Strategies for Engaging Substance-Using Veterans in Housing Recovery Programs

1. Working with Active Users: approaches GPDWebinar

2. AGENDA • Intro to the session • Overview • Techniques • Assessment • Intervention • Negotiation • Case Study • Discussion

3. GOALS • Explore strategies that extend to previously hard to engage substance using Veterans • Reduce risk and optimize outcomes for Veterans who use and/or abuse substances • Assist Veterans access housing • Connect motivational interviewing/harm reduction techniques to recovery process • Discuss practices to support recovery within the context of transitional housing

4. Substance Abuse Diagnosis • Recurrent use resulting in failure to fulfill major role obligation at work, home or school • Recurrent use in physically hazardous situations • Recurrent substance related legal problems • Continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by substance

5. WHYPEOPLE USE • Self medicate symptoms • To socialize • Works for them • Biological vulnerability • Learned behavior • To get a break from problems • Isolation • Feels good • Decreases inhibitions • Estimate 10% of the population has SA problem but 1% is homeless

6. Housing Risks Associated with Use • Rent Arrears • Unable to Maintain Unit • Noise Violations • Guests and Occupancy Violations • Problems with bills –lights, food • Arguments with neighbors • Illegal drugs in unit • Borrowing money

7. Goals for GPD Programs • The purpose is to promote the development and provision of supportive housing and/or supportive services with the goal of helping homeless Veterans achieve residential stability, increase their skill levels and/or income, and obtain greater self-determination. • The performance metric is at 65% for Veterans discharged from GPD to permanent housing

8. Regs regarding Substances • Grant and Pre Diem • 38 CFR Part 61.80 section 14 • Residents must be provided a clean and sober environment that is free from illicit drug use or from alcohol use that: could threaten the health and/or safety of the residents or staff; hinders the peaceful enjoyment of the premises; or jeopardizes completion of the grantee’s project goals and objectives

9. Why Veterans access GPD • Discussions with GPD Liaisons: • What are the identified gaps in service in helping homeless Veterans move towards housing? • How do the VA Homeless Programs see GPD as a resource? • Is GPD being used to provide a safe environment until VASH or other Subsidized/ unsubsidized Housing is available? • Is the GPD program seen as resource to address substance use issues? • Why would a Veteran be referred to GPD as opposed to VASH or other housing programs? • What resources does your program need to assist Veterans with the transition to housing?

10. Case Examples • Peter Smith has been referred to GPD. Peter has been homeless for over a year. He has been denied benefits multiple times and has expressed a desire to work. He has been unemployed for over 5 years. He had been employed as a roofer but drinking and falling got in the way. He says he wants to be sober but he has had multiple relapses since he has been in the program. • Is Peter appropriate for your GPD program? • What are Peter’s barriers to accessing and maintaining housing? • How will these barriers be addressed

11. Peter • Can Peter be accommodated in the program with multiple relapses? • Income is a barrier to housing Peter has not been housed for a year but what worked for him in the past? Could Peter be considered for a subsidized program such as S+C or VASH 3. Are there resources to assist with benefits and employment, tenancy skills, treatment and support around SA?

12. Techniques • Assessment • Stages of Change • Intervention • Motivational Interviewing • Negotiation • Harm Reduction Strategies

13. STAGES OF CHANGE • Pre Contemplation • Contemplation • Preparation • Action • Maintenance • Relapse

14. VALUE OF STAGES OF CHANGE • Stages of Change was based on research with self-changers • Intervention can begin before the action phase • Normal for people to try to change several times • Relapse is often part of the process • Interventions can be designed to match Veteran’s stage • Resistance is often the result of not understanding where a person is at • Instead of sobriety, the focus in on raising awareness and increasing motivation to change  • SoC handout

15. Motivation for Change • Look at Veteran’s goals and behaviors to discuss importance of components • Ask for examples and elaboration • Link tenancy barriers to identified behaviors • Look at competencies based on history and other successful changes • Look at barriers to the goals • Assess barriers using stages of change • Establish how negotiable some barriers are: guests, upkeep, rent • Looks at importance to person of the behaviors associated with barriers: such as drinking with friends in the house

16. Motivation for Change • Ensure a common understanding • Develop several paths to desired change • Weigh cost / benefits of components of each • Look back for competencies to build confidence • Look forward for hope and inspiration • Lay the foundation for future planning • Accept behavior may not fully change but outcome can be different

17. Working toward Recovery • Changing behavior is a long process • In order to achieve long lasting change the Veteran has to be fully engaged • Reducing/ stopping use can assist Veterans to attain their goals • Discussion of Recovery can be involved in all aspects of care • Once decision is made to access treatment it must be readily available • This requires coordination with all levels of care and support within the VAMC and community

18. Harm Reduction: Negotiating Change Harm Reduction is a perspective and a set of practical strategies to reduce the negative consequences of drug use, incorporating a spectrum of strategies from safer use to abstinence.

19. MOST SUBSTANCE USERS ARE NOT READY TO CHANGE

20. HARM REDUCTION • Offers Services to Active Users • Works on needs and goals identified by Veteran • Could have recovery as a means to the goal • Raises awareness of risk and strategies to reduce harm • Abstinence may be possible, but accepts alternatives that reduce risk associated with use • Prioritizes risks that may cause serious harm • Sees recovery as a non-linear process • Offers user friendly services • Low barriers, informal atmosphere, extended hours, location

21. HARM REDUCTION: examples • Harm Reduction can be applied to many behaviors that have negative consequences • Examples include: • Sleeping medication is someone is responding to voices all night and will not consider anti psychotics • Changing shifts if someone is not able to wake up early for whatever reason • Coming to an AA meeting when a person is using or have just had a slip

22. Enabling? Harm reduction connects use to harm • Goal focused: Reduces resistance • Begins the stages of change • Harm reduction requires person to look at behavior • HR requires an evaluation of priorities • Treatment is always one of the options • Uses the same rules as everyone else • This is the beginning of the conversation

23. Program Design • What are the stated goals of your program? • Does this reflect the goals of the Veterans referred to your program? • Does this reflect the priorities of the VA Homeless Programs? • How does 38 CFR Part 61.80 section 14 affect the program structure? • Are Veterans required to be sober when they come in? • How is relapse and/or use handled? • How does the program facilitate the transition to housing • What resources do you have access to • What are the gaps

24. Program Design • Clearly defined goals: making the program a choice • What is the population the program serves? • Will you serve active users, Veterans with psychiatric symptoms, Veterans with medical problems? • Structure to move towards goals: what are the paths to the goals. • Breaking down housing options with paths and timeframes • Availability of services: service agreements and/or staff competencies clearly stated: • Example: benefits advocacy, access to employment services, access to legal assistance, financial management skills, tenancy skills, medical/psychiatric assistance, substance abuse treatment resources • Looking at outcomes: does this meet GPD and Program outcomes

25. Wrap up and Discussion Follow up: Andrea White awhite@housinginnovations.us