Tuesday September 26th 2017

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Housing as Healthcare and Substance Use Treatment

Is Zero Tolerance Working for Drug Users?

Having a roof over your head is one of life’s most fundamental necessities; yet it eludes so many people in our society. Most of us who live in large American cities see homeless individuals on a daily and hourly basis.

Substance use is only one of many contributing factors to homelessness, but it is a substantial obstacle in securing and maintaining housing. Not only can substance use lead individuals to make poor decisions that can jeopardize their living situation, but larger systems of authority can restrict a substance user’s ability to obtain and retain housing. In fact, most transitional housing and sober living apartments have strict zero tolerance policies about substance use. This forces many substance users, especially those with chronic and persistent mental illness, to return back to the street after a single relapse.

I believe abstinence-based housing is inconsistent with the disease model of addiction, a concept that is – ironically – propagated within the very same programs. Basically, we have two systems when it comes to housing;

  1. Treatment First, which focuses on laying a foundation of sobriety and mental health compliance.
  2. Housing First, which focuses on maintaining housing.

In this article, I will discuss my experience with both housing paradigms. Then, we take a look a why I believe that Housing First is not only effective in treating substance use, but is also the only ethical on humane approach. Finally, I invite your questions or comments about the issue of drug use and housing.

We want to hear from you! Your comments are welcomed at the end. We’ll try to respond to each piece of feedback with a personal response.

Treatment First

Treatment First operates on a continuum of care that requires chronically homeless individuals (who are often mentally ill with Substance Use Disorders) to meet nearly impossible expectations. In fact, many find this system almost impossible to navigate. What are its core requirements?

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The treatment continuum usually starts with a detoxification program or a shelter. If the client stays in the shelter, they could then move on to residential treatment program where they must maintain mental health and substance use compliance in hopes of finding more permanent housing. Only when all these stages of treatment are completed is the individual rewarded with housing. If the individual relapses at any stage of treatment, he must then go back to the first stage and try again from the beginning.

Sober Living Environments (SLEs) as “Treatment First” Examples

I spent seven years working for a nonprofit that operated a detox and three sober living housing buildings on the same property. Before I rant about the problems with abstinent-only housing, I want to say that this program was expertly managed in a loving and professional way; it was a godsend to the people who came through the program. As far as SLEs are concerned, the program I worked for was superior for many reasons; mainly that we were a nonprofit and had beyond reasonable rent, as opposed to most sober living that charge exorbitant prices.

The issues that I have are not with the way individual programs are run (although there are many that I take issue with), but, rather, with the ideological clash of the disease model and abstinence-based treatment. This program is the perfect example of a Treatment First program. We bookended the continuum of Treatment First by offering detox first, with a glimpse of the housing they could be rewarded with if they played by the rules.

Being a county funded detox, many of our clients were homeless and lived on the street. Some detox clients were hand selected as potential sober living residents; they were asked directly if they were interested in housing. But it took more than just being picked, they then had to “prove” themselves as worthy and earn their place in the community.

The process began when the client entered detox. To prove that they were serious about becoming a permanent resident, they would have to go to residential treatment for an extended period of two months to one year. Once they completed the residential program, they could come back and receive a sober living residence. However, finding residential treatment was not always immediate and often required the client to go live at the local shelter and wait for a bed at a residential treatment center, which could also take a couple of months. If the client used a substance at any time in this continuum, they had to go back to square one, detox, and hope to start the process over again.

The Contradiction: Treatment First and The Disease Model

Countless times, I would see clients jump through all the necessary hoops and return to us like the prodigal son. However, rejoicing was short lived; forgiveness was nonexistent. Sometimes, it only took a couple of days before a drug test would be the impetus of a key being collected and property being thrown in a trash bags for the former resident to carry toward an unknown fate.

Is this how we treat people who have a disease? By punishing them for having the very symptoms that reflect the disorder?

The treatment for addiction is basically a process of convincing the afflicted that they have the disease of addiction. This disease is primary, and cannot be attributed to anything other than genetics and bad luck. The symptoms of the disease are the loss of choice and control of using drugs. Many believe that addiction is a disease , a concept that takes the maintenance of sobriety out of the client’s control. The disease theory remains constant, and unwavering, even while we rip away a sick person’s humanity when the client proves our hypothesis correct by using drugs.

Just imagine if an asthma clinic kicked out a patient for having a cough.

The Morals of The Disease Model

The reason that there is so much ambiguousness in the treatment of substance users is because the disease model of addiction cannot be separated from the “moral weakness” perspective. This is because:

  • The medical diagnosis of Substance Use Disorder relies on observing human behavior as a symptom of the disease.
  • Behavior is thought to be rational and voluntary.
  • Therefore, drug using behaviors are perceived to be controlled by values and thoughts.

Addiction is framed as both a lack of control and a lack of motivation. Since both motivation and behavior are connected to morals and values, it is impossible to separate the medical model and the moral model, although they claim to be two distinct schools of thought.

Housing First

Housing First’s focus on harm reduction, takes away some of the moral judgment and stigma of using substances, by viewing substance use as a relationship with substances and not a disease.

Housing First is a housing model that was first developed by Pathways to Housing, Inc. in New York City. What separated this model from traditional residential treatment and housing was that, unlike the mainstream of housing in the country, Pathways didn’t have a sobriety requirement for admission to obtain and maintain housing. Basically, Housing First is where chronically homeless individuals are given housing as the first intervention of services. Instead of having to earn housing through maintaining treatment expectations, residents are given housing first and then other interventions are then made if the resident chooses to do so.

Housing First and Social Work

Social workers, or support services, play a key role in carrying the legacy and practice of Housing First. Case managers maintain a case load of residents who are in their Housing First program. Housing First has been implemented in two ways:

  1. Via scattered sites known as assertive community treatment (ACT).
  2. Via on-site support known as congregate housing (CONG).

ACT is the longest practice of Housing First, wherein clients are put in housing apartments in various market rate buildings. Then, support services checks in with them in their apartment or at the social service office. The newer implementation, CONG, has Housing First residents live in the same building and support services work in the same building as their clients.

My Introduction to Housing First

In my first year of graduate school, I had the good fortune to intern at a supportive housing building. This building was a CONG program; all the resident’s in the building were in the Housing First program. Coming from a Treatment First experience, I was unfamiliar with Housing First or harm reduction in general. What I saw contradicted everything that I had thought I knew about substance use and what it meant to have the disease of addiction.

In this building were several residents who maintained a relationship with substances while also being able to maintain their responsibilities to varying degrees. In my time there, I worked with individuals who used substances, and met the criteria for Substance Use Disorder. Although these residents were actively using substances, we were still able to work on other issues, such as employment or family relations, that were important to them. I began to see that substance use and other problems can be independent of each other.

According to the disease model of addiction, substance users only get worse over time, and substance use must first be addressed before any other issue can change for the better. This was not what I observed in my time in supportive housing. What I saw were individuals who had a changing, and not always harmful, relationship with substances. They were able to improve other areas of their lives without changing their substance use at all.

Harm Reduction: The Foundation of Housing First

The central role that allows Housing First to be effective in retaining chronically homeless individuals diagnosed with severe mental illness and Substance Use Disorders is the centrality of harm reduction in the clinical practice. Instead of placing moral value or pathologizing substance use, harm reduction is a client-centered practice wherein the client chooses their own goals, regardless of their relationship with substances. Harm reduction recognizes that substance use is on a continuum, and any change which reduces harm or improves quality of life is considered a positive treatment success. The harm reduction alternative that is found in Housing Fist has been shown effective in:

  1. Improving service utilization.
  2. Lowering public costs.
  3. Better substance use outcomes.

Does Housing First Reduce Substance Use? And Does it Matter?

The research is mixed and unclear whether or not residents in Housing First use fewer substances than other forms of treatment. There is definitely not an increase in use, but as far as less use is concerned, the jury is still out. Some studies show that Housing First has a greater reduction on alcohol than illicit drugs; some studies show a decline in both illicit drugs and alcohol; while others show no difference at all.

What is shown across all studies is that Housing First is more effective than Treatment First in:

  • Significantly more days stably housed
  • Superior quality of life
  • Fewer criminal convictions
  • Fewer emergency room visits

And within this list lie both the problem of the Disease Model and the solution of Harm Reduction. Focusing on the frequency of substance use is missing the forest through the trees. When believing that addiction is a disease, the only measure of success is the amount of substance used, but within a harm reduction framework substance use is viewed as just one part of many parts of the human life, and success is measured by the decrease of the negative consequences that substances have on the other arenas of life as a whole.

Isn’t Quality of Life Enough?

Sociologically speaking, drug use is not a disease but rather one of many relationships that a person has with their environment. When we get so caught up in policing people’s behaviors, and bodies, we forget that the main purpose of any medical treatment is to increase quality of life. Life’s problems and substance use are independent of each other. Many people use drugs because they are homeless, not the other way around.

The Housing First paradigm shows that substance users are just as able to maintain housing as non-substance users when the variable of punitive substance use policy is removed. It is not the drugs that are creating a lower quality of life, it is us. We, and our socially constructed rules, are single handedly creating havoc in the lives of our most vulnerable citizens by punishing them for doing something that has been a part of the human experience from the beginning­––seeking the intoxicating rush of dopamine. By viewing substance use as a disease we let society off the hook, and squarely place the cause of the illness on the individual.

Unmanageability and the DSM Diagnosis

Social problems and difficulties interacting with the social environment are significantly accounted for in both past and current standards for diagnosing Substance Use Disorder. Of the eleven criterions for Substance Use Disorder listed in the DSM­-V, at least four specifically deal with the environment. If a person met only the four environmental criteria, and none of the physical symptoms, they would be diagnoses with a moderate Substance Use Disorder.

Negative social and environmental criterion make up over 1/3rd of the clinical diagnosis of having a mild, moderate, or severe Substance Use Disorder. Adjusting one’s ability to interact with their environment, directly impacts their diagnosis of having Substance Use Disorder regardless of the amount they use or their level of physical dependence. Things like homelessness, criminal arrests, and emergency room visits directly affect those four social criterions for Substance Use Disorder

And this is why Housing First is an effective treatment for Substance Use Disorder without actually altering the pattern of substance use in the individual. By treating the individual’s ability to successfully interact with their environment, not necessarily their drug use, the substance user lowers the diagnosable severity of their Substance Use Disorder without changing the amount or frequency of their substance use. Having housing is the most basic requirement to being able to maintain any resemblance to stability. Allowing substance users the same opportunities to obtain housing can actually “cure” people of mild and moderate Substance Use Disorders.

The Ironic Terminology

The irony lies in the names of the two housing paradigms; where the two modalities actually are named in a way that would be better suited in the reverse. Clinicians who work within the Treatment First continuum realize that finding housing for clients represents most of the time spent with their residents. Finding their clients a place to move onto after they have completed their current stage of treatment consumes all of the clinicians time. Conversely, Housing First clinicians can actually take the time to work on treatment goals with their clients because housing, the most difficult piece to the treatment puzzle, has already been taken care of. Placing individuals in housing as the first stage of treatment frees up time for clinicians to actually do their job and facilitate positive change in their clients’ life.

Ethics and Social Justice

Those who work in Housing First and supportive housing believe that housing is healthcare and very little can be accomplished from a mental or physical health perspective if housing is not secured. Not only is housing a basic component of well-being, it should also be a human right. The conditions that people live in when on the street are both emotionally and physically exhausting. It is inhumane to expect such a large portion of our population to live in such dire circumstances; especially when mental health and substance use create a complexity that further hinders the ability to improve one’s life.

Drug use itself is a civil rights issue. Drug laws and drug norms are socially constructed in a way that disproportionally effect different groups of people. People of color have higher rates of arrests than whites although both groups use drugs at the same rate. Our society seems to be confused on what type of stance we want to take on drugs. Clinically, it is mostly accepted that addiction is a brain disease, and therefore not something that the afflicted person can control. Knowing that a substantial portion of homeless people have this disease, Substance Use Disorder, it is bizarre that we allow a mainstream of abstinence based treatment to bar so many people who need help from finding appropriate and humane housing. Abstinence based treatment is a set up for failure for the most vulnerable.

Ecosystems Theory and Housing First: Looking at the Big Picture

For substance use to be addressed properly it needs to be looked at systematically. The Ecosystems theory prospective is the best lens to see substance use as it pertains to supportive housing. Ecosystems theory draws from both the ecological perspective and systems theory. Ecological perspective emphasizes the social environment and the ways in which the person interacts and communicates with the people in their environment. Systems theory looks at how all the individual areas (systems) of a person’s life are just small parts of the sum of an individual’s life, and how each system interacts with the other systems. This is basic social work theory that forces clinicians to look beyond the individual and see them as a complex series of interactions between people and institutions. It allows us to step back and realize that macro and mezzo systems have a direct effect on the individual.

Treatment First and traditional abstinence based treatment is just about the exact opposite of ecosystems theory. The medical model of addiction sees addiction as a primary disease that a person is born with and is not caused by any other condition. When addiction is seen as a disease of the brain, social factors such as poverty, homelessness, oppression, and the socially constructed criminal justice system have no impact on addiction, but rather are secondary to addiction. It operates on the assumption that life’s problems are a result, or symptoms of, the disease of addiction. Since problems stem from addiction, disease model theorists believe that sobriety must come before treating other life problems and once sobriety is found most of those secondary problems will take care of themselves.

Person-In-Environment

Central to Ecosystems Theory is the concept of “person in-environment” which views the human experience as constant interactions with various surrounding systems and being dynamically involved with each simultaneously. These systems could include family, friends, work, social services, and drug using peers. Housing First, and supportive housing, are the optimal clinical setting for working with “person in-environment,” because support services are working with clients in the client’s home environment. Particularly with CONG services, clinicians are able to observe their clients in their natural home environment. The home is a place where many of the client’s systems overlap and it is the most practical place to clinically assess residents.

Final Thoughts

The system that Housing First sees as the most import is, of course, housing. Housing First sees housing much like Treatment First views sobriety: that little can be accomplished until the primary problem is addressed. Supportive housing follows Maslow’s Hierarchy of Needs, which states that the most fundamental human needs must first be satisfied before other desires can be satisfied. Shelter, along with food, is one of those needs that are the most basic. The housing system lays the foundation for all other systems.

To expect an individual to address any type of problem area in their life without first having the most basic human need of shelter is impossible. Only once people have satisfied their need for shelter can they begin to comprehend changing their relationship to substances or mental health management. Without housing, any intervention is a setup for failure.

Referent Sources: Explorable: Ecological Systems Theory.
NCBI: Housing first improves residential stability in homeless adults with concurrent substance dependence and mental disorders. 2013.
NCBI: The role of housing: a comparison of front-line provider views in housing first and traditional programs. 2011.
The International Journal of Drug Policy: Where harm reduction meets housing first: Exploring alcohol’s role in a project-based housing first setting. 2012.
Wiley Online Library: Changes in daily substance use among people experiencing homelessness and mental illness: 24-month outcomes following randomization to Housing First or usual care. 2015.

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About Scott Novotny, MSW, CATC III

Scott Novotny, MSW, CATC III is a Social Work graduate student with a BA in Sociology. He is a Certified Addictions Treatment Counselor in the San Francisco Bay Area. Before graduate school, he spent seven years working at a treatment center. The center included a social model detoxification unit for alcohol and street drugs and sober living apartments.

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