Examining the Impact of Multifaceted, Short-term Interventions for Homeless

Families:

Substance Abuse Findings from the CMHS/CSAT

Homeless Families ProgramDebra J. Rog, PhD

Vanderbilt University

July 31, 2006

Presentation Overview

Describe the SAMHSA Homeless Families

Program

Highlight the substance abuse needs of the

participating mothers and the outcomes of

their participation in the interventions

Discuss the policy implications of the results

SAMHSA Homeless Families Program Initiative

Impetus for the Initiative

Families comprise a significant segment of the homeless population

Research indicates a portion of the population has mental health, trauma, and/or substance abuse disorders

Virtual absence of descriptive or empirical research on interventions for homeless families

Structure of the Initiative

14 sites

Conduct Site Process Evaluation

Design Cross-Site Study

8 sites

Conduct Cross-Site Outcome Study

Conduct Site-Specific Studies Conduct Program Ingredients Study

Began in October 1999

Phase I (2 years) Phase II (3 years)

Cross-site Research Questions

Are comprehensive, intensive, time-limited, multi-site interventions more effective than other treatment alternatives in:

Decreasing psychological distress?

Improving trauma recovery?

Decreasing substance use/abuse?

Improving residential stability?

Improving the general well-being of children?

Improving other outcomes, including health, resources, and parenting?

Are there consistent key dimensions of the interventions that appear to be positively associated with the outcomes?

-----------------------------------------------

What individual-level factors are associated with change?

Are there different identifiable patterns of change among the families on the outcomes?

Time limited (up to 9 mos)

Multi-faceted intervention

Mental health treatment

Substance abuse treatment

Trauma recovery

Securing and maintaining housing

Parenting skills

Household and money management

Goal setting

“Treatment as

Usual”

Alternative

treatment

approach

Basic Intervention

Approach

Comparison Intervention Approaches

Nature of the Interventions

Homeless Families Interventions

Site Target Intervention Comparison

Phoenix, AZ (Randomized)

Enhanced Intensive Case Management, Motivational Interviewing

Shelter Treatment as Usual

Wake County, NC Intensive Case Management with Wrap-around Services

Traditional Case Mgmnt with link to services

Connecticut* Intensive Care Coordination Treatment as Usual

Westchester, NY (Randomized)

Family Critical Time Intervention and Housing Apt Program

Shelter as Usual

Capital District, NY Modified Critical Time Intervention

Services as Usual

St. Louis, MO (Randomized)

Multi-dimensional Family Assistance

Outreach Intensive Case Management

Worcester, MA Comprehensive Family Health Practice

Treatment as Usual

Philadelphia, PA* Enhanced Family Therapeutic Community & Aftercare

Standard Family Therapeutic Community & Aftercare

*Target Primarily SA

Substance Abuse Service Program Emphasis

Measured whether there was:

SA training for staff designated SA staff a limited or full array of SA services on site

A 4-level ordinal measure was developed for each:

0 – None - no services or staff on site 1 – Low - two or less of the ingredients at

limited/low 2 – Med - having designated staff, training, some

level of on -site services

3 – High - staff, training, full array of services

Study Approaches Designs

Mix of randomized and non-randomized studies

Family Recruitment/Intervention Site

Shelters were most common site

Other settings include transitional and permanent housing, family health center, residential treatment center

Participant Eligibility Criteria

Families who:

Currently are homeless

Have at least 1 child 1.5 - 16 years old

Have mothers screened to have MH and/or SA issues

1573 families in cross-site baseline sample

1467 (93%) with baseline and at least 1 follow-up

Demographic Background & Substance Abuse Service

Needs

Demographics

Average Age 31 years (range 18 - 61)

Marital Status Varies by site: 6% - 26% currently married

Ethnicity Varies by site Range: 2 - 47% Hispanic/Latina

Disproportionately African American (49% - 85% in 6 sites)

Education 44% lack HS diploma/GED

Employment 96% have a work history 14% working

Pregnant 14% currently pregnant

MOTHER CROSS-SITE (n=1572)

Family Composition

Average of 2-3 total children in families

Currently 1-2 children (under age 18) living with them

31% of children are under age 5

9% of mothers are currently living with a partner

310

7

3

42

26

5

61

33

4

22

10

3

24

19

3

16

15

112

10

012

3

0

20

40

60

80

100

%

CDNY(n=239)

CT(n=203)

PA(n=227)

AZ(n=219)

MO(n=147)

NC(n=176)

WNY(n=188)

MA(n=157)

Substance Abuse History% reporting ever treated for substance abuse

Alcohol Drug Alcohol & Drug

6

13

4

3

35

14

3

47

46

6

33

9

12

25

12

2

17

11

5

14

1

112

2

0

20

40

60

80

100

%

CDNY(n=239)

CT(n=203)

PA(n=227)

AZ(n=219)

MO(n=147)

NC(n=176)

WNY(n=188)

MA(n=157)

% Reporting Current Substance Abuse

Alcohol Use to Intoxication Illegal Drug Use Alcohol Use to Intoxication AND Illegal Drug Use

Effectiveness of the Target Interventions

Key Outcome Results

Alcohol Use Drug Use

Overall Significant ImprovementOver Time (B, 3, 9, 15) √ √

Differential ChangeTx vs. Control N N

Significant Individual Level Predictors of Change (HLM results) Positive

Drug historyRace

Employment Employment

Staff Support

Negative Recurring trauma

SA services receipt

Recurring trauma

Conflict

1 or more children away

SA Services receipt

Outcome SummaryTreatment vs. Comparison Intervention Results

Alcohol Use Drug Use

Overall Significant ImprovementOver Time (B, 3, 9, 15) √ √

Change Related to Emphasis on Substance Abuse Treatment N Y

Significant Individual Level Predictors of Change (HLM results) Positive

Alcohol history

Employment Employment

Negative Recurring trauma

1 or more children away

SA services receipt

Recurring trauma

Conflict

1 or more children away

SA Services receipt

Outcome SummaryProgram Emphasis Results

Examining Patterns of Change in Outcomes

Key Outcome Results

Patterns of Change Over Time

Patterns of Change Over Time

Summary of Findings No target intervention effect on the substance

abuse outcomes (or other treatment outcomes)

Lack of intervention differences may be due to:

Low contrast between treatment and control interventions

Benefits of even low threshold treatment

Variation of service receipt within groups and confounding of problems and service receipt

Ability to obtain services outside the program

Too short a period of intervention to be effective

Summary of Findings Encouraging, though tentative evidence for on-site substance

abuse services

Poorer outcomes associated with:

Ongoing conflict and trauma

Having children away [trauma and SA outcomes]

Self-report on service receipt (most likely a proxy for

severity of the problem)

Having a job is related to more positive outcomes

Trajectory analyses typically one core group is accounting for

most of the change on an outcome

Implications of the Findings Findings suggest that shelter providers and other

homeless service providers should:

Screen for substance abuse conditions, among others

Provide on-site or easy access to services in these areas

Actively work with women who are continuing to experience violence to change their life circumstances

Incorporate conflict resolution strategies and interventions to strengthen a women’s ability to avoid relationships that continue to victimize her