Reprinted from "Concurrent Disorders" issue of Visions Journal, 2004, 2 (1), p. 40
Housing is an essential factor in the stability and recovery of individuals who have a mental illness. This is even more true for individuals who have both a mental illness and a problem with substance misuse. Unfortunately, substance misuse is one of the factors that contributes to people losing their housing, as well as their access to other recovery services. Once housing is lost, the only alternative left is either a shelter or a single-room occupancy hotel. In Vancouver, this means the downtown core, where drug and alcohol use are rampant. In an environment where drugs are readily available, it is even less likely that the person will be able to get control over either their illness or substance misuse.
This scenario is all the more serious given that:
for people who have schizophrenia, almost half are likely to have a substance use problem
for people who have a diagnosis of depression or bipolar disorder, the likelihood of concurrent substance misuse goes up to 60%
conversely, for people who have a substance misuse problem, a high proportion will also have a mental illness, especially depression
In other words, the co-occurrence of mental illness and substance misuse is the norm, not the exception. Living with both of these disorders exposes the person to greater risks, of which homelessness is just one. Others include a greater risk of contracting serious communicable disease associated with drug misuse, greater risk of suicide, greater risk of committing violent acts and a greater risk of being incarcerated for a criminal offence.
What is the role of housing in the solution
Clearly, mental health housing programs must recognize that the co-occurrence of mental illness and substance misuse is common. While individuals with drug problems can be disruptive and pose some risk to other program participants, eviction only exposes the individual to much greater risks. Housing programs need to have the capacity to provide a more effective response to someone who is missing drugs and alcohol. They also need to be less restrictive in accepting individuals who have had substance problems in the past or are even actively involved in substance misuse.
Current research indicates that the most effective intervention for mental illness and a co-occurring substance misuse problem is an assertive community treatment model. In the model, staff have the expertise to provide treatment for both mental illness and substance misuse in a comprehensive, integrated program. One of the keys to these programs is to overcome initial resistance to treatment by being very client-centred and starting with the needs that the client identifies. One of those needs is likely to be safe and stable housing, preferably not in an area where drugs are easily accessed. Another key is to be able to work with the inevitable and recurrent relapses that individuals will experience as they gradually gain control over both their substance misuse and their mental illness.
There are apparently contradictory findings on the role of specialized residential treatment programs for people who have co-occurring disorders. In a review of the literature, Drake et al.1 found very poor outcomes associated with residential treatment programs modeled on the intensive residential treatment programs that are common in the alcohol and drug dependence field. These programs had very high non-compliance rates associated with clients dropping out or being evicted from the program. The conclusion is that the expectations of these programs simply do not work for people who have a mental illness.
On the other hand, many people in the field believe that a supervised residential facility is needed for those individuals who are unable to make a start on recovery while living independently in the community. Such facilities provide structure and support rather than intensive treatment. Successful treatment seems to involve only one to two short group sessions a week, frequent repetition of program content and, most importantly, a supportive and creative approach to relapse.
Dual Diagnosis Residential Home: For more information, contact Roberta Chapman at the Mental Patients Association at (604) 738-2811
In summary, current policies with respect to substance misuse in many housing and residential programs are an ineffective response to substance misuse. The common response of eviction only compounds the problem and exposes the person to much greater risks. Safe, supportive housing is part of the solution, within the context of a carefully-paced program of recovery that accepts and works with inevitable relapse. Such a program can be provided by an assertive community treatment team with supported independent living units or, for some, a more structured residential setting. In time, relapses will become less frequent and of shorter duration and, for many people, two years in such a program can lead to effective control of both substance misuse and the symptoms of mental illness.
About the Author
John Russell was the Director of Greater Vancouver Mental Health Services. He now works as a consultant and was recently the Chair of the BC Mental Health Monitoring Coaliation
This article orignally appeared in the Spring 2000 issue of Visions. We are re-running it because of its relevance to the topic of housing in supporting people with concurrent disorders
selected relevant publications
Drake, RE, Mercer McFadden, C, Mueser, KT, McHugo, GJ, & Bond, GR, (1998). Review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophrenia Bulletin, 24(4), 589-608.