a few homeless individuals over time might counterbalance current reliance on cross-sectional self-report data and allow us to learn more about how homeless people actually survive and make decisions regarding living situations, treatment participation, and substance abuse. In addition to Koegel, Schwab from our New Hampshire group and Quimby in our Washington, DC, project are currently using ethnographic approaches in studies of the homeless ( Teague & Drake, 1990 ).

3.Longitudinal studies.
Numerous coping efforts, support systems, and societal protections must fail before people become homeless, and dual diagnosis interacts complexly in this longitudinal process ( Benda & Dattalo, 1988 ; Lamb & Lamb, 1990 ). The dearth of longitudinal data impedes our efforts to understand when and how to intervene to prevent and reverse homelessness. High-risk populations such as the dually diagnosed population should be followed longitudinally to clarify patterns of homelessness, the risk factors and protective factors that are associated with developing and recovering from homeless episodes, and the patterns of adjustment while homeless that should be construed as constructive coping rather than as psychopathology.

4.Prevention.
Studying and treating end-stage diabetes is considerably more difficult than understanding and intervening early in the course of the illness. Analogously, even complex biopsychosocial processes like homelessness may be more amenable to intervention at early stages or convenient points. For example, arranging for housing alternatives at the time of hospital discharge may be more effective than trying to engage severely disorganized individuals on the streets. This is not to say that those on the streets should be ignored, but rather that strategies that may be more clinically effective and cost-effective should be explored vigorously. Longitudinal research will facilitate identifying and implementing these strategies.

5.Separating protection and treatment.
Considerable evidence indicates that homeless people, including dually diagnosed individuals, are interested in help with meeting their basic needs much more than treatment ( Mulkern & Bradley, 1986 ) and that obtaining decent housing is a primary objective ( Hopper, 1989 ). Even their contacts with the mental health system may be intended to meet more basic needs ( Drake, Wallach, & Hoffman, 1989 ; Morrissey, Gounis, Barrow, Struening, & Katz, 1986 ). This finding suggests not only the primacy of housing but also the importance of separate consideration of protective and treatment functions of service providers. Housing arrangements should be the first priority for research as well as services; experiments with variations in protection, structure, and treatment are meaningful only when housing is available ( Hopper, 1989 ).

6.Housing.
Although clearly the cornerstone of care for the dually diagnosed homeless population, housing is considerably more difficult to study than treatment ( Goldman & Newman, 1990 ; Wittman, 1989 ). Just the practical problems of accessing housing for this population are enormous. The heterogeneity of the dually diagnosed population, the problems related to categorical programs, and the issue of context (e.g., whether the housing is in a drug-infested area) all complicate research. Numerous issues need to be studied: the usefulness of transitional versus permanent housing, group versus independent settings, congregate versus scattered site alternatives, when and how to institute drug-free housing, and how to use Section 8 vouchers most effectively. Current ideologies and hypotheses should be tested with designs that are as scientifically regorous as possible.

7.Engagement.
We know relatively little about engaging the dually diagnosed client and even less about what to do once the process of disaffiliation from people and institutions has eventuated in homelessness. Nearly all programs for dual diagnosis and for clinical subpopulations of the homeless recommend assertive case management, but there are few studies of how case management should be organized, staffed, and performed. Perhaps, as G. Morse in St. Louis is currently investigating, these services should be provided to the homeless population by nonprofessionals who share some key background experiences with the clients ( NIMH, 1990 ).

8. Treatment services.
Current studies of services for dually diagnosed individuals focus on models of integrating alcohol, drug, and mental health treatments ( NIMH, 1989 , 1990 ; Teague et al., 1990 ). Which service models to offer, when and how to link clients to these services, and how the services themselves should be integrated, are critical issues for the dually diagnosed homeless population. Many of these treatment hypotheses were reviewed earlier.

9.Assessing implementation and service utilization.
At this early point in the development of mental health services research, the field is limited by our knowledge of assessing implementation and services ( Brekke, 1988 ; Teague et al., 1990 ). Negative results may often be due to failure to implement the intended models ( Olfson, 1990 ). Researchers are essentially inventing the techniques for measuring services as they proceed ( Drake, Teague, & Freeman, 1990 ). Critical methodological studies should allow the field to move forward.
 

Commentary on Future Directions

The preceding discussion suggests concentrating on clinical and research directions that emphasize more humble, mundane goals rather than heroic ones. Goals associated with the protective, healthful functions of structured communities and residences seem important to implement and evaluate, in contrast to goals associated with reducing mental illness. As Koegel and Burnam (1988) pointed out, we must concentrate on creating environments rather than instituting treatment programs. Such a shift from the heroic to the humble-from trying to mitigate mental illness to offering protection against the elements and against substances of abuse-may be misconstrued by professional caregivers, who are prone to see clinical needs as equally or more salient. In this sense, professionalization can blur common sense, as in the absurd notion that we can provide adequate mental health care for people who are homeless. We must guard against "fostering the myth that more and better clinical programs will eventually solve the problem" ( Lewis, Shadish, & Lurigio, 1989 , p. 184).

Meeting basic priorities of safety and protection may call for the creation of living environments that provide secure housing and reduced availability of abused substances. Given the reality of American streets and shelters in the 1990s, the people we are concerned with will not find community there, but they may find it in more structured settings. Positive virtues of community may be better fulfilled in protective settings, given the reality of American cities. Thus, the Community Connections housing program for dually diagnosed individuals in Washington, DC, finds it necessary to hire security guards to protect their dually diagnosed clients from drug dealers in the local neighborhood ( J. Kline et al., 1991 ).

Structure, support, and protection may be particularly critical for the most vulnerable subgroups of the homeless population, and homeless persons themselves often seek these elements ( Drake, Wallach, & Hoffman, 1989 ). Certainly patients' preferences for structure should be honored when present, although not necessarily by reopening psychiatric hospitals. Strategies for research that involves assessing patients' preferences and studies of different housing arrangements with degrees of protection, structure, and support separated from treatment have been indicated in this article.


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