"I came to the city, and my first day here I spent all my money - $800 - on drugs. For the first time in my life I was homeless, and it set into me that I was addicted. . . . I entered treatment, and I think that without drug screening early on, I would never have stayed clean. Housing was important, too. In a shelter or on the streets, being around using people makes it almost impossible to recover. . . . I'm clean today, two years down the road. I work in construction; I made $40,000 last year. I'm making restitution for my child support. I fly my son down for visits during the summers."
- Mr. C., who successfully completed a treatment program in Birmingham with access to housing and work therapy
Therapy targeting homeless crack and alcohol abusers reduces substance abuse more if it offers patients housing and jobs, NIDA-funded research has shown. A key component is a requirement that participants stay drug free to remain in the housing and enter work therapy, according to the study's researchers at the University of Alabama at Birmingham.
This therapeutic approach, in which rules and consequences are applied to help people change their behavior, is called contingency management. In the Birmingham program, access to housing and employment is contingent on following the rules, which homeless participants soon learn: stay clean of drugs and alcohol, and you can live in a furnished apartment and enter work therapy. Test positive for drugs or alcohol and you go back into a shelter and lose your job until you are drug free.
The approach works. The Birmingham researchers have demonstrated that participants in the contingency management program remained abstinent from drugs substantially longer than patients who did not receive contingency-based housing and work therapy. "The contingencies for reinforcements of housing and a job are powerful motivators," says Dr. Jesse B. Milby, principal investigator for the project.
Patients in the Birmingham treatment program who participate in the work therapy program develop a sense of pride and kinship while learning job skills such as carpentry and painting.Program participants were either homeless or at risk of becoming so. Three-quarters of the patients were male, and 83 percent were African American. Average age was 38 years; average time spent in school was 12.5 years. Some 79 percent met criteria for one or more mental disorders - 56 percent for mood disorders, 39 percent for anxiety disorders, 6 percent for adjustment disorders, 4 percent for psychotic or organic mental disorders, and 4 percent for other mental disorders. The drug that participants said they used most frequently was cocaine followed by alcohol then marijuana.
In the study, participants were placed for 2 months either in existing local substance abuse treatment programs or an intensive day treatment program that included contingency management. The conventional treatment program consisted of weekly, 12-step-oriented group meetings and individual counseling sessions.
The intensive day treatment required program attendance for 5 1/2 hours every weekday, including group and individual counseling sessions and participant involvement in goal-setting exercises. Intensive day treatment patients also received transportation, lunch, and individual counseling. Patients who completed day treatment were then eligible for the contingency management component - housing and 4 months of work therapy refurbishing abandoned or dilapidated houses as long as they stayed drug-free. The renovated dwellings became housing for participants who met contingency requirements. So far, patient-workers have renovated six houses and have worked on four small apartment buildings now used as drug-free housing.
In the work program, patients learned job skills like carpentry and painting. They worked for "Bad Boy Builders," operated by a Birmingham contractor, and received minimum wages, which they used to pay modest rent for their own housing in dwellings that were previously refurbished by other program enrollees. The contractor provided tools, materials, insurance, and on-the-job training. Job references were provided for successful patients seeking to move on to other jobs.
Patients moved into the housing after four successive "clean" urine tests. Those who tested positive for drug use were immediately evicted from their apartments and taken to a local shelter to stay during the eviction. Following two successive clean drug tests, these participants were readmitted to their apartments. Most wanted to move back, and most qualified with clean tests, Dr. Milby says. After completion of the 4-month work therapy, treatment graduates were permitted to remain in the program-provided housing. Some program graduates continue to live in this housing, paying rent.
In the work therapy phase, the program seeks to establish a sense of pride, kinship, and unity among patients. One way the program builds this sense of community is by membership in Club Birmingham. The club holds social activities and distributes identification cards and tee shirts with the club logo.
"We want to provide models of social and recreational activities that are not related to substance abuse," says Dr. Milby. "When they have been homeless and using cocaine and alcohol for a long time, they forget that there are other ways to have fun. We give them a chance to enjoy themselves in drug-free settings like cookouts and fishing parties."
Investigators found that participants in treatment with contingencies were more likely than those in conventional treatment to test clean of drugs, move into stable housing, and be employed regularly following treatment. Those receiving the 4 months of contingency management had 18 percent fewer positive cocaine tests than did conventional care patients after 6 months. That study demonstrated that a multicomponent treatment that addresses homelessness, employment problems, and substance abuse may be the key to successful therapy, Dr. Milby says. However, he notes that participants in the day treatment group spent four times longer in counseling sessions, which is an important variable in addition to contingencies. "We questioned whether the intensive day treatment with contingencies was necessary or whether intensive day treatment alone was sufficient for best results."
A second study was designed to answer this question. In this study, currently under way, all participants are exposed to the intensive day treatment, but only half of the participants receive the abstinence-contingent housing and work therapy. A vocational counselor assists participants in developing job goals. Also, participants are allowed to enter program-provided housing as soon as they are drug-free for four successive tests. As a result, most participants move into the housing during day treatment. Once they complete day treatment, they move into work therapy and begin paying for housing. To help avoid relapse, aftercare therapy follows day treatment.
In this second study, several refinements have been made to the treatment regimen. Each week, patients define specific goals on issues such as addiction, housing, jobs, legal problems, psychiatric concerns, and family relations. "Patients review their own performance in meeting goals, and they are rated aloud by their peers and counselors," says Dr. Cecelia Lee McNamara, project coordinator. "They build self-esteem with a record of accomplishments on their goal sheets."
Following the 4 months of work therapy, clients in day treatment with the contingency management component were drug free an average of twice as many weeks as participants who received only day treatment. The two groups showed equally improved outcomes for days of homelessness and days of employment.
From the second study, it appears that the abstinence contingency works most powerfully on substance abuse, says Dr. Milby. This study also shows that contingency management with day treatment may also reduce the risk of transmission of HIV, the virus that causes AIDS, according to Dr. Joseph Schumacher, another investigator.
Because of the increased costs of providing contingency management, Dr, Milby and his team next plan to study the cost-effectiveness of the enhanced day treatment when used in combination with contingency management.
Sources
- Milby, JB; Schumacher, J.E.; Raczynaski, J.M.; Caldwell, E.; Engle, M.; Michael, M.; and Carr, J. Sufficient conditions for effective treatment of substance abusing homeless persons. Drug and Alcohol Dependence 43:39-47, 1996.
- Schumacher, J.E.; Milby, J.B.; Caldwell, E.; Raczynski, J.; Engle, M.; Michael, M.; and Carr, C. Treatment outcome as a function of treatment attendance with homeless persons abusing cocaine. Journal of Addictive Diseases 14(4):3-85, 1995.