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Alcoholism, Drug Abuse, and the Homeless

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Alcoholism, Drug Abuse, and the Homeless Alcoholism, Drug Abuse, and the Homeless Dennis McCarty ,Massachusetts Department of Public Health, Boston, MA Milton Argeriou ZStabilization Services, Boston, MA Robert B. Huebner ~ National Institute on Alcohol Abuse and Alcoholisml Rockville, MD Barbara Lubran 5 National Institute on Alcohol Abuse and Alcoholism, Rockville, MD I Credible estimates of the prevalence of alcohol and drug Wright, 1989; J. D. Wright, Knight, Weber-Bardin, & abuse suggest that alcohol abuse affects 30% to 40% and Lam, 1987). drug abuse lO% to 15% of homeless persons. A review of In this article, we explore homelessness, alcoholism, policies that address substance abuse among the homeless and drug abuse and their interrelationships. The preva- finds that interventions alternate between control and re- lence of alcohol and drug abuse among the homeless is habilitation. However, the unique needs of a changing assessed, and major correlates are identified. A historical homeless population require an integration of alcoholism review and analysis of treatment and public policies to- and drug abuse recovery services with programs for ward homeless inebriates suggests an interplay between women, adolescents, and the mentally ill. Alcohol- and strategies of control and rehabilitation. Finally, legislative drug-free housing is essential to support and maintain and policy initiatives are discussed that have encouraged recovery. Psychology can contribute in the development of the development of community-based treatment services effective programs for homeless individuals struggling with (as alternatives to incarceration for public inebriation) addiction and alcoholism. and more recently promoted the development of dem- onstration programs to address gaps in the alcoholism and drug abuse treatment of homeless men and women. Journalists and investigators who observed and studied Some of the approaches described here use safe, low-cost, individuals in streets and soup lines, taverns and bars, alcohol- and drug-free housing to provide strong support courts and jails, and flop houses and missions through for recovery among individuals with alcohol- and drug- the 19th and early 20th centuries noted that alcoholism related problems. and alcohol abuse were frequent correlates of homeless- ness (McCook, 1893; Rice, 1918; Solenberger, 1911; Prevalence of Alcohol and Drug Problems Straus, 1946; Sutherland & Locke, 1936). These obser- The reported prevalence of alcoholism and drug abuse vations persist across decades and generations. among the homeless varies, depending on the sample and Compared with the homeless population studied in the definitions of alcoholism, drug abuse, and homeless- the 1950s and 1960s, the "new homeless" of the 1980s ness; the setting (e.g., street versus shelter); and the meth- are not only more numerous, but they are also more vis- ods and assessment tools used (Dennis, 1987; Fisher, ible; they sleep in public places and are not confined to 1989; Stark, 1987). Fisher's (1989) analysis of studies skid-row areas of town (Rossi, 1989, 1990). Whereas the published since 1980, for example, found that the prev- homeless population from prior decades consisted pri- alence of alcohol-related problems ranged from 2% to marily of older, White men, the current homeless are 86% of the samples. Similarly, the estimated prevalence much more heterogeneous. They are younger, better ed- of drug abuse ranged from 2% to 70%. Although the es- ucated, and more likely to use drugs, and they exhibit timates varied greatly, the rates of apparent alcohol and more symptoms of mental illness (Fisher, 1989; Garrett, drug abuse tended to be highest in samples drawn from 1989; Hopper, 1989; Institute of Medicine, 1988; Rossi, shelters, streets, and clinics. Among the homeless, men 1990; J. D. Wright, 1989). A substantial number--per- were more likely to report alcohol- and drug-related haps 25%--of the new homeless are women (Rossi, 1990), problems, whereas higher rates of mental illness were re- and in many larger urban areas a majority of the homeless ported among women. Fisher (1989) concluded that al- are from communities of color (African-American, La- coholism was perhaps as much as nine times more prev- tino, and American Indian; J. D. Wright). High levels of alcoholism, extreme poverty, and social isolation, how- ever, form consistent communalities between the old and Preparation of this article was supported, in part, by Grant R I8- new homeless (Rossi, 1989, 1990). The most prevalent AA007915 from the National Institute on AlcoholAbuse and Alcohol- health problem observed among men and women who ism. Correspondence concerning this article should be addressed to wander city streets and rural roads without a place to call Dennis McCarty,Massachusetts Department of Public Health, 150 Tre- home is alcohol abuse (Institute of Medicine, 1988; J. D. mont Street, Boston, MA 02111. November 1991 • American Psychologist 1139 Copyright 1991 by the American Psychological Association, Inc. 0003-066X/91/$2.00 Vol. 46, No. 1t, 1139-1148 alent among the homeless population than among the (15%) than among Latinos (10%) and Asians (6%; J. D. general community. Wright & Weber). The Robert Wood Johnson Health Care for the Data on associated health problems suggested that Homeless projects provide an extensive database on al- men and women diagnosed as alcohol abusers were more cohol- and drng-related health problems among homeless than twice as likely as other homeless patients to have men and women who receive medical attention. This liver disease, seizure disorders, various injuries and trau- program originally provided grant support to 19 cities to mas, and nutritional deficiencies (J. D. Wright & Weber, develop strategies for linking homeless individuals to pri- 1987). They also had elevated rates of drug abuse, mental mary health care. Services are now federally funded and illness, hypertension, pulmonary disease, and arterial are located in 109 communities in 41 states and Wash- disease. The homeless persons "who abuse either alcohol ington, DC, and Puerto Rico (Lewin/ICF, 1989). Analysis or drugs are generally in the worst possible shape, more of first-year data suggested that alcohol abuse could be estranged, less intact, ticker, and with the poorest pros- diagnosed in at least 23% of the almost 30,000 homeless pects for the future" (J. D. Wright, 1989, p. 102). individuals who were examined (J. D. Wright & Weber, In summary, data from the Health Care for the 1987). Because alcoholism is often underdiagnosed and Homeless Program suggest that alcohol and drug-related more likely to be observed and diagnosed when individ- problems frequently complicate the lives of homeless uals are seen more than once, when adjusted for underre- women and, especially, homeless men. The homeless, porting, the evaluators estimated that the prevalence of problem drinker receiving services from a Health Care alcohol-related problems was about 38% among Health for the Homeless clinic tends to be a middie-aged, White Care for the Homeless clients (J. D. Wright, 1989; J. D. male, whose health is more impaired than that of other Wright et al., 1987; J. D. Wright & Weber, 1987). Similar homeless clients. correction procedures suggested that about 13% of the Cause and Consequence clients experienced drug-related problems. The causes of homelessness are complex and include both Correlates of Alcohol and Drug Abuse individual/personal, and societal/structural factors. Social Age, sex, and race are among the variables strongly as- factors contributing to the homelessness of the 1980s in- sociated with alcohol and drug abuse among the homeless. clude (a) the presence of a large segment of our society Health Care for the Homeless data estimated that 47% living at or below the poverty level, (b) the loss of millions of the homeless men and 16% of the homeless women of low-income housing units to conversion, urban renewal, could be classified as problem drinkers (J. D. Wright & gentrification, fire, and abandonment, (c) drastic reduc- Weber, 1987). Men aged 30 to 49 years (40%) and 50 to tions in federal support for subsidized housing, (d) "real 64 years (43%) had the highest adjusted prevalence of dollar" decreases in public assistance to low-income fam- alcohol abuse among the Health Care for the Homeless ilies, (e) insufficient emergency housing assistance, and clients (J. D. Wright & Weber). Alcohol-related problems (f) reductions in the demand for unskilled labor and fewer were observed less frequently among older (32%) and opportunities for day labor. Among individual factors, younger (22%) men. Although women were less likely to substance abuse continues to rank as a leading cause of have alcohol-related problems, the rates of drug abuse homelessness. More than one half of Health Care for the were relatively similar among men (11%) and women (9%; Homeless clients sampled identified alcohol and drug J. D. Wright & Weber). The strongest correlate of drug abuse as a major factor (22%), or the single most impor- abuse was age; rates of drug abuse were greatest among tant factor (32%), leading to their loss of housing (J. D. younger homeless persons, and decreased with age (J. D. Wright & Weber, 1987). Another study reported that in Wright, 1989). a Los Angeles sample of inner city adults, 80% indicated Ethnic backgrounds also influenced the prevalence that their alcohol problems preceded their homelessness of alcohol- and drug-related problems. Whereas 60% of (Koegel & Burnham, 1987). the American
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