Transcript Examining the Impact of Multifaceted, Short-term Interventions for Homeless Families: Substance Abuse Findings from the CMHS/CSAT Homeless Families Program Debra J.

Examining the Impact of Multifaceted,
Short-term Interventions for Homeless Families:
Substance Abuse Findings from the CMHS/CSAT
Homeless Families Program
Debra 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

Began in October 1999
Phase II (3 years)
Phase I (2 years)
8 sites
14 sites


Conduct Site Process
Evaluation
Design Cross-Site Study

Conduct Cross-Site
Outcome Study
Conduct Site-Specific
Studies
 Conduct Program
Ingredients Study

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?
Nature of the Interventions
Basic Intervention
Approach

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
Comparison Intervention
Approaches

“Treatment as Usual”

Alternative treatment
approach
Homeless Families Interventions
Site
Target Intervention
Comparison
Phoenix, AZ
(Randomized)
Enhanced Intensive Case
Management, Motivational
Interviewing
Wake County, NC
Intensive Case Management with Traditional Case Mgmnt
Wrap-around Services
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
Shelter Treatment as
Usual
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 followup
Demographic Background
& Substance Abuse Service Needs
Demographics
MOTHER
CROSS-SITE
(n=1572)
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
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
Substance Abuse History
% reporting ever treated for substance abuse
100
33
80
60
26
%
40
20
0
61
19
10
15
42
7
10
3
CDNY
(n=239)
22
24
10
16
3
5
4
3
3
12
1
CT
(n=203)
PA
(n=227)
AZ
(n=219)
MO
(n=147)
NC
(n=176)
WNY
(n=188)
Alcohol
Drug
Alcohol & Drug
3
12
0
MA
(n=157)
% Reporting Current Substance Abuse
100
80
46
60
%
14
40
47
20
4
35
9
12
33
25
13
0
6
3
3
6
CDNY
(n=239)
CT
(n=203)
PA
(n=227)
AZ
(n=219)
Alcohol Use to Intoxication
Illegal Drug Use
12
MO
(n=147)
11
1
2
17
14
2
5
12
1
NC
(n=176)
WNY
(n=188)
MA
(n=157)
Alcohol Use to Intoxication AND Illegal Drug Use
Effectiveness of the Target
Interventions
Key Outcome Results
Outcome Summary
Treatment vs. Comparison Intervention Results
Alcohol Use
Drug Use
Overall Significant Improvement
Over Time (B, 3, 9, 15)
√
√
Differential Change
Tx vs. Control
N
N
Significant Individual Level Predictors
of Change
(HLM results)
Positive
Drug history
Race
Employment
Employment
Staff Support
Negative
Recurring trauma
Recurring trauma
Conflict
1 or more children
away
SA services receipt
SA Services receipt
Outcome Summary
Program Emphasis Results
Alcohol Use
Drug Use
Overall Significant Improvement
Over Time (B, 3, 9, 15)
√
√
Change Related to Emphasis on
Substance Abuse Treatment
N
Y
Significant Individual Level Predictors
of Change
(HLM results)
Alcohol history
Positive
Employment
Employment
Negative
Recurring trauma
Recurring trauma
Conflict
1 or more children
away
1 or more children
away
SA services receipt
SA Services receipt
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