, 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 Abuse and Alcoholisml Rockville, MD Barbara Lubran 5 National Institute on 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 Indian men had apparent alcohol abuse The relationship between abuse of alcohol and drugs problems, the rates of problem drinking for homeless La- and homelessness, however, is probably bidirectional. Al- tino (28%) and Asian (17%) men were below average (47%; though, alcohol and drug abuse can increase the risk of J. D. Wright & Weber, 1987). More'than one third of homelessness, displacement and loss of shelter can also African American (38%) and White (35%) men had ev- increase the use and abuse of alcohol and other drugs idence of alcoholism. Among women, American Indians (American Public Health Association, 1990). (36%) experienced a substantially greater prevalence of The loss of low-income housing units (specifically, alcohol-related problems when compared with African boarding houses), for example, had a particular impact American (13%), Latino (4%), and White (12%) women on substance-abuting individuals and others who relied (J. D. Wright & Weber). Differences in drug abuse prev- on inexpensive housing units as a buffer against living alence were less apparent, but African American (13%) without a conventional place for a home. Wittman (1987) and Latino (12%) men had the highest rates (J. D. Wright was quite explicit, "Much of the blame for the presence & Weber). Two or more alcohol, drug, or mental health of homelessness generally, and among people with alcohol problems were reported more often among African problems in particular, may be attributed to a decline in Americans (16%), American Indians (16%), and Whites the availability of housing for low-income, high problem

1140 November 1991 • American Psychologist groups" (p. 74). In this instance, substance abuse is neither sions still adhere to a program based primarily on prayer, the cause nor the consequence of homelessness, but rather food, shelter, and work (Glaser et al., 1978; Stoil). a condition that was aggravated by the loss of housing. Perhaps the most pervasive strategy for treating Alcoholism, alcohol abuse, drug abuse, and homelessness homeless inebriates has been arrest and jail. New York are clearly interrelated--complicating and exacerbating City, for example, prohibited in 1833 one another. and established a police force in 1845. A primary re- sponsibility for the new police department was dealing Public Policy and the Treatment of Homeless with derelicts in the Bowery (Murtagh, 1967). Nationally, Substance Abusers over the decades, arrests for drunkenness, public intoxi- cation, and disorderly conduct increased until alcohol- Historically, efforts to deal with homeless substance related arrests accounted for almost one half of all re- abusers reflect prevailing social attitudes and beliefs re- ported arrests in 1964 (Pittman, 1967). Studies of repeat garding the causes of homelessness, alcohol and drug offenders found that most were homeless men living in abuse, and the character of the homeless substance abuser. skid-row areas (President's Commission, 1967). Wiseman's (1970) analysis of skid row and the strategies Services for homeless alcoholics began to move be- used to cope with homeless public inebriates suggests two yond almshouses, shelters, and jails after World War II. dominant approaches. The first views the homeless ine- The growth of (AA) and the con- briate as a nuisance to be controlled and contained pri- viction that alcoholism is a treatable illness has led to marily through punishment and incarceration. The sec- specialized community clinics for the assessment and ond technique assumes that rehabilitation and treatment of alcoholics. Demonstrations of recovery have can be achieved through therapy, prayer, or simply, hard encouraged more humane views of the alcoholic and fos- work. Public policy tends to shift over time from a focus tered demands for alternatives to the "drunk tank." on control and containment to an emphasis on therapy and rehabilitation. An understanding of both policy Urban Renewal and Rehabilitation strategies is critical to an appreciation of how legislation, Service development has also been influenced by urban regulation, and guidelines both ameliorate and aggravate renewal programs. Widespread interest in rebuilding cities the lives of homeless men and women struggling with and cleaning up skid rows has focused attention on the addiction to alcohol and other drugs (M~ikel~i & Room, most problematic residents--the homeless chronic ine- 1985). briate (e.g., Tenants Relocation Bureau, 1961). The De- Historical Approaches to Control and Rehabilitation troit Mayor's Rehabilitation Committee on Skid Row Problems, and the Michigan State Board of Alcoholism, Services for homeless inebriates changed little from 1800 for example, cosponsored the First Annual International through 1940. Almshouses, shelters, and jails were the Institute on the Homeless Alcoholic ("The Homeless Al- primary institutions caring for the indigent and derelict coholic," 1955). Subsequent meetings were sponsored by (Baumohl & Room, 1987; Straus, 1955). In colonial the National Council on Alcoholism, and the name America, community workhouses cared for the unsettled changed from the Institute on the Skid Row Alcoholic poor, the feeble, and the drunkards (Stems & Ullman, (National Committee on Alcoholism, 1956) to the Insti- 1949). States began to assume responsibility for alms- tute on the Homeless and Institutional Alcoholic (Na- houses and poor farms before the Civil War. Massachu- tional Council on Alcoholism, 1961). setts opened three almshouses around 1855, and although Papers presented at the institute meetings reflect the the names changed from almshouses to poor farms to struggle to develop intervention strategies for homeless hospitals, care for alcoholics was always a primary part alcoholics and to balance those efforts with the needs of of their mission. The state almshouse in Tewksbury, Mas- the criminal justice system and urban planners. Straus sachusetts, for example, became a state hospital. The (1955) observed at the first meeting that few homeless Massachusetts State Hospital for Dipsomaniacs opened men benefited from outpatient treatment in a Yale Plan in 1883 in Foxborough, but by 1918 the mission had Clinic. For most homeless individuals, the primary needs changed to care primarily for shell-shocked veterans from were food, shelter, and clothing. World War I (Baumohl & Room). The second institute included more discussion of Rescue missions and shelters also began in the mid- programs linked to courts. Murtagh (1956) reviewed ef- dle of the 19th century. The Salvation Army's campaign forts of the New York City Welfare Department to develop to save souls has always emphasized outreach to homeless rehabilitation services for chronic inebriates. A homeless individuals struggling with alcoholism (Glaser, Greenberg, men's court was formed, and offenders were given a choice & Barrett, 1978; Hofman, 1956; Stoil, 1987). The first of jail or program participation. The program provided Salvation Army shelter in the United States opened in food, shelter, and work. Men could also choose to par- the Manhattan Bowery in 1891 (Stoil). On biennial ticipate in AA meetings and see a chaplain. The Los An- "Boozers' Days," mission officers would round up public geles police department operated a similar program inebriates and provide food, coffee, and shelter (Stoil). (Hindman, 1956). However, few aftercare services were Although the Salvation Army no longer scours streets available and repeat admissions were common occur- and flophouses to find inebriates, it and other rescue mis- rences in New York City, Los Angeles, and other cities.

November 1991 • American Psychologist 1141 Hospital-based treatment services were also ex- intoxication and establish a community-based continuum plored. Boston established a 300-bed rehabilitation pro- of care for the detoxification and voluntary treatment of gram at Long Island Hospital in 1951 (Myerson, 1956a). alcoholism. Decriminalization had a direct impact on A three-year follow-up of 101 men found that 12 were services for public inebriates, primarily the homeless al- sober and living independently, 20 were sober but living coholics living in skid-row sections of urban communities. at the hospital, 22 had occasional relapses but reentered Detoxification centers replaced drunk tanks during the treatment quickly, and 47 continued to be chronic ine- 1970s, and there was an expectation that individuals briates (Myerson, 1956a, 1956b, 1960). In Michigan, ser- would enter long-term treatment. Detoxification centers vices for homeless alcoholics were integrated into pro- provided more humane treatment and improved medical grams in general hospitals ("The Homeless Alcoholic," care for chronic inebriates (DenHartog, 1982). 1955). Although most states have adopted the Uniform Act A general impression of the early efforts is that they or similar provisions (Finn, 1985), debate about the effects offered little more th~n what was found in the Salvation of the act have continued for more than a decade. Kurtz Army sheltersmfood, shelter, and work. The programs and Regier (1975; Regier & Kurtz, 1976) argued that the tended to serve court-mandated individuals. Alcoholics Uniform Act was a flawed policy and unlikely to improve Anonymous was available but not well integrated, and the life of chronic public inebriates because a medical aftercare services were nonexistent or weak. model treatment system is not suited to the needs of homeless alcoholics. Blumberg (1976) responded that Halfway Houses treatment services were more humane than jail and could During the 1950s the obvious need to improve aftercare interrupt the cycle of addiction that leads to skid-row and linkages with self-help led to the development of half- living. Most who entered the debate agreed that detoxi- way houses and recovery homes. Men leaving institutions, fication alone was insufficient to solve the problem of whether hospitals or jails, did not have the skills and re- public inebriates and that additional support services were sources to sustain sobriety. Halfway houses bridged the required (Chafetz, 1976). Room (1976) suggested that gap between institution and independence and provided alternative living and recreational facilities were key ele- time to establish jobs and rebuild a sense of self-esteem ments in effective social interventions. More recently, and confdence (Blacker & Kantor, 1960). A 1958 survey Finn's (1985) analysis of admissions to detoxification and of all states, U.S. territories, and Canadian provinces sug- subsequent treatment reinforced the belief that the Uni- gested that there were at least 30 programs in 17 states, form Act did not and could not change the life-style of Washington, DC, and one Canadian province that could all chronic inebriates. He suggested that services are in- be described as halfway houses (Blacker & Kantor). The effective because treatment programs tend to focus on programs had a mean age of four years and averaged 26 drinking and alcohol abuse and often overlook concurrent beds. Most of the staff were recovering alcoholics, but problems such as a lack of housing, job skills, and social 40% of the programs included professionals. Participants supports. Others (Armor, Polich, & Stambul, 1978; Fagan tended to have histories of homelessness and chronic & Mauss, 1986; McCarty, Mulligan, & Argeriou, 1987) drunkenness offenses. Although data on outcomes were have also observed the limited effectiveness of treatment limited, programs considered about one third of the services with homeless alcoholics. graduates rehabilitated (Blacker & Kantor). Gradual Recently, detoxification facilities originally designed reintegration into the community appeared to provide to service clients with alcohol problems are being called an important aftercare function and substantially im- upon to detoxify individuals with alcohol, drug, and co- proved outcomes. Blacker (1966) concluded that special occurring drug and alcohol problems. The Diagnostic programs were required to link homeless inebriates with and Rehabilitation Center in Philadelphia, for example, treatment and social services. reported that until 1987, most of its clients were alcoholic. Today, more than one half of the clients have a primary The Uniform Act and Detoxifieation Centers diagnosis of crack addiction (Whitman, Friedman, & While community-based services were developing, pres- Thomas, 1990). In Boston, data from 617 homeless clients sures on the criminal justice system increased. Courts suggest that alcohol is the major problem in 53% of the struggled to process an overwhelming caseload of drunk- cases, cocaine in 21%, alcohol and drugs in 19%, poly- enness offenders, and drunk tanks were the primary de- drug in 4%, heroin in 2%, and miscellaneous drugs about toxification facility. The President's Commission on Law 1%. In addition to changes in drug of choice, the treatment Enforcement and Administration of Justice (President's population is substantially younger, more likely to be from Commission, 1967) studied the impact of drunkenness communities of color, and includes more women. These offenses on courts and police and recommended decrimi- rapid changes mean that services and personnel may be nalization of drunkenness offenses, the establishment of ill equipped to respond to the needs of a changing pop- community-based detoxification centers, and coordinated ulation of homeless men and women. aftercare services. The Uniform Alcoholism and Intoxi- Debate over models for detoxification tend to com- cation Act (National Conference of Commissioners on pare medical and social models. Medical models of de- Uniform State Laws, 1971) or "Uniform Act" was drafted toxification use medication and professional medical su- in 1971 and encouraged states to decriminalize public pervision to ease withdrawal and characterize approxi-

1142 November 1991 • American Psychologist mately two thirds of all detoxification services (Sadd & projects). The mission of this demonstration program was Young, 1987). Social models effect withdrawal in a sup- to provide for homeless men and women with alcohol portive nonmedical environment designed to reduce the and other drug problems and, at the same time, system- discomfort of the individual, without the use of medi- atically assess the nature and effectiveness of the inter- cation. Both approaches appear to be equally effective ventions through site-level outcome evaluations and a (Sadd & Young, 1987). A. Wright and Manov (1989), national evaluation of the full demonstration program. strong proponents of social model programs, state, These demonstration projects illustrated both the rewards and difficulties associated with the development The advantage of the social model approach is that while it is no more effectivethan any other approach, it is more efficient. of services for homeless men and women struggling with For a given amount of money, it is possible for us to reach much alcoholism and drug abuse. It was generally believed that larger numbers of people with social model services. It therefore traditional treatment and recovery approaches were not appears to us from a public policy point of view, more public effective, in isolation, with homeless individuals because funds for alcohol services should be channeled to social model they did not seek out the homeless substance abuser, pro- programs than to clinical programs to ensure we are using public vide continuity of care and support, and facilitate re-entry monies most efficiently.(p. 35) into the community (Lubran, 1990). The design of the In summary, the widespread establishment of public NIAAA/NIDA demonstration projects were driven more detoxification facilities has been marked by debates re- by specific community needs and target populations than garding structure and function. Despite a number of con- by treatment philosophy. Each project tried to improve troversies, these detoxification centers are entry points to access to care, increase the coordination of services, and recovery for many men and women. Centers report, enhance program responsiveness to the unique needs of anecdotally, that some individuals begin a long recovery a variety of subpopulations of homeless persons (e.g., after many detoxifications and that the services help others public inebriates living on skid row, women with children, continue to function and remain in their community with persons who were experiencing both mental health illness better health. Although the Uniform Act may not have and alcohol abuse, and native Americans). met its most idealistic goals, a system of emergency and Improving the physical and psychological access to aftercare services has been created and many homeless care was approached in many ways by the NIAAA/NIDA alcohol and drug abusers have benefited. Demonstration Program. In two projects, low-demand service settings that accepted intoxicated persons at any The McKinney Act time of day were established in the community (Bonham, In the 1980s, a variety of public interventions were de- Hague, Abel, Cummings, & Deutsch, 1990; Dexter, signed to respond to the growing population of homeless 1990). These service settings (called a sobering up station people. The Stewart B. McKinney Homeless Assistance in one project) served as alternatives to life on the streets Act (1987; Public Law 100-77), enacted in July 1987 (see or time in the county jail. More important, these low- Foscarinis, 1991, this issue, and Kondratas, 1991, this demand settings provided the first point of contact with issue), represented the first comprehensive federal initi- the human service system for many homeless persons ative to provide urgently needed assistance to protect and with alcohol and other drug problems. Access to care was improve the lives and safety of the homeless. The act ad- also improved in a number of projects by establishing dresses the needs of homeless persons in the areas of programs that sent paraprofessional and professional staff emergency food and shelter, health and mental health to street corners, public places, and locations where hous- care, substance abuse treatment, housing, educational ing was extremely marginal (e.g., welfare hotels) to make programs, job training, and other community services. contact with homeless persons on a one-to-one basis and Specifically, Section 613 of the act authorized the National offer food, shelter, and information on alcohol and other Institute on Alcohol Abuse and Alcoholism (NIAAA), in drug treatment opportunities (Blankertz & White, 1990; consultation with the National Institute on Drug Abuse Ridlen, Asamoah, Edwards, & Zimmer, 1990). (NIDA), to establish a demonstration program for home- Coordination of care was approached in many proj- less persons with alcohol/or drug problems (Lubran, ects by developing programs of case management and 1990, p. 12). working at the system level to build interorganizational In response to this legislative authority, a national linkages (McCarty, Argeriou, Krakow, & Mulvey, 1990; demonstration program (formally titled the NIAAA/ Willenbring, Whelan, Dahlquist, & O'Neal, 1990). Case NIDA Community Demonstration Grant Projects for management has been conceptualized and operationally Alcohol and Drug Abuse Treatment of Homeless Indi- defined in many ways, but the general approach imple- viduals) was initiated in 1988 to evaluate a variety of mented in the demonstration program evaluates a client's community-based service models sensitive to the needs service needs, actively facilitates contact with community of homeless individuals (Argeriou & McCarty, 1990). resources to meet those needs, and helps individuals de- Grants were awarded on a competitive basis to nine proj- velop their own problem-solving and coping skills. Vari- ects located in eight cities: Anchorage, Alaska; Boston, ations on this general approach included using a team of Massachusetts; Los Angeles, California; Louisville, Ken- case managers in working with an individual client, sig- tucky; Minneapolis, Minnesota; New York, New York; nificantly reducing the size of a case manager's caseload, Oakland, California; and Philadelphia, Pennsylvania (two and making contact with clients at critical milestones in

November 1991 • American Psychologist 1143 the treatment process (e.g., the period immediately after dropped significantly during this period (Moore detoxification). Complementing the efforts of individual & Gerstein, 1981). case managers to coordinate care, the demonstration On a smaller scale, regulation of bars and liquor projects have also sought to strengthen the network of stores and enforcement of local ordinances can also re- human service organizations that serve homeless persons duce the availability of alcohol and drugs and problems in their communities by creating multi-agency working related to their use and abuse (American Public Health groups, public forums, and formal interorganizational Association, 1990). Two communities, for example, at- agreements (Bennet, Weiss, & West, 1990). tempted to restrict the availability of fortified wine (al- Finally, the NIAAA/NIDA Demonstration Program cohol content greater than 14%) in skid-row areas. Be- attempted to make alcohol and other drug services more cause it is usually inexpensive and has a high alcohol responsive to homeless persons by linking treatment with content, fortified wine is often a beverage of choice among housing. One approach was to couple a three-month stay public inebriates. in rural alcohol treatment program with a four-month In Portland, Oregon, for example, a local task force posttreatment stay in a transitional housing program in recommended a ban on the sale of fortified wine in the an urban setting that emphasized finding permanent old-town business area (Newton & Duffy, 1987). When housing, developing vocational skills, and establishing a the ban was implemented, public inebriates left the area; social support network that encouraged an alcohol- and after a short period, however, they returned. Merchants drug-free life-style (A. Wright, Mora, & Hughes, 1990). reported that problems associated with public intoxica- Another innovative approach to linking treatment and tion continued but occurred less frequently (Newton & housing was a residential program specifically designed Duffy). An analysis of the ban suggests that the use of for homeless women and their preschool children. The fortified wine was only one factor that contributed to distinctive feature of this program was a state-of-the-art homelessness and public intoxication and that compre- residential facility that permitted children to live onsite hensive programs are required to address homelessness, while their mothers received alcohol and drug treatment, alcoholism, and drug abuse. parenting skills training, money management classes, and A second and less successful experiment with re- assistance in job training (Comfort, Shipley, White, Grif- strictions on the sale of alcoholic beverages took place in fith, & Shandler, 1990). San Francisco. Neighborhood leaders in the Tenderloin Although outcome data still are unavailable, the ex- district called for a ban on fortified wines to inhibit con- perience of the projects during their early implementation tinued neighborhood deterioration ("Cheap Potent period reflect the continuing separation of homeless per- Wine," 1990). After a Wall Street Journal article criticized sons into two groups: the "disreputable" homeless and the sale of fortified wine, two major wine companies vol- the "deserving" homeless (Wiseman, 1987). Homeless untarily suspended the sale of fortified wines for six substance abusers fall into the former category and are months to retailers in the Tenderloin area ("Cheap Potent often badly treated by a society that simultaneously seeks Wine"; Dolan, 1989). Community leaders reported, to assist the deserving poor. Some projects faced consid- however, that dealers continued to sell fortified wines; erable community resistance because of the population some stocked up before the ban, others purchased the being served and the nature of the proposed interventions. wine through stores outside the Tenderloin area ("Cheap Resistance prevented the development of a sobering-up Potent Wine"). station in Anchorage (Dexter, 1990) and signifcantly de- The experiences in Portland and San Francisco sug- layed the start-up of a women's residential treatment fa- gest that restrictions on availability of alcohol and other cility in Philadelphia (Comfort et al., 1990). All nine drugs, retail outlets, and advertising can contribute to projects found that there was a significant unmet need reductions in public intoxication and problems associated for services for homeless individuals with alcohol or drug with life on skid row. Restricting and regulating sales problems who had been excluded or turned away from alone, however, appears to be insufficient; communities other services systems, including services specifically de- must also be prepared to develop comprehensive service signed to serve the homeless population. Even alcohol systems for homeless men and women. and drug treatment programs exhibited reluctance to Alcohol- and Drug-Free Housing serve the homeless because many are unpredictable, cause trouble, present medical problems and risks, and make Homeless men and women with a history of addiction to extreme demands on service providers (Lubran, 1990). alcohol and other drugs need safe and sober housing to continue a successful recovery after detoxification and Restrictions on Availability treatment. Individuals who return to the street without Policies have been used most often to create rehabilitation safe housing, without new friends, and without employ- and punitive options for homeless inebriates, but policies ment opportunities, are unlikely to maintain sobriety. can also reduce access to alcohol and illegal drugs. The For many, safe housing means an alcohol- and drug-free most notable effort was the Volstead Act residence--a safe, clean, sober, and inexpensive residence (1919-1933), which outlawed the use of alcoholic bev- that promotes and supports recovery. Self-help and peer erages. Although this policy is generally regarded as a support are central elements in the most successful res- failed experiment in social engineering, deaths caused by idences.

1144 November 1991 • American Psychologist A variety of housing models exist. In some com- turns to a life on the streets" (p. 153). As previously noted, munities, flophouses and hotels have been converted to the Oxford House approach to the establishment of al- alcohol-free living centers (Korenbaum & Barney, 1987; cohol- and drug-free housing represents one inexpensive Wittman, 1989). Similar in structure to traditional single- method of partially fulfilling the need for sober housing. room residences, these centers require residents to remain Other models of alcohol- and drug-free housing, such as sober. Massachusetts has used rental subsidies to develop lodges, single-room-occupancy hotels, and congregate more than 100 such single-room units of alcohol- and living facilities with on-site services can also be imple- drug-free residences. mented to promote safe and sober homes (Wittman, Legislation passed by the U.S. Congress in 1988 en- 1989). courages a second model, the Oxford House. The first Oxford House opened in 1975, when a halfway house in Mental Illness and Alcohol and Other Drug Abuse Maryland was threatened with closure because of funding The comorbidity of mental illness and alcohol and other cuts. The residents leased the house and maintained a drug problems among a large segment of the homeless sober environment. They developed a management population poses a particularly difficult challenge. Gen- handbook and a list of traditions to guide house operations eraUy, studies of homeless men and women with both (MoUoy, 1990). New houses were leased when waiting mental illness and alcohol- or other drug-related problems lists were sufficient to fall another house. Houses operate call for the establishment of a network of community- independently and democratically and are financially self- based mental health, social welfare, housing, and sub- supportive. Only individuals who drink, use drugs, fail stance abuse services, with emphasis on interageney con- to pay their rent, or are disruptive are asked to leave. The sultation and coordination and cross-discipline education number of Oxford Houses grew slowly until the 1988 of service staff. Recommended services include outreach, Omnibus Drug Act included a requirement that each state supportive living environments, individualized treatment establish a revolving load fund and encourage the devel- programs tailored to the diagnosis and functional level opment of independent democratically operated housing of the client, and specialized case management (Institute for men and women in recovery (Madigan, 1988). States of Medicine, 1988). It is also clear that much more needs are currently establishing the loan programs, and as of to be learned about the most effective approaches to the June 1,1991, there were 256 Oxford Houses in 24 states treatment and management of homeless individuals with (Molloy, 1991). dual diagnoses (Dennis, 1987). The provision of services The establishment of alcohol- and drug-free homes to this subgroup is particularly difficult because of com- and hotels also benefits the surrounding neighborhoods munity resistance to program siting, the difficulty of en- and communities. The residents and their home become gaging clients in care, and even the occasional reluctance models of recovery for the community, and they dem- of caregivers to assume responsibility for the most chal- onstrate that an escape from the custody of addiction is lenging clients. J, D. Wright and Weber (1987) observed possible. The expansion of alcohol- and drug-free housing that although homeless persons are often perceived as to neighborhoods and housing projects appears to be an undesirable by human service institutions, "the alcohol- effective intervention and direction for public policy. impaired, the drug-abusive, and the mentally ill are more Critical Needs in Comprehensive Approaches 'undesirable' than others, and those who are both alco- holic or drug-abusive and mentally ill are the most un- The heterogeneity of today's homeless, substance-abusing desirable of all" (p. 95). Given this reality, one of the first population and the complexity of their service needs re- steps to improving services for homeless substance abusers quires a multifaceted comprehensive response that, un- may be critical examination and education of caregivers fortunately, few if any state or municipal governments regarding their responsibilities and the right to equal are willing to underwrite in the current economic at- treatment for the most disabled homeless. mosphere. Some of the elements of a comprehensive pro- gram are well-known and have long been recommended Services for Women With Children and are being tested in the NIAAA/NIDA Demonstration Program. As Garrett (1989) pointed out, the recommen- The unprecedented growth in the number of homeless dations of Bogue (1963) and Blumberg, Shipley, and families necessitates special attention to women with Shandler (1973) "reflect themes that resemble contem- children(see Milburn & D'Ercole, 1991, this issue). The porary viewpoints about policy and program initiatives NIAAA Community Demonstration Projects in New for homelessness in the 1980's" (p. 313). The sad truth, York (Ridlen et al., 1990) and Philadelphia (Comfort et of course, is that failure to act is usually as costly dollar- al., 1990) are exploring intervention strategies sensitive wise, and more costly in terms of human suffering. to the special needs of homeless women with children. In addition to the standard therapeutic substance abuse Housing and Aftercare program, both projects suggest that other programmatic The need for alcohol- and drug-free housing and aftercare elements such as parenting skills training, nutrition ed- is foremost. J. D. Wright (1989) stated, "The best treat- ucation, budgeting skills, housekeeping training, hygiene, ment and rehabilitation facilities imaginable can have but and vocational education are required to help young modest effects if, at the end of treatment, the patient re- homeless women recover and learn to parent successfully.

November 1991 • American Psychologist 1145 Roles for Psychology A final concern is the stigma associated with being homeless and having an alcohol or other drug problem. Although there are exceptions, psychologists have not The distinctions between the disreputable homeless and contributed substantially to the development, implemen- the deserving homeless are clear, and the maintenance of tation, and evaluation of services for the homeless with federal and state funding of programs to assist the former alcohol- and drug-related problems. A first step in re- will become far more difficult as budget difficulties and dressing this problem would be to increase recognition deficiencies increase. of the pervasiveness of alcohol and drug abuse and the contributions of substance abuse to many clinical prob- REFERENCES lems in all levels of society. Clinical training programs should include significant exposure to alcoholism- and American Public Health Association. (1990). Alcohol and other drug drug-abuse assessment and treatment, and provide op- problems among the homelesspopulation (position paper).American portunities for students to work with homeless men and Journal of Public Health, 80, 243-246. Argeriou, M., & McCarty, D. (Eds.). (1990). Treating alcoholism and women. drug abuse among homeless men and women: Nine community dem- Psychologists can also contribute more strongly to onstration grants. Binghamton, NY: Haworth Press. the development and evaluation of services and policies. Armor, D. J., Polich, J. M., & Stambul, H. B. (1978). Alcoholism and Too often interventions have been developed without an treatment. New York: Wiley. articulated framework and systematic evaluation. Rig- Baumohl, J., & Room, R. (1987). Inebriety, doctors, and the state: Al- coholism treatment institutions before 1940. In M. Galanter (Ed.), orous evaluation is essential to guide development and to Recent developments in alcoholism (Vol. 5, pp. 135-174). New York: demonstrate effects. Campbell's (1969, 1981) "experi- Plenum Press. menting society" is a particularly relevant concept when Bennet, R. W., Weiss, H. L., & West, B. R. (1990). Alameda County applied to services for homeless persons, Our commit- Department of Alcohol and Drug Programs for Comprehensive ment should be toward solving the problem rather than Homeless Alcohol Recovery Services (CHARS). In M. Argeriou & D. McCarty (Eds.), Treating alcoholism and drug abuse among the to a particular solution. Because shelters and other service homeless: Nine community demonstration grants (pp. 111-128). providers tend to feel protective of their guests and staff, Binghamton, NY: Haworth Press. research is often viewed as an exploitation of the homeless. Blacker, E. (1966). Aftercare residential program planning: Boston's pro- Evaluators must work closely with service providers to gram for the chronic drunkenness offender (Report No. 32). Wash- ington, DC: North American Association of Alcoholism Programs. ensure real benefits for homeless men and women. Stake- Blacker, E., & Kantor, D. (1960, June). Halfway houses for problem holder-based evaluations (Bryk, 1983) are one approach drinkers. Federal Probation, 24, 18-23. to helping evaluators become sensitive to service providers Blankertz, L. B., & White, K. M. (1990). Implementationof rehabilitation and understanding their perspective. program for dually diagnosed homeless. In M. Argeriou& D. McCarty Finally, psychologists can continue to support social (Eds.), Treating alcoholism and drug abuse among the homeless: Nine community demonstration grants (pp. 149-162). Binghamton, NY: and legislative policies that respond to homeless persons Haworth Press. with dignity. Men, women, and children who struggle Blumberg, L. (1976). Comment on "The Uniform Alcoholism and In- with the consequences of the loss of shelter and the af- toxication Treatment Act." Journal of Studies on Alcohol, 37, 105- termath of addiction must be empowered so that they 110. Blumberg, L., Shipley, T., & Shandler, I. (1973). Skid row and its alter- can recover and maintain sobriety in safe, low-cost, al- natives: Research and recommendations from Philadelphia. Phila- cohol- and drug-free homes. delphia: Temple University Press. Bogue, D. (1963). Skid row in American cities. Chicago: University of Chicago Press. Bonham, G. S., Hague, D. E., Abel, M. E., Cummings, P., & Deutsch, Summary R. S. (1990). Louisville'sProject Connect for the HomelessAlcohol The new homeless, because of their sheer numbers and and Drug Abuser. In M. Argeriou & D. McCarty (Eds.), Treating alcoholism and drug abuse among the homeless: Nine community multiplicity of needs, cannot be managed with the policies demonstration grants (pp. 57-78)~ Binghamton, NY: Haworth Press. of the past. Treatment, housing, and policy initiatives Bryk, A. S. (Ed.). (1983). Stakeholder-based evaluation: New directions must evolve to reflect the increased heterogeneity among for program evaluation (No. 17). San Francisco: Jossey-Bass. homeless persons. In too many communities, prayer, food, Campbell, D. T. (1969). Reformsas experiments.American Psychologist, shelter, and work are still the principal programs available 24, 409-429. Campbell, D. T. (1981). Introduction: Getting ready for the experi- for homeless alcohol and drug abusers. The NIAAA/ menting society. In L. Saxe & M. Fine, Social experiments: Methods NIDA Community Demonstration Projects for homeless for design and evaluation (pp. 13-18). BeverlyHills, CA: Sage. alcohol and other drug abusers are pioneering the devel- Chafetz, M. E. (1976). Comment on "The Uniform Alcoholism and opment of rehabilitation strategies responsive to the pre- Intoxication Treatment Act." Journal of Studies on Alcohol, 3 7, 100- 101. senting problems of this group. The results should help Cheap potent wine: A tale of two cities. (1990, Winter). Prevention File, shape the directions of future efforts. In this article, we 5(1), 4-6. have emphasized the critical role that sober housing plays Comfort, M., Shipley, T. E., White, K., Grittith, M. E., & Shandler, in the recovery process. Ironically, with the "franchising" I. W. (1990). Family treatment for homeless alcohol/drug-addicted of the Oxford House model across states and the estab- women and their preschool children. In M. Argeriou & D. McCarty (Eds.), Treating alcoholism and drug abuse among the homeless: Nine lishment of the revolving loan fund in each of the states, community demonstration grants (pp. 129-147). Binghamton, NY: it may prove to be the easiest program element to put in Haworth Press. place. DenHartog, G. L. (1982). A decade of detox." Development of non-hospital

1146 November 1991 • American Psychologist approaches to --A review of the literature (Sub- among the homeless: Nine community demonstration grants (pp. 31- stance Abuse Monograph Series No. 2-82). Jefferson City, MO: Di- 46). Binghamton, NY: Haworth Press. vision of Alcohol and Drug Abuse. McCarty, D., Mulligan, D., & Argeriou, M. (1987). Admission and re- Dennis, D. L. (1987). Research methodologies concerning homeless per- ferral patterns among alcohol detoxification patients. Alcoholism sons with serious mental illness and~or substance abuse disorders Treatment Quarterly, 4(1), 79-90. (Proceedings of a two-day conference sponsored by the Alcohol, Drug McCook J. A. (1893). Tramp census and its revelations. Forum, 15, Abuse and Mental Health Administration). Rockville, MD: Alcohol, 753-766. Drug Abuse and Mental Health Administration. Milburn, N., & D'Ercole, A. (1991). Homeless women: Moving toward Dexter, R. A. (1990). Treating homeless and mentally ill substance abusers a comprehensive model. American Psychologist, 46, 1161-1169. in Alaska. In M. Argeriou & D. McCarty (Eds.), Treating alcoholism Molloy, J. P. (1990). Self-run, self-supported houses for more effective and drug abuse among the homeless: Nine community demonstration recovery from alcohol and drug addiction: A technical assistance man- grants (pp. 25-30). Binghamton, NY: Haworth Press. ual (DHHS Publication No. ADM 90-1678). Bethesda, MD: Alcohol, Dolan, C. (1989, June 16). Gallo conducts test to placate critics of its Drug Abuse and Mental Health Administration. cheap wines. The Wall Street Journal, p. B3. Molloy, J. P. (1991). Report to the June 1991 Meeting of NASADAD on Fagan, R. W., & Mauss, A. L. (1986). Social margin and social re-entry: the progress, problems, and prospects of Oxford House expansion. An evaluation of a rehabilitation program for skid row alcoholics. Silver Spring, MD: Oxford House. Journal of Studies on Alcohol, 47, 413-425. Moore, M. H., & Gerstein, D. R. (Eds). (1981). Alcohol and public policy." Finn, E (1985). Decriminalization of public drunkenness: Response of Beyond the shadow ofprohibition. Washington, DC: National Academy the health care system. Journal of Studies on Alcohol, 46, 7-23. Press. Fisher, E (1989). Estimating the prevalence of alcohol, drug, and mental Murtagh, J. M. (1956). The New York City program for the skid row health problems in the comtemporary homeless population. Contem- alcoholic. In Institute on the Skid Row Alcoholic of the Committee porary Drug Problems. 16, 333-389. on the Homeless Alcoholic (pp. 6-15). New York: National Committee Fosearinis, M. (1991). The politics of homelessness: A call to action. on Alcoholism. American Psychologist, 46, 1232-1238. Murtagh, J. M. (1967). Arrests for public intoxication. In Presidents Garrett, G. R. (1989). Alcohol problems and homelessness: History and Commission of Law Enforcement and Administration of Justice, Task research. Contemporary Drug Problems, 16, 301-332. force report: Drunkenness (pp. 65-67). Washington, DC: Government Giaset; E B., Greenberg S. W., & Barrett, M. (1978). A systems approach Printing Office. to alcohol treatment. Toronto, Canada: Addiction Research Foun- Myerson, D. J. (1956a). The rehabilitation program of the Long Island dation. Hospital of Boston. In Institute on the Skid Row Alcoholic of the Hindman, W. L. (1956). The utilization of modern techniques in treating Committee on the Homeless Alcoholic (pp. 56-71 ). New York: National the skid row alcoholic in the southwest. In Institute on the Skid Row Committee on Alcoholism. Alcoholic of the Committee on the Homeless Alcoholic (pp. 49-55). Myerson, D. J. (1956b). The "skid row" problem: Further observations New York: National Committee on Alcoholism. on a group of alcoholic patients, with emphasis on interpersonal re- Hofman, P. J. (1956). A review of a private agency program in a met- lations and the therapeutic approach. The New England Journal of ropolitan community. In Institute on the Skid Row Alcoholic of the Medicine, 254, 1168-1173. Committee on the Homeless Alcoholic (pp. 35--43). New York: National Myerson, D. J. (1960). Rehabilitation for skid row: The Boston/Long Committee on Alcoholism, Island Hospital Rehabilitation Program for the Homeless Alcoholic. The homeless alcoholic: Report of First Annual International Institute In Fifth and Sixth Annual Institutes on the Homeless and Institutional on the Homeless Alcoholic. (1955). Detroit, MI: Detroit Mayor's Re- Alcoholic (pp. 1-5). New York: National Council on Alcoholism. habilitation Committee on Skid Row Problems and the Michigan National Committee on Alcoholism. (1956). Institute on the Skid Row State Board of Alcoholism. Alcoholic of the Committee on the Homeless Alcoholic. New York: Hopper, K. (1989). Deviance and dwelling space: Notes on the resettle- Author. ment of homeless persons with alcohol and drug problems. Contem- National Conference of Commissioners on Uniform State Laws. (1971). porary Drug Problems, 16, 391-414. Uniform Alcoholism and Intoxication Treatment Act (with com- Institute of Medicine. (1988). Homelessness, health and human needs. ments). In G. J. Scrimgeour & J. A. Palmer (1976), Guidance manual Washington, DC: National Academy Press. for implementation of the Uniform Alcoholism and Intoxication Koegel, P., & Burnham, A. M. (1987). The epidemiology of alcohol Treatment Act (pp. A I-A 14). Bloomington, IN: Institute for Research abuse and dependence among homeless individuals: Findings from in Public Safety. the inner-city of Los Angeles. Los Angeles: University of California, National Council on Alcoholism. ( 1961). Fifth and Sixth Annual Institute Department of Psychiatry. on the Homeless and Institutional Alcoholic. New York: Author. Kondratas, A. ( 1991). Ending homelessness: Policy challenges. American Newton, S. P., & Duff3', C. P. (1987). Old town Portland and an old time Psychologist, 46, 1226-1231. problem. Alcohol Health & Research World, I1(3), 62-65, 91. Korenbaum, S., & Barney, G. (1987). Program planning for alcohol- Pittman, D. J. (1967). Public intoxication and the alcoholic offender in free living centers. Alcohol Health and Research World, 11(3), 68-73. American society. In President's Commission on Law Enforcement Kurtz, N. R., & Regier, M. (1975). The Uniform Alcoholism and In- and Administration of Justice, Task force report: Drunkenness (pp. toxification Treatment Act: The compromising process of social policy 7-28). Washington, 19(2: Government Printing Office. formulation. Journal of Studies on Alcohol, 36, 1421-1441. President's Commission on Law Enforcement and Administration of Lewin/lCF. (1989). The health needs of the homeless: A report on persons Justice. (1967). Task force report: Drunkenness. Washington, DC: served by the McKinney Act's Health Care for the Homeless program. Government Printing Office. Washington, DC: National Association of Community Health Centers. Regier, M., & Kurtz, N. R. (1976). Policy lessons of the Uniform Act: Lubran, B. G. (1990). Alcohol and drug abuse among the homeless A response to comments. Journal of Studies on Alcohol, 37, 382-392. population: A national response. In M. Argeriou & D. McCarty (Eds.), Rice, S. (1918). The homeless. Annals of the American Academy of Po- Treating alcoholism and drug abuse among the homeless: Nine com- litical and Social Sciences, 77, 140-153. munity demonstration grants (pp. 11-23). Binghamton, NY: Haworth Ridlen, S., Asamoah, Y., Edwards, H. G., & Zimmer, R. (1990). Outreach Press. and engagement for homeless women at risk of alcoholism. In M. Madigan, E. R. (1988, November 10). Omnibus Drug Initiative Act of Argeriou & D. McCarty (Eds.), Treating alcoholism and drug abuse 1988. Congressional Record, 134 (No. 152). among the homeless: Nine community demonstration grants (pp. 99- M/ikeRi, K., & Room, R. (1985). Alcohol policy and the rights of the 109). Binghamton, NY: Haworth Press. drunkard. Alcoholism Clinical and Experimental Research, 9(1), 2-5. Room, R. (1976). Comment on "The Uniform Alcoholism and Intox- McCarty, D., Argeriou, M., Krakow, M., & Mulvey, K. (1990). Stabi- ication Treatment Act." Journal of Studies on Alcohol, 37, 113-144. lization services for homeless alcoholics and drug abusers. In M. Ar- Rossi, P. H. (1989). Down and out in America. Chicago: University of geriou & D. McCarty (Eds.), Treating alcoholism and drug abuse Chicago Press.

November 1991 • American Psychologist 1 147 Rossi, P. H. (1990). The old homeless and the new homeless in historical holism and drug abuse among the homeless: Nine community dem- perspective. American Psychologist, 45, 954-959. onstration grants (pp. 79-98). Binghamton, NY: Haworth Press. Sadd, S., & Young, D. W. (1987). Non-medical treatment of indigent Wiseman, J. P. (1970). Stations of the lost: The trecltment of skid row alcoholics: A review of recent research findings. Alcohol Health & alcoholics. Chicago: University of Chicago Press. Research World, 11(3), 48--49. Wiseman, J. P. (1987). Studying the problem of alcoholism in today's Solenberger A. (1911). One thousand homeless men. New York: Russell homeless [Summary]. In J. Baumohl (Ed.), The homeless with alcohol Sage Foundation. problems: Proceedings of an NIAAA-sponsored research conference Stark, L. (1987). A century of alcohol and homelessness. Alcohol Health (pp. 8-9). Roekville, MD: National Institute on Alcohol Abuse and & Research World, I1(3), 8-13. Alcoholism. Sterns, A. W., & Ullman, A. D. (1949). One thousand unsuccessful Wittman, E D. (1987). Alcohol, architecture and homelessness. Alcohol car~ers. The American Journal of Psychiatry, 105, 801-810. Health & Research World, 11(3), 74-79. Stewart B. MeKinney Homeless Assistance Act of 1987, §! 1301 et. seq., Wittman, E D. (1989). Housing models for alcohol programs serving 42 U.S.C. (1987). homeless people. Contemporary Drug Problems, 16, 483-504. Stoil, M. (1987). Salvation and sobriety. Alcohol Health & Research Wright, A., & Manov, W. (1989). Los Angeles: Sober transitional housing World, 11(3), 14-17. and employment services. In Homeless, alcohol and other drugs Straus, R. (1946). Alcohol and the homeless man. Quarterly Journal of (DHHS Publication No. ADM 89-1614). Roekville, MD: National Studies on Alcohol. 7, 360--404. Straus, R. (1955). The homeless alcoholic, who he is, his locale, his Institute on Alcohol Abuse and Alcoholism. personality, the approach to his rehabilitation. In First Annual Inter- Wright, A., Mora, J., & Hughes, L. (1990). The Sober Transitional national Institute on the Homeless Alcoholic (pp. 7-14). Detroit, MI: Housing and Employment Project (STHEP): Strategies for long-term Detroit Mayor's Rehabilitation Committee on Skid Row Problems sobriety, employment and housing. In M. Argeriou & D. McCarty and the Michigan State Board of Alcoholism. (Eds.), Treating alcoholism and drug abuse among the homeless: Nine Sutherland, E., & Locke, H. (1936). Twenty thousand homeless men. community demonstration grants (pp. 47-56). Bingharnton, NY: Ha- Chicago: Lippincott. worth Press. Tenants Relocation Bureau. (1961). The homeless man on skid row. Wright, J. D. (1989). Address unknown: The homeless in America. New Chicago: City of Chicago. York: Aldine de Gruyter. Whitman, D., Friedman, D., & Thomas, L. (1990, January 15). The Wright, J. D., Knight, J. W., Weber-Bardin, E., & Lain, J. (1987). Ail- return of skid row. US. News & World Report, pp. 27-29. ments and alcohol: Health status among the drinking homeless. Alcohol Willenbring, M. L., Whelan, J. A., Dahlquist, J. S., & O'Neal, M. E. Health & Research World, 11(3), 22-27. (1990). Community treatment of the chronic public inebriate: I. Im- Wright, J. D., & Weber, E. (1987). Homelessness and health. New York: plementation. In M. Argeriou & D. MeCarty (Eds.), Treating alco- McGraw-Hill.

1148 November 1991 • American Psychologist