Homeless and Housing writer Darby Penney interviewed Dr. Ken Minkoff, a leading national expert on integrated treatment of individuals with co-occurring psychiatric and substance use disorders, on the range of housing options that need to be available to help people who have experienced homelessness find housing that reflects their self-identified preferences at the stage they are in in their lives.
In order to successfully house people who are experiencing homelessness and have substance use disorders, a “one-size-fits-all approach” must give way to “person-centered, trauma-informed, recovery-oriented, and integrated approaches,” said Ken Minkoff, M.D., Assistant Professor at Harvard, a Senior Systems Consultant for ZiaPartners in San Rafael, CA (www.ziapartners.com), and a leading national expert on integrated treatment of individuals with co-occurring psychiatric and substance use disorders.
“People [experiencing homelessness] commonly have a whole array of co-occurring mental health conditions and substance use disorders; one or more of their mental health or substance use conditions may be significantly out of control, and one of these conditions may be a more significant problem for them than the other. People may also have serious physical health conditions and disabilities, including cognitive issues as a result of substance use or traumatic brain injury, as well as developmental disorders. They may be responsible for children, they may be survivors of domestic violence, and there is a high prevalence of trauma,” he said. “So individuals have different preferences about what their most important goals are at a particular moment, which includes their desired living situations, the kinds of services they want, and how important housing is on their list of needs.”
Dr. Minkoff believes that communities must, therefore, make a range of housing options available so that people experiencing homelessness who also have substance use conditions can choose the type of housing that best fits their vision for a happy life, their preferences about what is their most important next step for help (e.g., housing, employment, medical care, mental health care, or substance use treatment), and their current “stage of change” for each issue in their recovery.
Stage of change is issue specific, not person specific, and best practice interventions, including housing, need to be “stage-matched,” according to Dr. Minkoff. “We need to be respectful of people’s choices,” he said. “We must get much better at acknowledging that people need to have meaningful choices that offer them the kind of support they currently want. For people with substance use conditions, one approach to stage-matched (for substance use) housing is to think of housing options in terms of whether they are ‘wet,’ ‘dry,’ or ‘damp.’ This is not about whether we will ‘let’ you drink or drug—it means that we reach out to you where you are, provide housing that matches where you are in your approach to using substances, and then help you get where you want to go by being successful in that housing,” he said.
“Dry” housing refers to housing—usually group housing—where abstinence from alcohol and drugs is an expectation. “When we invite someone to live in dry housing, we [should not] demand that people follow an inflexible rule in order to keep their housing, because [it may be] the only housing option they are offered,” Dr. Minkoff explained. Ideally, people living in dry housing will have “a genuine desire to live in a setting where everyone will be abstinent … People with substance use issues who choose this housing are usually in a ‘late action’ or ‘maintenance’ stage of change regarding their substance use. They are committed to sobriety.”
Minkoff said that, in dry housing, there should never be a “one-strike, you’re out” policy. “If and when people slip, it is taken seriously, and people in the house wrap around the person with helpfulness. They ask, ‘How can we help you achieve your goal of sobriety?’ But if people revert to using and no longer want to be sober, then we help them find a living situation that fits them better at this point in their life,” he said. “Knowing how to work with people properly is so important,” he said. “You have to be non-punitive and respectful; you need to have the right attitude. There is a big need throughout the entire system to shift to this way of thinking and working with people.”
“Wet” housing refers to housing in which people may drink or use substances in the privacy of their home, unless this leads to behavior that will cause them to lose their housing. Most of us live in “wet housing,” Dr. Minkoff observed. The scattered site housing first approach used by Pathways to Housing (https://pathwaystohousing.org/) and the supportive housing developed in Seattle by DESC (http://www.desc.org/) are two examples. Wet housing is often an apartment in which a person lives independently, with wraparound support focused on maintaining housing.
“You must be very purposeful about developing wet housing,” Minkoff cautioned. “You need to build relationships with people based on where they are currently and help them move from a ‘pre-contemplative’ stage of change regarding their substance use to a ‘contemplative’ stage, in which they are open to discussing their substance use with housing support staff, even though they may not want to change. We need to understand that it is the person’s life and they get to make their own choices. We can help them learn skills that will enable them to keep their housing if they agree to let us help them. So, for example, people don’t need to be sober or take psychiatric medications to stay in wet housing, but what they can’t do is urinate in the hallway. So we talk to them about that, or about the fact that they can’t invite dealers into the building and keep their housing, not whether they drink or drug.” If wet housing is done right, Minkoff noted, people’s drug and alcohol use usually goes down and their mental health improves, because they are in safe housing and have supportive relationships with staff.
“Damp” housing is a variation of the Housing First concept, according to Minkoff, in which people are choosing to live in a group setting because they want social support, but they are not yet interested in being abstinent. The focus is on helping the person be successful in this housing environment, as well as being a successful member of the community. In damp housing, each person has his or her own space, but there are also common areas, shared activities, and a sense of community. It does not come with expectations of sobriety, like dry housing, but offers additional layers of support and expectations, compared to wet housing. Minkoff explained, “The most important message in damp housing is: ‘Although we recommend that you don’t use, it is your decision. However, if you are going to use, the most important requirement is that you are able to talk to us about it and share your experiences with the community, so we can all pull together to help you figure out the right amount of use that will allow you to be successful in this program.’”
“The approach is to let people know we are there for them if they want to come in off the street, and that we realize this can be hard. We welcome people into our community and let them know our job is to help them be successful here. It is their choice whether or not they accept mental health or substance use services. While there aren’t expectations of sobriety, it is expected that any substance use is done in a way that doesn’t hurt the community. And the program must be designed without hidden expectations of sobriety, despite rules to the contrary. That just sets people up to fail,” Minkoff said. “It is important that the expectations in damp housing are transparent to everyone.”
To be responsive to people who are experiencing homelessness and who have substance use conditions, we need to build programs and housing resources that are respectful of people’s choices and reflect their self-identified preferences at the stage they are in in their lives, Minkoff believes. “Unless we understand that different people want different things from their housing, including how they choose to approach using substances, and unless we realize that we are talking about a continuum of housing to match those choices, we will fail people in the housing we provide, as well as waste resources trying to force people into mismatched housing programs,” he said.
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