The Pursuit of Recovery

Hiding behind his hands. This is what Jimmy would resort to whenever anyone's attention drew close to him. Bent over, covering his face so that no one would see him, Jimmy displayed an apparent shyness that seemed a bit awkward for a 59-year-old man. Measuring 5-foot-10, he shrunk as he crouched forward, wanting to disappear. Then as his friends would chide him, “Come on, Jimmy,” the man with graying hair and missing front teeth would smile, even laughing as he peered from behind aging finger gates.

Growing up on a farm, you needed your hands to tame the land and your family. At least this was Jimmy's experience. His father physically and verbally abused the children in the household and insisted that they tend to the farm, even if their studies suffered. As a sharecropper, his father decided it best to pull Jimmy from school when he was in the 6th grade, never to let him return. Jimmy resented his father for this and for his inability to read. When he was old enough, he left the farm and tried to make a life for himself in the city.

Jimmy began drinking beer and later whiskey in these years. It was all part of having a good time with his friends. Employment was difficult for Jimmy. Illiterate and with few work skills, he was limited to being a laborer on construction sites and similar settings. As a teenager he had begun hearing voices and experienced paranoia, some of which he managed with his alcohol use. But this also cost him a number of jobs. In time Jimmy began to try other drugs with some of his coworkers and friends until someone introduced him to crack cocaine. It did not take long for him to lose his place and his belongings. He had no friends and had no contact with his family.

This road of destruction finally met its end in an abandoned house where he was getting high. As some neighbors stumbled upon him, he lashed out in fearful anger, attacking them to get them out of the house. Addicted and homeless, Jimmy was arrested and mandated to treatment for his drug addiction.

Who are the homeless?

This true story is not unlike that of many people who have become homeless, seemingly stuck behind many psychic and social barriers. Despite the stereotypes of the skid row homeless, clinicians would be mistaken to see this group, representing 2.3 to 3.5 million of the U.S. population in a given year, as a homogenous entity. Addiction counselors know that each person's story is unique, and they also understand how ethnicity, gender, religion, physical ability, sexual orientation, veteran status, and socioeconomic class all may affect someone.

The homeless population represents a heterogeneous group of men, women, and children, all of whom share the common condition of having lost their place of residency. Living in shelters, cars, abandoned buildings, or under bridges, they fight for survival knowing that they could be displaced from these temporary spaces and lose all of their personal belongings. Without protection they may be attacked by fellow street people, the police, or a group of mischievous teens. Battered women, representing a large number of homeless women, live in fear of their former partners, who may attack or even kill them in spite of restraining orders and numerous legal interventions.

Children, one of the fastest growing segments of the homeless population, are frequently moving from school to school, not knowing where they might live and whether they might be taken from mothers who sometimes are regarded as unfit because of their low economic status and high-risk lifestyles. Being homeless constitutes a state of crisis riddled with uncertainty.


It is important to note that those who become homeless are more likely to experience trauma—and multiple levels of it. Like Jimmy, many have experienced childhood trauma and will need counseling to work through these painful memories as they affect current functioning. For homeless women, childhood trauma often extends into adulthood, especially when domestic partners become abusive and the patterns continue. Veterans, who make up an estimated 33% of the overall homeless population, often bring with them the experience of trauma in combat situations. More recently, a number of female veterans have been reporting sexual trauma while serving in the military. 1 Then after becoming homeless, many are victimized while living on the street.

Addiction and mental health treatment

Addiction and mental health problems are common among the homeless population. Burt and associates2 conducted a study of nearly 3,000 homeless persons and found that in the 30 days prior to survey, 38% of the homeless experienced problems associated with alcohol abuse, 26% with drug abuse, and 39% with mental health issues. When considering that many of these problems co-occur, the combined percentage of homeless persons affected by one or more of these problems reached 66%. There is a clear need for addiction and mental health services for these men and women.

Despite the great need, some homeless persons may be reluctant to enter a treatment program, not understanding that recovery works and how chemical addiction has impaired their lives. Education always serves as a positive approach to influence attitudes toward lifestyles among peers. Addiction counselors can assemble focus groups within shelters or other gathering places where homeless patrons are able to discuss issues surrounding their drug and alcohol abuse. They might discuss how lifestyle choices have led to homelessness and how taking responsibility for the consequences of such choices is a first step toward alleviating the chronic disease of addiction.

A pilot drug-free program in the Men's and Women's Emergency Shelter at Atlanta Union Mission is being proposed as a way addiction counselors can support members of the homeless population before they enter treatment. This program will be entitled “The Drug Free Club” and is designed to educate homeless men and women at regular intervals each week on the negative consequences of drug and alcohol abuse and to encourage abstinence with peer support.

Each Friday after the men and women have lunch in the shelter's community kitchen, those who agree to be part of The Drug Free Club will commit to 30 days of maintaining a drug- and alcohol-free status. These individuals will be expected to attend and take an active role in the drug and alcohol educational groups, verbalizing their questions during the group process. An addiction counselor will facilitate these groups, track attendance, and distribute educational materials. The pilot program will be funded internally by the mission.

This drug-free program in the shelter will continue for a period of one year to test the effectiveness of education to connect with the homeless population. Those men and women who recognize that they have a serious drug and alcohol addiction through this health promotion and prevention process will then be referred to recovery programs.

Michael Brubaker, MDiv, MS


James Bass, MSA, DHSC, CAC II This is but one way in which the homeless might enter a recovery program. Many enter treatment through referrals from other programs, hospitals, court systems, ministers, family members, and friends. Some will come without a referral, simply trying to escape the many consequences related to their drug and alcohol use. The addiction counselor working with this population soon learns to assess these clients' motivation, wondering if they are truly looking for recovery or simply “three hots and a cot” (the improved quality of food and housing in recovery programs over basic shelters). Either way, the counselor has an opportunity to support positive change and to plant the seeds of recovery.

Some programs have embraced their role as providers of high-quality food and shelter and used them as motivators for abstinence. The model of “abstinence-contingent housing”3 ensures basic shelter for all clients but offers to those who remain abstinent an opportunity to enjoy better-quality housing with other recovering persons, free of charge. Over a period of time as participants begin to work and earn income, they are expected to pay reduced-rate fees and to prepare for eventual discharge.

Work therapy can be another essential component, in which homeless clients either support their own therapeutic setting or work in the local community earning income under extra supervision. Milby and associates tested this model.3 In the first phase, the program they established hired and trained clients to refurbish an apartment building that eventually would be used for housing. The clients' wages were restricted and could be used only toward rent once they completed the project. In later years of the program, new clients were trained in the local community to work on various construction projects. Work therapy provides technical and basic work skills, and when it is combined with employment services such as résumé writing and interview coaching, clients gain the needed support to build or rebuild their careers.

When working with dually diagnosed clients, addiction counselors also would be well advised to work closely with a mental health clinician and to choose their confrontation techniques wisely. Research has shown that dually diagnosed veterans leave traditional substance abuse treatment programs at higher rates than they leave programs that provide mental health treatment. The counselor-client relationship is always critical and can make the difference in whether a client remains in treatment. A good basic resource for addiction counselors is the Treatment Improvement Protocol that addresses substance abuse treatment for persons with co-occurring disorders, available free from the Center for Substance Abuse Treatment.4

Trauma services also are important for men and women, yet their experiences are best treated in gender-segregated groups. Clients with post-traumatic stress disorder may experience heightened anxiety and sensory arousal triggered by other clients, the physical environment, and even staff members. Addiction counselors need to screen for recent and lifetime trauma and to make appropriate referrals as needed.

Need for support services

Women with children need support with childcare services or they are less likely to enter and remain in treatment. Homeless mothers who still have custody of their children use drugs and alcohol at lower rates, experience physical and sexual victimization at lower levels, and engage in high-risk sexual behaviors less frequently. Many try to hide their substance use from their children and fear loss of custody to child protective services. Retaining custody is a powerful motivator for many women, and supporting them in treatment may help them achieve sobriety and attain many other goals for themselves and their children.

Also, HIV services are important for many addicted persons, but especially for those living on the street. Among active drug users, it is estimated that 19% of those living on the street are HIV-positive. Those at highest risk among this segment are Hispanic males and African-American females, who test positive for HIV at rates of 28.8% and 38.4%, respectively.5 A combination of high-risk behaviors that include intravenous drug usage, unprotected sex, and exchanging sex for drugs, money, or food all contribute to these high rates of HIV transmission among homeless individuals. Addiction counselors need to provide HIV education and encourage their clients to get tested.

Many homeless clients also will have a criminal history that contributes to their homeless status, and legal charges resulting from being homeless. Those with felony backgrounds will have a harder time finding employment. After Sept. 11, 2001, many low-income men and women with former felony charges lost their jobs because of failed security clearances. Also, homeless individuals often run into legal difficulties after becoming homeless, obtaining misdemeanor charges for offenses such as public urination and loitering. Without public facilities and day shelters, these persons have few choices in where to stay and to use the bathroom. Addiction counselors can support these clients by working closely with probation and parole officers, as well as by helping clients to see any connections between substance use and legal consequences.

With legal assistance, some clients may be able to expunge charges from their record, which might improve their ability to get hired. Furthermore, addiction counselors might need to advocate for clients with employers after the clients establish a measure of stability.

Recognizing strengths

Despite the many challenges that the homeless face, there is a measure of resiliency that addiction counselors need to recognize in these men, women, and children. To survive on the street with little or no resources is no small miracle, and many clients and counselors may miss this fact.

Jimmy, the client mentioned earlier in this article, was often ashamed of his inability to read, but as he adapted this also created some strengths. With a powerful memory he was able to negotiate his way around a large metropolitan area without reading a single word. In recovery he began to recognize the power of his intellect and began taking literacy classes to improve his reading skills.

His literacy training was but one part of his recovery program, but for Jimmy it represented his willingness to face his many challenges. He quit using alcohol and crack, started taking antipsychotic medication, satisfied his legal requirements, faced his father in a Gestalt-oriented group exercise, and began paying for his own place to stay. Still shy in many ways, Jimmy became Jim, and was able to greet strangers face-to-face. He commanded respect from his peers and the staff for his perseverance and willingness to grow. Jim took advantage of his opportunities, escaped chronic homelessness, and began to live life anew.

Michael Brubaker, MDiv, MS, is a Fellow with the Department of Counselor Education at the University of Florida. He has worked in the addiction field for more than eight years in administrative, clinical, and research capacities. His e-mail address is brubake1@ufl.edu.
James Bass, MSA, DHSc, CAC II, is the Chief Program Officer at Atlanta Union Mission, responsible for six ministry centers that together offer a continuum of rescue and recovery services. He has served for more than 30 years in the social services field, in both public and private nonprofit recovery settings.

References

1. Benda BB. Survival analyses of social support and trauma among homeless male and female veterans who abuse substances. Am J Orthopsychiatry 2006; 76:70–9.
2. Burt MR, Aron LY, Douglas T, et al. Homelessness: Programs and the People They Serve. Washington D.C.:Urban Institute; 1999.
3. Milby JB, Schumacher JE, McNamara C, et al. Initiating abstinence in cocaine-abusing dually diagnosed homeless persons. Drug Alcohol Depend 2000; 60:55–67.
4. Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With Co-Occurring Disorders. Treatment Improvement Protocol (TIP) Series, Number 42. DHHS Pub. No. (SMA) 05-3992. Rockville, Md.: Substance Abuse and Mental Health Services Administration; 2005.
5. Smereck GA, Hockman EM. Prevalence of HIV infection and HIV risk behaviors associated with living place: On-the-street homeless drug users as a special target population for public health intervention. Am J Drug Alcohol Abuse 1998; 24:299–319.