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Dual diagnosis substance abuse in Vancouver mental health boarding homes : a need assessment survey Hayward, Timothy James 1990

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DUAL DIAGNOSIS SUBSTANCE ABUSE IN VANCOUVER MENTAL HEALTH BOARDING HOMES: A NEED ASSESSMENT  SURVEY  by TIMOTHY  JAMES  HAYWARD  B.S.W., The University of British Columbia,  A  THESIS S U B M I T T E D THE  IN' P A R T I A L  1988  FULFILMENT OF  REQUIREMENTS  FOR T H E DEGREE OF  MASTER  WORK  O F SOCIAL  in THE  FACULTY  OF GRADUATE  STUDIES  (School of Social Work)  We  accept this thesis  as  conforming  to the required standard  THE  UNIVERSITY  O F BRITISH  February  © TIMOTHY  JAMES  COLUMBIA  1990  HAYWARD,  1990  In  presenting this  degree at the  thesis  in  University of  partial  fulfilment  of  of  department  this thesis for or  by  his  or  requirements  British Columbia, I agree that the  freely available for reference and study. I further copying  the  representatives.  an advanced  Library shall make it  agree that permission for extensive  scholarly purposes may be her  for  It  is  granted  by the  understood  that  head of copying  my or  publication of this thesis for financial gain shall not be allowed without my written permission.  Department The University of British Columbia Vancouver, Canada  DE-6 (2/88)  ABSTRACT  This study explores the dual diagnosis substance  abuse phenomenon within the  context of Vancouver area mental health boarding homes. The target population consisted of thirty-nine mental health boarding homes used by Greater Vancouver Mental Health Services, Mental Health Residental Services. An attempt was made to  survey  estimate look  directors  (n=37),  staff  (n=unknown),  the prevalence of dual diagnosis  for  associations  characteristics of staff,  between  and  substance  substance  residents  (n = 422),  to:  abuse within these homes;  use/abuse  and  the  demographic  directors, and residents; examine boarding home policies;  and to establish what, if any, services should be developed. Questionnaires were completed by twenty-nine  directors (78%), twenty  staff  members (% unknown),  and ten residents (3%), from twenty-nine boarding homes with a total resident population of 358. Results indicated that one hundred and fifteen residents (32%) consumed alcohol, and 57 residents (16%) had consumed alcohol during a specified two week period.  Only eight residents  (2%) out of a potential 358  (from four different facilities)  reportedly had substance related problems during the specified two week period. However,  substance  referrence  to the  abuse  two  was  week  identified  time  in  eleven  limitation. Further,  facilities staff  (38%),  without  and directors from  fifteen facilities (52%) had at some time tried to get help for a resident with a substance diagnosis homes  abuse  problem. Thus,  substance  reportedly  abuse had  while very few  residents  reportedly had dual  problems, a considerably greater number of boarding  problems  related  ii  to  dual  diagnosis  substance  abuse.  Twenty-four directors (86%) and thirteen staff (68%) were interested in receiving a workshop on dual diagnosis substance abuse. It is the recommendation of this author that a drug education program/workshop for boarding home directors and staff be developed through the Greater Vancouver Mental Health Services "dual diagnosis program."  iii  DEFINITION OF TERMS  (1) In accordance with the World Health Organization's (1986) definition of drug and  alcohol  abuse,  for  the  purposes  of  this  project  substance  use will  be  considered substance abuse when it causes "problems related to health (physical and  mental), behavior, family, work, money, [or] the law" (p.6), and when it is  "hazardous (e.g., any use of alcohol or amphetamines  by a driver of a vehicle  may put him or her at risk of an accident), or dysfunctional (e.g., interfering with responsibilities as parent or worker), or harmful (e.g., producing damage to health)" (p.8).  (2) The term mental the  mental  health  health boarding home has been used to refer to all of  community  residential  living  facilities  used  by  the  Mental  Health Residential Services division of Greater Vancouver Mental Health Services. These  facilities  include  "boarding  homes,"  "group  homes,"  "half-way  houses,"  "three-quarter-way houses," and the like.  (3) The term boarding home director has been used to refer to all persons who  are  homes,  directly  whether  responsible they  be  for  the  "directors,"  management "supervisors,"  and  operation  of boarding  "coordinators,"  "managers,"  "people in charge," "operators," or in some cases, "owners."  iv  T A B L E OF CONTENTS Abstract  ii  Definition of Terms  iv  Acknowledgements  ix  I. General Introduction  1  II. Knowledge Building Functions and Rationale for the Selection of Issues ... 5 III. Outline of the Problem Area A. Historical Overview B. Incidence/Prevalence of the Problem C. Societal Awareness D. Problematics (Current Issues) E. Connection To Social Work F. Treatment Strategies  10 10 15 22 24 27 32  IV. The Research Problem  36  V. Research Method A. Research Design B. Research Sample C. Survey Instruments D. Data Analysis E. Methodological Difficulties in Researching this Topic VI. Research Findings A. Pretest and Subsequent Questionnaire Revisions B. Preliminary Description of the Survey Sample C. Prevalence/Incidence of Substance Use and/or Abuse D. Demographic Characteristics of Residents E. Demographic Characteristics of Directors and Staff F. Boarding Home Policies G. Program Options: What, if Anything, Should be Done?  40 40 41 41 43 44 47 47 53 57 76 90 93 121  VII. Concluding Remarks A. Summary of Findings B. Discussion C. Recommendations D. Limitations of the Study and Suggestions for Further Research ...  142 142 147 159 164  Bibliography  169  Appendix 1. University of British Columbia Ethical Approval Form  179  Appendix 2. Introductory Letter to Directors  180  v  Appendix 3. Introductory letter to Staff  182  Appendix 4. Introductory Letter to Residents  184  Appendix 5. Director Pretest Questionnaire  186  Appendix 6. Staff Pretest Questionnaire  193  Appendix 7. Resident Pretest Questionnaire  199  Appendix 8. Director Revised Questionnaire  206  Appendix 9. Staff Revised Questionnaire  212  Appendix 10. Resident Revised Questionnaire  217  Appendix 11. Alcohol and Drug Programs Letter of Endorsement  222  Appendix 12. Greater Vancouver Mental Health Service Society Letter of Endorsement  223  vi  List of Figures  Figure 1. Prevalence of Substance Use in Mental Health Boarding Homes  59  Figure 2. Substance Use Versus Substance Abuse  66  Figure 3. Prevalence/Incidence of Substance Abuse  73  Figure 4. Resident Gender  77  Figure 5. Distribution of Residents' Average Age by Boarding Homes  79  Figure 6. Medication Use  81  Figure 7. Boarding Home Size  85  Figure 8. Psychiatric Diagnoses  87  Figure 9. Boarding Home Response to Substance Abuse  98  Figure 10. Alcohol Consumption at Special House Functions  103  Figure 11. Are Substance Use and Substance Abuse Synonymous Terms?  106  Figure 12. Can Going Out for a Drink of Alcohol be a Positive Accomplishment?  Ill  Figure 13. Support for Specified Services  124  Figure 14. Support for a Workshop  134  vii  List of Tables Table 1. Riverview Hospital Inpatient Totals: 1963 - 1988  14  Table 2. Director and Staff Responses to Alcohol Consumption by Residents .... 96 Table 3. Support Evidenced for Special Services  122  Table 4. Support Evidenced for In-Home Services  126  viii  ACKNOWLEDGEMENTS  There have been many intellectual, emotional, and financial contributors to this thesis project. To my family and friends ... thank you. Special thanks are extended to my wife Ann, for her unfailing support, my son Kyle, for his enduring love, and my baby Deric, for being such a cute and cuddly little guy.  Also, I would like to thank the Greater Vancouver Mental Health Service Society, and the Alcohol and Drug Programs, for their endorsement of this study, and the boarding home residents, staff, and directors who agreed to participate.  Finally, I would like to thank my thesis committee members, Dr. Kathryn McCannell, and Dr. John Crane, for their patience and insight.  ix  I. GENERAL INTRODUCTION  Many mentally ill people who in the not so distant past would have been confined to large psychiatric institutions have been "freed" from those oppressive walls of cold stone to live in "the community." However, this attempt to "normalize" people with psychiatric problems has not been without its problems. While many people were "deinstitutionalized," the community support services that should have been developed to help make the transition into the community a relatively smooth one were largely neglected. Given the highly competitive nature of  our  "liberal"  democratic  society,  it  is  not  surprising  that  many  deinstitutionalized people began to experience the same problems that have been experienced by other unemployed, stigmatized, and socially oppressed groups. Recently, there has been increasing attention paid to the seemingly high incidence of drug and alcohol abuse by persons with psychiatric problems. In fact, the new label of "dual diagnosis" substance abuse has been coined to specifically refer to people with both psychiatric and substance abuse problems. There is a need for studies focusing on substance abuse and psychiatric problems in Canada, as the vast majority of North American studies in this area have been conducted in the United States, and there is a shortage of information specific to Canada. Exploring the prevalence of dual diagnosis substance abuse within boarding homes will help establish what future directions in Canadian health policy should be.  Political trends indicate that we are likely to see  a period of increased  "neoconservatism," with decentralization of social and health services and a shift towards privatization. Economic restraint is likely to continue. There has been a 1  2 shift  away  from  Keynesian  economics  and  Beveridge's  social  ideas,  which  established and reinforced the government's responsibility and ethical obligation to end unemployment and provide a wide range of health and social expenditures, to  the  contemporary  preoccupation  with  inflation  that  has  established  and  reinforced the government's responsibility and fiscal obligation to reduce its health and  social  renewed  expenditures.  its  commitment  The to  recently  reelected  reducing the  Conservative  national  deficit  by  government  has  further reducing  government expenditures. Social goals and economic goals are no longer seen as mutually reinforcing but, rather, as almost mutually exclusive. In response to this increasing  concern about  inflation and decreasing  concern about unemployment,  Lightman (1986, p.25) says that:  All  social  and  economic  fundamental value choices. necessity  -  that  we  policy  in  any  society  is  built  upon  The frequently-cited argument of economic  have  no  choice  but  to  cut  back  goverment  spending in the social and health areas in order to conquer inflation and to concomitantly reduce the  deficit - is fallacious. It is not a  statement  or  of  any  objective  fact  reality,  but  rather  reflects  a  particular constellation of presumed social priorities.  During political  the  past  climate.  decade  we  have  The Meech Lake  moved towards an increasingly Accord,  with  its  conservative  proposed redistribution of  power from the federal to the provincial government is a clear example of the federal government's  commitment to decentralization. The Free Trade Agreement  that has recently relaxed the north south trade barriers between Canada and the United States clearly delineates government's close alliance with business interests. There is a trend towards privatization and against universality which seems sure  3 to continue. As inflation continues to raise the costs of services supported by tax dollars, we can expect that services for the mentally ill will feel their "funding freeze." Because community based services are expensive, because the demand for services will drive up costs, and because there will be an unwillingness to use scarce resources for "marginal" people, not only are services for dual diagnosis clients  likely to  suffer  from economic  "restraint," but the  continued policy of  deinstitutionalization itself will be met with stiff resistance, and if it continues at all it will be under funded.  Already,  in the  United States many  bureaucrats,  politicians,  and health  care  "professionals" have championed a movement towards "reinstitutionalization." In a disconcerting but revealing statement, Cronklin (1985, p. 5 2) says: I am getting an increasing sense of something ugly spreading through our land. It is a mean-spirited attitude toward poor people, and it is essentially  based  on the  belief  that  they  are  responsible  for their  plight - and that if they were only willing to pull themselves up by their  bootstraps  officials  -  whatever  that  of the U.S. government,  means  -  they  could.  When top  including President Reagan himself,  say these people really prefer to live in the streets and to eat in soup kitchens, it lends an air of legitimacy to those feelings.  As it happens, the area of "substance  abuse" is currently in political favor in  British Columbia, and the Social Credit government has designated several million dollars  to  enhance  services  for  persons  with  psychiatric  and substance  abuse  problems. The Social Credit party is a staunch supporter of privatization and is closely  aligned with the interests of "big business,"  so it is unlikely that  its  4 commitment to providing funding in this dual diagnosis area will continue. Research in this area is extremely timely.  Of further note, it is hoped that the findings of this study will be published, and will increase the awareness of Canadian health professionals concerning the significance of this dual diagnosis problem. This research will also reinforce the importance of revising university social work curricula, and providing in service training to help social workers develop knowledge and skills in the area of dual diagnosis substance abuse.  II. KNOWLEDGE BUILDING FUNCTIONS AND RATIONALE FOR THE SELECTION OF ISSUES  The primary  function of this project concerns exploration and mapping (Crane,  1988), and includes the following processes: 1.  Exploring findings in the literature to identify relevant issues regarding dual diagnosis substance abuse.  2.  Estimating the prevalence of dual diagnosis substance  abuse in Vancouver  area mental health boarding homes. 3.  Exploring a variety of variables, such as demographic characteristics, to test the  strength  of associations  between  these factors and the prevalence of  substance use and/or abuse in mental health boarding homes. . 4.  Exploring the responses  of boarding home directors and staff to substance  use and/or abuse by residents, and boarding home policies as they relate to this issue. 5.  Mapping  out  alternatives  and  policy  directions  based  on  the  research  Findings.  Our general knowledge about dual diagnosis substance abuse will be increased by the information generated in this study. The more we know about dual diagnosis substance abuse the more likely it will be that our response to this phenomenon will be effective,  appropiate, and in the clients' best interests.  Furthermore, we  will be able to ascertain if mental health boarding homes offer a suitable forum for the development of treatment and/or preventative services.  5  6 If mental health boarding home residents do have substance abuse problems, then existing services can be utilized, or new services can be developed to reduce the prevalence of these problems. While there may be a greater prevalence of dual diagnosis substance abuse among "street" people or "homeless" people, it is very difficult to initiate programs with persons who cannot be found or contacted. Services could be quite effective with boarding home residents, as they are a "captive" audience, in the sense that they can be identified, located, and approached with relative ease. Of course, one must be sensitive to the client's rights  (to refuse services), and not take the "captive audience" notion too  literally.  On the other hand, it is just as important to determine that mental health boarding home residents do not have substance abuse problems as it is to determine that they do. If residents of mental health boarding homes do not have substance abuse problems it provides us with some valuable information concerning the effectiveness of contemporary mental health residential services. Are mental health boarding homes meeting the needs and/or demands of dual diagnosis substance abusing persons? And if not, then why not? The area of dual diagnosis substance abuse is in its infancy, and studies such as this are needed to provide new information and stimulate further thought. The generation of new diagnostic labels, and creation of new service "industries" is a serious business, and is not always in the "consumer's" best interests. Only through careful attention to the issues at hand can we truly be sensitive to the needs of people with both psychiatric and substance abuse problems. This study will not only add to our knowledge about dual diagnosis substance abuse, but by so doing  7 will  also  help  "professional  to  protect  abuse"  that  dual  can  diagnosis  result  substance  from  abusers  professionals  against  applying  the  generalized  solutions to individual problems.  The  rationale for this study is largely derived from a recent Vancouver based  study by Kroeker (1988), which surveyed the perceptions and practices of both community mental health and alcohol and drug abuse professionals, concerning dual  diagnosis substance  Health  abuse  treatment services.  that  18.7% of persons  discharge statistics  primary  diagnosis  and  history  of  substance  Kroeker found from Mental discharged in  abuse,  while  1986  16.8%  had a  of  those  discharged in 1987 had a primary diagnosis and/or history of substance abuse. Furthermore,  Mental  Health  emergency  services  estimated  that  90% of cases  coming to their attention involved alcohol or other drug abuse as part of the precipitating event. Kroeker found that Alcohol and Drug Program (ADP) directors estimated  that  while  only  about  15% of  their  assessments  involved  specific  diagnosis of mental disturbances, many more of their clients had some level of mental disturbance that interfered with treatment. ADP counsellors did not think that mentally disturbed people were suitable ADP clients. On the other hand, Mental  Health  program  directors and staff  thought that  about  75% of their  'cases' involved substance abuse. Differences were found between the responses of treatment staff  and directors. Mental Health treatment staff  prevalence rate of dual diagnosis substance  specified  a lower  abuse in assessment and caseloads  (3-10%, with only one estimate of 20%) than did their directors (5-35%, with a median of about 20%). Similarly, program directors of both ADP and GVMHS consistently reported higher levels of exchange of information for their units than  8 did the treatment staff.  Both ADP and Mental Health Program staff indicated  that they did not generally provide education, orientation, therapy or supportive follow-up for clients whose 'secondary' diagnosis was other than their program's primary focus.  While there was a general consensus that existing services were not adequately meeting the needs of dual diagnosis substance abusers, there was a great deal of dissension over the exact kinds of services that should be developed. Eighty-five percent of the  program directors and ADP staff  felt  that a separate  service  should be developed, while most of the Mental Health program staff thought that services  should  be  developed  within existing  programs. However,  all  of  the  respondents in Kroeker's study supported and/or emphasized the need to have staff with expertise in both problem areas, and for relevant training to be offered to the various units, teams, clinics, half-way houses and boarding homes in both systems. While the development of special residential facilities was not a strongly supported treatment option, a number of respondents did support the idea of integrating  substance  facilities, such as  abuse  and mental health elements in existing residential  mental health boarding homes.  Drawing on the findings of Kroeker, I plan to further explore the phenomenon of dual diagnosis homes,  to  substance  establish  if  abuse, there  is  within the both the  context need  of mental health boarding  and/or the  demand for new  treatment services in facilities of this kind in Vancouver. However, as the vast majority of studies  on dual diagnosis substance  abuse have focused either on  groups of deinstitutionalized 'homeless' or hospitalized acute care patients, a study  9 of dual diagnosis substance abuse would be incomplete without an overview of deinstitutionalization and homelessness. Accordingly, the following section provides a brief historical overview of the treatment of persons with psychiatric problems in the United States and Canada. This overview sets the stage for a summary offindingson dual diagnosis substance abuse. As mentioned above, these findings are primarily from studies of "homeless people" or hospitalized acute care psychiatric patients. Particular attention will be paid to the latter of these two types of studies, as it is from similar hospital facilities that the majority of mental health boarding home residents have come.  III. OUTLINE OF THE PROBLEM AREA  A. HISTORICAL OVERVIEW  By  the early  1900's concern for the treatment of children and "neurotics" had  evolved, and the disciplines of social work and psychology became interested in the  mentally  generated  disturbed  by the  (Elpers,  large  1987).  Further  interest  in mental  amount of psychiatric casualties  during the First World War (Guest,  in the  1985). Similarily, the use  health  was  armed forces of forward aid  stations during the Second World War to try and restore psychiatric casualties to combat  readiness  encouraged  a new  "treatment"  oriented  approach by mental  health professionals.  Pressure to deinstitutionalize psychiatric patients came from a myriad of different sources.  The  commitment,  civil  liberties  advocated  for  movement less  fought  restrictive  for  an  treatment  end  to  settings,  involuntary and  initiated  lawsuits which defined the right to refuse treatment. This increased emphasis on "patients'  rights" created  professionals,  a backlash of resistance  among many mental  health  which is nicely characterized in the following statement by Shwed  (1980, pp. 196-197):  In  an  age  of consumerism,  trusted  professional  groups  have  come  under suspicion. This increasing distrust has contributed to the climate for  legislation  replete and  placing the  actions  of professionals  under surveillance,  with rigid auditing procedures, and requirements to document  justify  standards  of practice.  So  deep is  the  mistrust  among  certain segments of society that traditional mechanisms for monitoring 10  11 standards of practice have been viewed with suspicion.  Given the medical profession's history of autonomy and power, and the hobbling effect that close scrutiny can have,  it is  not surprising that some physicians  have reacted strongly to the suggestion that they be held accountable by persons outside  of the  professions" health,  medical fraternity. -However, neither  have  where  been eyed  professionals  with  once  is  suspicion, especially  it  surprising that  in the  supported the maintenance  "the  area of mental  of institutions  have been compared to Nazi concentration camps, and where  that  "treatments," in  any other context would have been condemned as unconscionable tortures. Deutsch (1949, p.449) surveyed over two dozen state hospitals in the United States and found:  scenes that hundreds  rivalled the  of  filth-infested  naked wards,  horrors of the  mental in  all  patients degrees  Nazi  concentration camps -  herded of  into  huge,  deterioration,  barnlike,  untended  and  untreated, stripped of every vestige of human decency, many in states of semi-starvation.  In fact,  recent lawsuits  permanent  memory  loss  by ex-psychiatric patients and  psychological  damage  subjugation in human brainwashing experiments Institute in the  who claim to have  at  due  to  their involuntary  Montreal's Allan  1950's and 1960's, (Burstow & Weitz, 1988)  suffered  Memorial  (where they were  subjected to massive doses of mind altering drugs such as d-lysergic diethylamide (LSD), electroshock several times a day for weeks on end, sensory isolation, and forced listening to repetitions of demeaning and degrading messages) indicates this parallel may be even closer than we allow ourselves to believe.  12 Another  example  psychiatric  of  hospitals  the is  horrible  provided  living by  conditions  Griffin  that  (1989,  existed  p.26),  who  in  Canadian  provides  the  following account of a survey conducted in 1918:  We  discovered  many  things  that  shocked  us.  In  the  asylum  in  Saint-John, New Brunswick, for example we found on the top floor a group of patients who were put to bed in coffin like boxes, with hay in the bottom and slats on the top and who were locked in these boxes at night. Two of these boxes were left unlocked for  patients  who were trusties, and who were given the job of dealing with noisy patients. by  They accomplished their task  urinating  throught  the  slat  through a revolting procedure  openings  on  the  faces  of  noisy  patients....  While an insistence on accountability can impede service delivery, certainly, given the  characteristic  patients,  by  helplessness of psychiatric patients,  protecting  their  rights,  but  benefits  it  the  not  only benefits  profession  through  the the  demonstrable legitimization of treatment practices.  Deinstitutionalization  is  generally  thought  to consist of three  equally important  components: preventing institutional admissions, returning patients to the commun  and establishing and maintaining responsive residential environments. Unfortunatel only the  second of these three  goals has been met. Populations in State and  county mental hospitals in the U..S. dropped from approximately 560,000 patients in 1955  (about one-half of all patient care episodes), to 160,000 in 1977 (less  than ten percent of all patient care episodes), to 125,200 in 1982 (more than a three/fourths reduction from 1955 (Goldman, Adams, & Taube, 1983). In Canada, days of care in psychiatric hospitals dropped from 10,829,594 in 1979-1980, to  13 6,607,898 in 1982-1983 (Statistics Canada,  1987).  While there was an increase  from one to two public mental hospitals in British Columbia between 1971 and 1977 (the addition occurred in 1975), there was a decrease from 47 to 42 public mental hospitals in Canada, and there were decreases in the number of patients on the books on December 31 of those  respective years in British Columbia  (2,989 to 1,953) and Canada (34,244 to 20,281) (Statistics Canada, 1971, 1973, 1974, 1975, 1976,  Table  1  shows  the  1972,  1977).  extent  of  the  deinstitutionalization movement  Columbia by reviewing the reduction in inpatient totals  in  British  at Riverview Hospital  between the years 1963 and 1988. There was a reduction from 3,793 patients in  1963,  1989).  to 638  patients  in  1988  Inpatient totals were calculated as of December 31 of each year, and  exclude the geriatric patients. 1963  (Brooks, personal communication, November  and 1964  The largest reductions were between  (503 persons),  1964 and 1965  (507 persons),  the years  1973  and 1974  (393 persons), 1971 and 1972 (258 persons), 1974 and 1975 (241 persons), and 1982  and 1983  totals  between  (213 the  persons). While there were  years  1978  and  1979  (38  slight increases  persons),  1985  in inpatient  and  1986  (20  persons), and 1983 and 1984 (19 persons), there has nonetheless been a steady decrease  over  the  years  for  which data  are  available.  However, this large  reduction in the number of institutionalized patients seems to have occurred in the  absence,  rather  than  the  proliferation,  of  alternative  living  settings  and  community services (Shwed, 1980; Scull, 1981).  Quine (1981) has identified the same pattern, of moving formerly institutionalized  14 Table 1. RIVERVIEW HOSPITAL INPATIENT TOTALS: 1963 •• 1988 Number of Patients in Residence December 31 Each Year Year 1963 1964 1965 1966 1967 1968 1969 1970 1971  Patients 3793 3290 2783 2746 2677 2614 2482 2470 2322  Year 1972 1973 1974 1975 1976 1977 1978 1979 1980  Patients 2064 1906 1513 1272 1220 1146 1099 1137 1113  Year 1981 1982 1983 1984 1985 1986 1987 1988  Patients 1099 1000 787 806 787 807 679 637  Source: Clinical Records Department, Riverview Hospital (Brooks, personal communication, November 1989). Inpatient totals do not include geriatric patients.  15 people into the  community without providing the necessary  support systems in  England. While most studies that have looked at homelessness and the mentally disturbed have been conducted in the United States, Davis (1986)  substantiated  that the "phenomenon of the new young chronic," and the "lack of fit" between these people and the health care delivery system is also a very real problem in Vancouver.  Ironically, just  as  availability of help decrease. psychiatric mentally  services have ill  young  the  Many other  largely  adult"  need  for  help  increases  authors have  failed to meet the  (Bachrach,  1982a;  so  too  does  concluded that  the  existing  needs of the "chronically  Bachrach,  1982b;  Glass,  1982;  Goldfinger, Hopkin, & Surber, 1982; Talbott, 1986; Test, 1985), and that many members  of  this  "chronically  ill" population  (Ridgely, Goldman, & Talbott, 1986; inadequacy of existing  Sheets,  have 1982;  community services raises  substance Safer,  abuse  problems  1987). The apparent  some interesting  questions,  as  length of stay in the community is often used as an outcome measure, but the length of time spent in the community is not necessarily an indicator of whether the person's life is improving or deteriorating.  B. INCIDENCE/PREVALENCE OF T H E P R O B L E M  Numerous studies have been conducted to identify the characteristics of the many homeless people who have flooded North American cities.  One such study  conducted by the New York Men's Shelter in 1976, which found that of  was 1,235  men provided with accommodations in a given night, thirty percent had a record of previous psychiatric hospitalization (Reich & Siegel, 1978). Based on interviews with these men, the  shelter  concluded that  nearly fifty  percent of them had  16 overt mental illness,  and many had secondary alcohol problems. However,  reliability of these conclusions  the  may not be very high, as the information was  based on self reports, (it is probable that some people would be reluctant to volunteer information of this kind), and the people who stay at the New York Men's Shelter are likely not representative of all homeless people.  Lamb and Grant (1982 & 1983) conducted a study of 102 men and 101 women in county jails in the U.S. who had been referred for psychiatric evaluation, and found that 39% had been living on the streets, on the beach, in missions, or in cheap, transient  "skid row" hotels at the  time of their arrest.  Many  of the  subjects had extensive experience with the criminal justice system and the mental health system,  and refused to stay  at mental health boarding homes  because  they wanted their autonomy (this was especially true for the younger people).  In  another  study,  Merricucci,  Wermuth,  and Sorensen  (1988)  interviewed  the  directors of eight psychiatric and substance abuse facilities in San Francisco: one inpatient  alcohol abuse  unit, one  outpatient  psychiatric unit, one psychiatric emergency  alcohol abuse unit,  unit, one  outpatient  and four inpatient psychiatric  units. All of the respondents indicated that they were more frustrated with the problems behavioral  they and  faced  making  substance  referrals  abuse  problems.  psychiatric board-and-care and halfway substance  abuse  problem" (p.620).  than  they  The  authors  houses refuse  And in  a  were  to  with conclude  take  their that  patients  Vancouver study,  clients' "most with a  Davis  (1987)  surveyed the demographics and client movement in supervised boarding homes by examining 232 referrals made for boarding home placement, from January  1983  17 to December 1985. Seventy-three percent of the sample were male, fifty percent were under age thirty-five, fifty-four percent were schizophrenic (the largest single category), twenty percent had organic brain disorders (especially prevalent among older clients  with  histories  of substance  abuse),  evicted from their last place of residence  and thirty percent  (twenty-four  had been  percent from psychiatric  boarding homes, and six percent from private accomodations). "Often the reason for eviction had to do with substance  abuse or violent behavior" (p. 11). Of the  232 referrals, forty-one percent refused boarding home placement, and twenty-two percent  "were  turned down by the  placement  worker as  inappropriate for a  boarding home. This could have been for a variety of reasons; the client could have [had] an established history of drug abuse or antisocial behavior" (p. 12).  The studies cited above indicate that many people with substance abuse problems are not admitted to community residential facilities, but say nothing about those who are admitted. One would expect that many of the boarding homes would have  at  least  some  residents  studies of dual diagnosis  with  substance  substance  abuse  problems.  The  following  abuse by patients in psychiatric acute care  hospitals, indicate that the prevalence of dual diagnosis substance abuse is quite high in these settings. Of course, these findings cannot be directly extrapolated to mental health boarding homes, but one would expect there to be, at the very least, a considerable number of referrals to boarding homes involving substance abusing ex-mental patients.  Many authors have reported that substance people  with  psychiatric  problems,  and  abuse is a serious problem among  especially  among  those  with  chronic  18 problems (Ridgely, Goldman, & Talbott, 1986; Reimhan, hospitalized  Safer,  1987;  Sheets, Prevost, &  1982). Bean-Bayog (1987) found that ten to fifteen with  schizophrenic  symptoms  had  serious  drinking problems,  Fischer (in Ridgely, Goldman, & Talbott, 1986)  estimated  patients in a U.S. psychiatric hospital  drugs; almost  abused  percent of people  that fifteen  and  percent of  one-third of  335  patients who were admitted to the hospital over a three month period said that they had abused drugs at some time; and about one-half of these 335 patients who were under age 30 had abused drugs at some time. The U.S. Department of Health, Education and Welfare found that twenty-two percent of admissions to state mental hospitals in 1964 were diagnosed as alcoholics (Googins, 1984), and Crowley,  Chesluk,  Dilts,  and  Hart  (1974)  determined  that  drug  problems  contributed to one-third of fifty consecutive admittances to a psychiatric hospital.  In  their  study  surveyed 305  of  addictive  of 309  behaviors,  O'Farrell,  Connors, and  Upper (1983)  patients hospitalized on ten psychiatric wards at a large  Veterans Administration (VA) Medical Center. Four of the patients were dropped from  the  study  due  to  missing  demographic  data.  Of  the  305  subjects,  thirty-three percent were found to abuse alcohol, and five percent (numbers are rounded) were found to abuse other drugs. Fowler, Liskow, Vasantkumar, Tanna, and  Valkenburg  (1977)  studied  120  of  124  admissions  to  the  Veterans  Administration Hospital in Iowa City. The sample did not include any females, persons of age sixty-five  or older, or persons who remained in the hospital for  less than four days. Four people were dropped from the study because they left the hospital before the fourth day. The researchers the  alcoholics  in the  study  found that forty percent of  had a psychiatric dignosis  that  was  unrelated to  19 substance abuse.  Trier  and Levy (1969) studied  175  psychiatric  admissions  to  the  San Mateo  County General Hospital from December fourth to December twenty-second,  1967.  Five people had been admitted twice and three had been admitted three  times,  so  doctor  the  sample  actually  consisted  of  164  people.  The  examining  administered a questionnaire, and rated the admissions as: Emergent, or requiring immediate  attention;  Elective, or included  the  able  to  Urgent, or  able  wait  more  than  of  arrival,  manner  time  to  wait  up  twenty-four of  arrival,  to  twenty-four  hours.  hours;  Information  evaluation,  and  and  obtained discharge,  diagnostic findings, services provided, disposition, and demographic information. Of the 175 admissions, fifty percent of the Emergent cases involved drug or alcohol addiction,  forty-seven  percent  of  the  Urgent  cases  involved  alcohol  or drug  addiction, and forty-eight percent of the Elective cases involved alcohol or drug addiction.  Also of interest is a study by Solomon and Davis (1986), involving 550 who were discharged from two state psychiatric receiving hospitals County, Ohio, between July 1980  and March 1981.  people  in Cuyahogo  While only five percent of  the sample were given a primary diagnosis of an alcohol disorder at admission, social workers assessed that thirty-five percent had a need for alcohol counselling at  discharge.  Solomon  and  Davis  (p. 66)  conclude  that  "the  social  worker's  assessment [which indicates that there was a high incidence of alcohol abuse] is probably a more accurate estimate of the extent of this problem for they have a sense of the patient's social history." Furthermore, the  authors claim that  the  20 new  generation  of "chronically mentally ill" are largely eighteen  years old, and "share with others of their age alcohol  abuse."  This  view  of  the  mentally  to thirty-five  a high incidence of drug and  disturbed  substance  abuser  as  a  normative member of a dysfunctional (age) group is a significant departure from the biomedical view,  which emphasizes  innate and incurable disease states; the  former view proffers a considerably more optimistic prognosis.  In another  interesting  consecutive  patients  Emergency  Admitting,  study,  questionnaires  were  administered to  503  of  511  admitted to the Orange County Medical Center, Psychiatric  psychiatric emergencies  during  October,  1971  (Atkinson,  1973).  Of  the  503  studied, drug abuse was implicated in 107 cases (21%),  alcohol abuse was implicated in 103 cases (20%), both drug and alcohol abuse were  implicated in 60  abuse  was  judged  cases (12%), and some degree  relevant  to  Gershan (1968)  the  psychiatric  also  found  a  of alcohol and/or drug  problem in high  270  degree  of  cases (53%).  Hekimian  and  dual  diagnosis  substance  abuse, in their study of adult drug abusers in a psychiatric inpatient  service: fifty percent had schizophrenia.  Many other studies have also found relationships between substance specific  diagnostic  commented that  categories.  For  instance,  Meyer  "antisocial personality disorder" is  often linked to substance  the  and  abuse and  Hesselbrock  diagnoses  that is  (1984) most  abuse. Mirin, Weiss, Sollogub, and Michael (1984a, &  1984b) claim that there is a strong relationship between "affective disorders" and substance  abuse. And, following their review of the (medical) literature, Ridgely,  Goldman,  and Talbott (1986) concluded that  substance  abuse  was  most  often  21 associated with "schizophrenia," "personality disorders," and "affective disorders."  In a one year study, Bergman and Harris (1985) found that fifty-two percent of sixty-five  chronically disturbed people had histories of drug and/or alcohol abuse  associated sixty  with  hospitalization.  percent of admissions  substance  abuse  and  McKelvy,  Kane  and Kellison (1987) found that  to a psychiatric hospital had a dual diagnosis of  mental  illness,  including both  those  who  met  DSM-III  criteria for a dual diagnosis and those who did not, but whose substance abuse adversely affected their psychiatric problems nonetheless.  The vast  diversity of research findings, indicating that  anywhere  from ten to  sixty percent of psychiatric inpatients have substance abuse problems, is due to a number of factors, such as geographical differences, availability definitions  of of  Nonetheless,  housing, "abuse"  it  is  clear  problems have substance strengthened  by evidence  total and that  community "mental  resources,  illness,"  significant  employment opportunities,  and  numbers  variations sample of  in  operational  selection  people  with  criteria.  psychiatric  abuse problems as well, which is a conclusion further that  actual incidents  are  substantially  underdiagnosed  (Safer, 1986). Given that considerable numbers of psychiatric acute care hospital patients  have  dual  diagnosis  substance  abuse  problems,  and  most  Greater  Vancouver Mental Health Services boarding home referrals involve persons who have just been discharged from either Riverview Hospital or one of the regions acute care facilities, one would expect a considerable number of these referrals to have dual diagnosis substance abuse problems as well.  22 C. SOCIETAL AWARENESS  There  is  a  growing  awareness  in  Canada  that  the  popular  trend  towards  deinstitutionalization is not without its problems. Canadians frequently refer to the lack of community based services for the mentally ill, and while it is true that many  Canadians  do  not  want  these  services  developed  neighborhoods, there seems to be a general agreement  in  their  own  that something must be  done. Most of the attention has been focused on the "homeless," who were once thought  to  be  almost  exclusively  deinstitutionalized  psychiatric  patients  with  nowhere to go, and no one to help them. Canadians' concern over the plight of the mentally ill homeless may be fueled as much by their embarrassment as it is by their altruism, and public concern has recently focused more and more on the increasing numbers of "normal" Canadians who have joined the ranks of the homeless.  Our  hearts  go  out  to  the  single  mother,  struggling  against  overwhelming odds with her three young, ever so cute and wide eyed children, but we are less likely to rush to the aid of an unkempt, shiftless young adult "ex-mental patient."  Canadian society has traditionally given mixed messages about drug use, and as Klerman (1970) points out, it was not until the white middle class society began to be  affected  by drug abuse  that  public concern became  mobilized. Klerman  (p. 313) calls the contemporary practice of condoning and sanctioning drug use for therapeutic  use  only,  (and  even  then  only  under  professional  supervision),  a  "Pharmacological 'Calvinism' that says if a drug makes you feel good it must be bad." He further claims that the response  of the public derives as much from  23  fear of social change as for real concerns for the health and safety of drug users, whose drug use challenges the dominant value system. Klerman's analysis, which came "hot on the heels" of the social and political rebellion of North American youth during the 1960's, is in many respects a product of its time, but even today, with our emphasis on "participaction," health, exercise, and anti-drug campaigns, there is a constant push and pull between health concerns and the economic contributions of large tobacco and alcohol manufacturers and distributors. Ironically, even the emphasis on good health has been fueled by concerns over the rising costs of health care. Nonetheless,  it is clear that  Canadian society has a decidedly negative view of drug use outside of certain limited contexts, and there is little doubt that the ingestion of large amounts or prolonged use of many drugs (whether they are "therapeutic" or not) causes physical and social problems. Whether or not we accept the view that for people with psychiatric problems, "drug use is synonymous with abuse," it is clear that the abuse of drugs is a problem, regardless of who the abuser is. Thus, the apparently significant amount of substance abuse among certain populations of people with psychiatric problems, is a problem that demands our attention if deinstitutionalization is to realize its full potential.  Dual diagnosis substance abuse is considered by many mental health professionals and non-professionals to be a significant problem that confounds the effects of clinical intervention and primary care. Furthermore, the areas of substance abuse prevention and treatment are currently politically popular in British Columbia, and while this interest may be fairly short-lived, at least for the present, money is being designated for the development of programs in this area. Thus, there is a  24 beginning awareness of the dual diagnosis  substance  abuse  problem within the  mental health and political spheres, but it is not an area that has yet obtained a high degree of societal awareness. regarding  substance  abuse  "in  Interestingly,  general,"  the obverse seems to be true  with  professionals  and  politicians  struggling to keep pace with ordinary Canadians who are speaking out against the potential dangers of drug use and abuse. Furthermore, it may be questioned if  mental  health  professionals  problem," or are creating  are  becoming  of  aware  the problem by differentiating  with and drug abusers without  the  "dual  diagnosis  between drug  abusers  psychiatric problems.  D. PROBLEMATICS (CURRENT ISSUES)  A current issue that confronts mental health professionals of  identifiying substance  previously  mentioned,  abusers  substance  among persons abuse  is  concerns the difficulty  with psychiatric problems. As  often  underdiagnosed.  It  is  hardly  surprising that misdiagnosis often occurs, as the symptoms of mental disturbances are  often  intoxication  very  difficult  or  withdrawal  instance,  can  reaction,  and  induce  a  to  distinguish (Salzman,  prolonged  phencyclidine  1981).  (PCP)  induced  people  were  admitted  to  symptoms  D-lysergic  "schizophrenic"  schizophrenia" so much that, especially many  from those  or  states  caused  diethylamide  by drug  (LSD),  for  briefer "schizophreniform" resemble  "acute  paranoid  during the early years of PCP overuse,  hospitals  with  misdiagnoses  of  acute paranoid  schizophrenia (Cohen 1985). Similarily, people experiencing an acute amphetamine psychosis  are often  misdiagnosed  as  "paranoid," "schizophrenic," or "emotionally  labile hypomanics with paranoid ideation" (Ellinwood, 1976; Tinklenberg, 1976). It  25 is also easy to confuse psychiatric problems with the symptoms  associated with  chronic opiate intoxication (Meyer & Hesselbrock, 1984) and withdrawal (Dackis & Gold,  1984),  cocaine  use  (Cohen,  1985),  repeated  use  of tetrahydrocannabinal  (cannibis) (Cohen, 1985), and alcohol abuse and withdrawal (Cohen, 1985; Mirin, Weiss, Sollogub, & Michael, 1984).  In fact, most psychoactive drugs are similar in both structure and action to the human  brain's  neurotransmitters  (Bridgeman,  1988).  Mescaline  is  similar  in  structure to norepinephrine, and both effect noradrenergic synapses. Psilocibin and LSD  are  heroin  are  molecular  expansions  biochemically  of  similar to  the  serotonin  molecule,  the  brain's  enkephalins.  and  morphine and  "Some  aspects of  mental illness can be looked on not as disturbances of the rational machine but as  drug-induced altered  states of consciousness" (Bridgeman, p.436).  It  is  not  surprising that it is often difficult to detect cases of substance abuse, and mental health boarding home directors and staff are not immune to this problem. Are boarding home directors and staff able to identify substance abuse by residents when/if it occurs? Have they received any training to assist them at this task? While the  detection  of drug abuse can be difficult in almost any situation, it  becomes even more so when the abuser also has identified psychiatric problems, as there is the possibility that unusual behaviors associated with substance abuse will be attributed to the individual's psychiatric problems.  In addition to the diagnostic mental  disturbances  and  problems caused by the similarities between many  drug  induced  states,  problems  occur  due  to  the  co-ingestion of prescribed and unprescribed drugs. The widespread use of alcoholic  26 beverages  in our society,  and our increasing reliance on chemotherapies  treatment of mental disturbances, makes  the  co-ingestion  in the  of psychoactive drugs  and alcohol especially likely. Furthermore, alcohol use is not only exacerbated by some psychiatric conditions, but can lead to conditions that result in psychoactive drug  prescription  Goodwin (p. 123),  (Preskorn  &  Goodwin,  1987).  According  to  Preskorn and  "interactions between alcohol and psychoactive  drugs can fall  into three basic categories: 1.  additive - separate effects of the drugs summate when taken together.  2.  synergistic (potentiation)  - observed effects are greater than the  expected  sum of each drug's individual effects. 3.  And, antagonistic - effects of one drug neutralize the effects of the other."  Persons with psychiatric problems are part of a highly medicated group. Thus, the interactive effects of coingested prescription and nonprescription drugs and the possible exacerbation of psychiatric symptomology has led to speculation that even small  amounts  of substance  use  may be  abusive,  for people  with psychiatric  problems. Kroeker (personal communication, March, 1989) suggested that many of the  Vancouver area  consume  mental  health  boarding homes  may  permit residents  to  alcohol at Christmas parties and other special functions. If alcohol is  allowed at special functions, and if, due to the interactive effects described above and  the  similarities  symptomologies,  we  synonymous terms,  between conclude  various that  drug  substance  rests  on  use  states  and  and  substance  psychiatric abuse  are  then it would logically follow that boarding home operators  are condoning if not encouraging substance course,  induced  the  premise  that  abuse  substance  use  by residents. and  This logic, of  substance  abuse are  27 synonymous terms.  The  next section summarizes several studies that suggest the biomedical disease  model is the theoretical model most often used in the mental health field today. These  summaries  are  followed  by  a  discussion  of  the  illegitimacy  of  the  biomedical disease model, as it relates to dual diagnosis substance abuse, and the link between this study and the area of social work is made clear.  E. CONNECTION TO SOCIAL WORK  Kovess and Lafleche (1988) administered a survey questionnaire to thirty seven mental  health  Hospital,  professionals  in  two  outpatient  clinics  and had an admirable 82% response  rate.  of Six  Montreal's out  Douglas  of seven social  workers responded, eight out of eight psychologists responded, seven out of eleven nurses responded, five out of seven psychiatrists responded, and four out of four "others" responded. Based on their findings, the authors concluded that the model these  professionals  centered  around  used  corresponded  individual  therapy.  to  the  The  medical  respondents  model, spent  with very  treatment little  time  addressing their clients' social, political, or economic concerns, but rather, seemed to identify the "problem" as existing primarily within the individual.  In  another study, Pekarik and Finney-Owen (1987) used The National Directory  of  Mental Health to identify  144  mental health outpatient  service  agencies in  Kansas, Nebraska, and Missouri, and then randomly selected 36 agencies in cities with  populations  of 50,000 or greater,  and  14  in areas  with populations of  28 49,999 or less. This distribution was  selected to correspond with the national  ratio of urban-to-rural agencies (approximately 75% of mental health outpatient community  services  are  in  urban  areas).  Thirty  seven  of the  fifty  agencies  selected responded (an 86% response rate), returning a total of 173 questionnaires (56%  of the  total number mailed out).  Based on their findings,  the authors  concluded that therapists overestimated the length of treatment received by three times,  based  established  by  Therapists  also  on  U.S.  the  Community  National  Mental  Institute  of  preferred longer treatment  Health Mental  Center Health  (CMHC) (NIMH)  averages in  1982.  periods than their clients did, with  77% preferring eleven or more visits, and nearly one third preferring twenty one or more visits, compared to surveys of public clinic clients which indicate that about three-fourths of clients expect treatment to last less than ten visits, and NIMH's 1981 figures indicating that the CMHC average is five visits. Similarily, the authors concluded that therapists underestimated dropout rates, perceived the therapy process  as more positive  than it actually was,  and did not attribute  client dropout to the same factors that clients attributed it to (therapists were more likely to emphasize client "resistance" and less likely to emphasize clients' dislike of the therapist or therapy).  Of course, there are limitations to the generalizations one can make about an area population on the basis of national surveys. All that can be determined is the  extent to which the local population compares to national averages.  It is  possible that the therapists in Pekaric and Finney-Owen's study actually did have longer treatment  sessions, and lower dropout rates  than the national average.  Similarly, the local clients might actually have preferred longer treatment periods  29 than  the  national  professionals,  average.  Nontheless,  this  study  does  indicate  that  these  too, relied on the medical model. The biomedical model is firmly  entrenched in the North American mental health treatment system,  despite  the  apparent popularity (at a theoretical level at least) of "interactional" intervention models. Given the current climate of political conservatism, the biomedical model is  likely  to  continue  dominating the  mental  health  field,  and influencing the  future direction of mental health community programs. Despite the prevalence of the biomedical disease model in the fields of mental health and substance abuse, the literature suggests that, for mentally disturbed populations, substance  abuse  results more from 'problems of living' than it does from physiological aberrations. Substance  abuse  may result from people preferring to self-medicate  with drugs  rather than accept the label of "mental illness" (Bergman & Harris,  1985), or  from people seeking some relief from distressing psychiatric symptoms or trying to  retain  some  control over  their  own  lives  (Lamb,  1982),  or  from  people  attempting to escape loneliness by joining drug subculture peer groups (Bergman &  Harris). Regardless of the specific cause of an individual's substance abuse, as  long as we view dual diagnosis substance professionals  will be better  abuse as a social problem, then no  suited to the task of addressing the problem than  social workers.  Social workers are uniquely well suited to the task of bridging the gap between mental  health  professional  and  drug  and  commitment to social change  facilitators, they can work together substance  alcohol  abusers.  abuse  professionals.  and well developed  Through skills  as  their process  to better meet the needs of dual diagnosis  "The goals of mental health and substance  abuse  treatment  30 are complementary and serious attempts to address this dual diagnosis population must employ concomitant programming" (Ridgely, Osher, & Talbott, 1987). As a United States Government statistician  said, separating these services was very  much a political expedient, but the concerns of the patients are often poorly met through this kind of expediency (Sheehan, 1975).  The connection of this study to social work is, I think, self evident. Many social workers  are  employed  in the  area  of mental  health,  and whether  they  are  working in hospital or community settings, they are in direct contact with dual diagnosis  substance  abusers,  relevant  to this  abusers  are still relatively  and so have  a vested interest  in exploring issues  problem area. In addition, services for mentally undeveloped  treatment  profession  in  strategies, this  area  and  to  through  substance  (Bachrach, 1987), which provides social  workers with an excellent opportunity to be innovators in the new  ill  carve the  a  solid  niche  accumulation  for  of  development of the  social  knowledge  work  and  the  development of expertise.  The preponderance of the biomedical model in the mental health field makes it especially  important  that  we  explore  and  emphasize  the  cultural,  political, and social factors associated with dual diagnosis substance  economic,  abuse. Thus,  the term "to carve a niche" for social work does not imply that we have a "vested interest"  in riding the  industry" of dual diagnosis  biomedical wave and capitalizing on the  substance  abuse.  Rather, we  have  "new  an interest  in  fighting for consumers' rights and social change, and in focusing attention on the "problems  of  living" that  reinforce  drug  abuse  for  people  with,  as  well  as  without, psychiatric problems. What are the explanatory models of directors, staff, and residents of mental health boarding homes? These models are likely to be closely aligned with those of each boarding homes' professional and financial affiliates, and are likely to influence attitudes towards, and behaviors in response to, dual diagnosis substance abuse. Attitudes concerning the inherently abusive nature of substance use,  are likely to be closely  linked to respondents'  explanatory models, as are peoples' perceptions regarding the  prevalence  of  "substance abuse" in mental health boarding homes. It is imperative that boarding home directors, staff, and residents not only have access to information delineating the microbiological facets of "mental illness" and dual diagnosis substance abuse, but that they also have access to information delineating the individual, political, economic, social, and cultural facets of "psychiatric problems" and dual diagnosis "coping mechanisms."  The next section outlines some treatment strategies for dual diagnosis substance abusers. Two studies, successful specifically  outlining one highly successful  and one moderately  treatment program are reviewed. While these programs did not target  mental health boarding  home residents,  their treatment  strategies can be extrapolated to a wide range of treatment locales, including boarding homes, and provide useful ideas regarding possible components of future services.  32  F. TREATMENT STRATEGIES  There are many different approaches to treating dual diagnosis substance abusers. One  approach  psychopathology  operates must  on be  the  premise  secondary  to  that the  the  treatment  modification  of  of  associated  drug  consuming  behaviors (Meyer & Hesselbrock, 1984). This view purports that, while primary drug  abuse  counseling  treating substance  and rehabilitation is  not  adequate  by  itself,  by  first  abuse it is possible to stabilize peoples' disorganized thinking  enough  that  they  can  Woody,  & McLellan,  continue  1984).  with  psychotherapy  and  Another approach operates  medication on  the  (O'Brien,  premise  that  dwelling on cause-effect relationships only complicates the issue, and that in most cases the two diagnoses are so enmeshed and mutually reinforcing that, in order for clients to respond positively, the substance abuse and psychiatric issues must be  addressed  concomitantly  (McKelvy,  Kane,  & Kellison,  1987).  Solomon and  Davis (1986, p.73) espouse this second approach when they say that: "alcoholism and mental health professionals  need to work together  this  abuse]  [dual  diagnosis  substance  to develop programs for  population." And Rounsaville, Dolinsky,  Babor, and Meyer (1987, p.512) state that "in devising the alcoholics' treatment plan, the poorer prognosis conferred by coexisting psychiatric disorders underscores the  value  of  offering  treatments  presupposes  preference  for  a  adjunctive the  treatments."  subordination  concomitant  treatment  of  While one  approach  the  use  treatment is  of to  clear.  "adjunctive" another,  Both  of  the these  approaches commonly operate within the parameters of the biomedical model, and are thus differentiated that cultural,  from a third approach, which operates  social, economic,  and political factors  are the  on the  premise  primary source of  33 peoples' psychiatric and substance abuse problems (Glen & Kunnes, 1973).  Hellerstein  and  Meehan  schizophrenia  and  people  histories  with  (1987)  substance of  reported  abuse multiple  outpatient follow-up, was successful  that  treatment  an  group  hospitalizations  outpatient they and  dual  began poor  in  diagnosis 1984,  compliance  for with  in reducing the number of days per year of  hospitalization for the group participants. People were referred to this open-ended group  from  both  inpatient  and  outpatient  psychiatric  and  substance  abuse  treatment facilities. The group, which consisted of ten initial members, met once every week and consisted of three phases: 1.  Engagement  involved  identifying  mutual  problems,  such  as  psychotic  symptoms, chronic suicidality, and drug abuse. 2.  Interpersonal skill developement involved learning to listen and respond to each other.  3.  Problem solving involved working on family issues, use of time, housing, and work problems.  During each of these phases there was continued "psychoeducation" about drug abuse, psychosis, and psychotropic medications. While 100% attendance, from nonprescription substance  abstinence  use, and compliance with psychotropic medications  were not mandatory, the group leaders did insist that all participants express a desire  to decrease their substance  attend self-help  abuse.  Participants were also encouraged to  groups, such as Alcoholics Annonymous. Hellerstein and Meehan  found that, for the original ten members, there was a reduction from 382 days per year of hospitalization for the year prior to joining the group (with a mean  34 and standard deviation of 38.2  +/- 21.4), to 78 days per year of hospitalization  for the first year of the group (with a mean and standard deviation of 7.8  +/-  9.9). Just as the aforementioned treatment group involved "psychoeducation about drug abuse,"  so  too do Ridgely, Osher, and Talbott (1987) conclude, following  their  of  the  review  literature,  that  despite  the  formats  of  substance  abuse  programs, almost all involve drug/alcohol education.  In an Oregon study, Stark and Kane (1985) found that providing people with detailed  information about the  proposed treatment  (psychotherapy  for  substance  abusers), during initial intake procedures, increased the likelihood that they would return for treatment.  Clients were divided into four groups. One group received  general  about  information  psychotherapy.  Another  group  received specific  information about psychotherapy for substance abuse. The third group was given information about the drug used, and acted as a control to determine if it was simply the attention that the clients received, rather than the specific content of the information exchanged, that effected  rates of return. The last group, which  received the standard information gathering (versus information giving) intake, also served as a control group. Stark and Kane found that there was a significant difference  between  square = 8.62,  the  p<.05).  groups However,  for  clients  the  that  effects  returned  were  at  least  shortlived.  No  once  (chi  significant  difference was noted between the four conditions after 90 days (chi square = .18).  It seems that, expect is experience  while initially, being given accurate information about what to  important, subequently, is  the  the  prime determinant  level  of satisfaction  of the  with  the  length of treatment.  treatment Clients were  35  included as active members of the treatment process during initial interviews, and may have been relegated to a secondary role during subsequent encounters, due to the "therapist driven" formats of many conventional treatment programs. Both of the preceding studies indicate that involving the consumer in the treatment process is important if program goals are to be achieved. We can extrapolate this conclusion to mental health boarding homes, and ensure that treatment or preventative dual diagnosis substance abuse services incorporate a high level of consumer involvement and maintain open lines of communication.  The  literature reviewed  in this  chapter  formed the  background for the  development of the present study, which investigates the occurrence of dual diagnosis substance abuse within the context of mental health boarding homes. Specific research questions will be outlined in the next chapter.  IV. THE RESEARCH PROBLEM  Following from the literature review, this chapter details the research questions that have been formulated for this study. Five specific questions have been identified, and each one will be presented in turn. Various elements of the questions will be identified, and question formulation will be linked to the literature reviewed in the preceding chapters.  (1) How prevalent is dual diagnosis substance abuse in community mental health boarding homes?  The literature indicates that there is a significant dual diagnosis  problem amoung the "young adult chronic" population. Many of these people are transient and homeless, and either refuse to enter mental health boarding homes or do not meet the entrance criteria that have been established by the boarding homes themselves. However, these studies have focused on persons who do not live in boarding homes, rather than those who do. The literature suggests that dual diagnosis substance abuse is quite prevalent in psychiatric acute care hospital settings. The majority of Vancouver area mental health boarding home client referrals involve persons who have just been discharged from such facilities. Thus, one would expect that some of these dual diagnosis substance abusers would end up in mental health boarding homes. How many of the boarding home residents have histories of drug and/or alcohol abuse? How many currently have substance abuse problems? How many have had drug or alcohol related problems in the past two weeks? What types of substances are commonly abused? These and other questions will be explored.  36  37 (2)  Is there  boarding  a  relationship  home  residents  between and  the demographic  dual  diagnosis  characteristics  substance  of mental  health  The literature  abuse?  indicates that there are associations between both the incidence and prevalence of dual diagnosis substance abuse and both peoples' age and psychiatric diagnoses. The high incidence of dual diagnosis substance abuse among the "homeless" suggests that dual diagnosis substance abusers are both unemployed and highly transient. What is the average age and gender of residents in different boarding homes? What level of education is common? Are these people employed? What are the identified primary diagnoses of the boarding home residents? This study explores the above characteristics and maps out associations between them and dual diagnosis substance abuse.  (3) Is there  a  directors  mental  diagnosis  of  relationship  substance  health abuse  between boarding problem?  the demographic homes  and  characteristics their  of the staff and  perceptions  of  the  dual  Do age, gender, job position, and level of  education affect the way people view the problem, and consequently affect the responses of individuals, and policies of boarding homes? Peoples' "explanatory models" effect their perceptions, which in turn effect their actions. A review of the  literature  unearths  large  variations between the  findings  of different  researchers. These variations are due, in part, to different operationalizations and, thus, different interpretations of data. While a review of literature focusing on associations between individual and group characteristics and emotions, cognitions, and behaviors has not been included here, (as it does not relate directly to dual diagnosis substance abuse), this study will explore the demographic characteristics of boarding home directors and staff, and map out relevant associations. It is  38  believed that information regarding the demographic charateristics of caregivers will provide useful insights into the mental health boarding home infrastructure.  (4) How  do  problems?  mental health boarding  homes respond to  residents' substance abuse  The literature indicates that many community mental health and  substance abuse services are not currently designed to meet either the substance abuse or the psychiatric problems of this dual diagnosis population, and that most services are based on the precepts of the biomedical disease model. Do mental health boarding home staff and directors refer substance abusing residents to outside agencies, and if so, where? Do they have inhome dual diagnosis substance abuse treatment services, and if so, what? Is alcohol consumption allowed in boarding homes regularly, at special functions and parties, or not at all? Do the boarding homes have established policies concerning substance use and/or abuse by residents? These and other related questions remain unanswered.  (5) Should  special services be  substance abuse problems?  offered in  response to  residents' dual  diagnosis  Services could be offered to both clients and staff.  Would recreational services, regular drug and alcohol free social outings, job training and employment opportunities, drug education programs and substance abuse counselling, or self-help and support groups be useful treatment approaches? Do staff recognize a need for, and have an interest in attending a special workshop focusing on secondary diagnosis substance abuse and related issues? Would they like to have a self-help group, or a drug education program offered jointly by the mental health and drug and alcohol programs, available  within  their boarding homes? It is hoped that this study will, in conjunction with  39  information extracted from the literature, result in some concrete recommendations for the development of new programs to help people with psychiatric problems stop or minimize their use of drugs and/or alcohol.  V. RESEARCH METHOD  A. RESEARCH DESIGN  This study involved a naturalistic design, and  according to the guidelines  of Reid  Smith (1981), as I had no control over the subject's perceptions or practices  in relation to dual diagnosis substance abuse, or over the prevalence, frequency, severity,  or  types  of  substance  use  and/or  abuse.  manipulation of experimental conditions. Rather, this  There  study  was  no direct  involved: estimating  the prevalence of substance  use and/or abuse in mental health boarding homes;  identifying  features,  boarding  certain home  specified  policies,  such  and mapping  as demographic  out relevant  characteristics and  associations;  and lastly,  mapping out suitable alternatives and policy directions.  The  study  followed  a  dimensional (Crane,  1988) conceptual  model.  Thus,  attempts were made to examine a global concept (dual diagnosis substance abuse) within a specific context (mental health boarding homes). Considerable amounts of data were  gathered  determined  from  using survey  questionnaires.  information gathered  The questionnaire  through personal interviews  items with  were service  providers in the feild, and by examining the literature. Findings that are specific to dual diagnosis substance homes,  are largely  abuse, within the context of mental health boarding  unavailable,  so connections  were  made  between  available  studies and the issues at hand. And finally, a "map" was developed, outlining the principle sub-areas of the dual diagnosis phenomenon.  40  41  B. RESEARCH SAMPLE  Due to the small size of the population (thirty-nine boarding homes, minus two pretest facilities) all of the units in the population were initially contacted, eventually resulting in a sample size of twenty-nine facilities (78%). These homes had  from  two to forty-seven  residents,  totaling 358 residents  across all  twenty-nine homes. The sample consisted of a fairly heterogeneous group, as many of the boarding homes are run by different agencies and cater to different client groups. It was hoped that not only the staff and directors of the boarding homes would participate in the study, but that the residents would also 'stand up and be counted.' There were a number of reasons for surveying all three of these groups: first, to increase the sample's heterogeneity, and provide a more comprehensive picture of 'the way it is;' second, to increase the chance that residents,  staff  and  directors  would  support  any  subsequent  policy  recommendations, by including them in the planning process, and thereby instilling in them a sense of ownership in the project; and finally, to circumvent the all too common practice of not including the actual service consumer in decisions that determine what services they need. As previously mentioned, a pretest of two boarding homes was conducted to test the survey instruments.  C. SURVEY INSTRUMENTS  Data was collected from the staff, directors, and residents of boarding homes using survey questionnaires. I had intended to personally visit the boarding homes to administer questionnaires to residents, and collect the director and staff  42  questionnaires that had previously been mailed to the boarding home directors (along with introductory letters). However, in four cases, completed questionnaires were returned to me in the mail (I was unable to visit these facilities). Both quantitative and qualitative data were gathered. The quantitative data were generated by a series of closed ended questions designed to gather factual data concerning the prevalence of and response to dual diagnosis substance abuse. The qualitative data were generated by a series of open ended questions designed to elicit the respondents' perceptions of and attitudes  towards dual diagnosis  substance abuse. The survey questionnaires were designed specifically with the target population in mind, and were pretested prior to full scale application. This was done to enhance internal validity.  It was assumed that the use of mailed questionnaires would minimize the amount of time needed to survey people, and reduce project costs and interviewer bias.  The questions  asked (and the  ways  that they  were  asked) were  standardized from one respondent to the next, although some adjustments were made to ensure a good fit between questionnaires and the "director," "staff," and "resident" groups. Careful attention was paid to constructing simple and easily understood questions, to maximize the consistency of interpretations. It was hoped that some (limited) clarification could be obtained, if necessary, while personally visiting the facilities to collect director and staff questionnaires. Additionally, an attempt was made to personally administer resident questionnaires, not only to increase the response rate, but also to both provide and receive clarifications where appropriate. It was hoped that obtaining data from the three respondent groups would reduce problems of bias.  43  In an attempt to increase the response rate, which is generally recognized as a significant problem with mailed questionnaires, a number of measures were adopted. As mentioned above, the residents' questionnaires were not mailed, but were distributed directly by the researcher, who was (in some cases) present while they were completed, and personally collected them upon completion. Directors were telephoned following their receipt of the mailed questionnaires, and this is believed to have increased the rate of response for directors considerably. Also the questionnaires were printed on colored paper with an attractive and easy to use layout. Questions were worded politely and included clear concise instructions. And, not only was University of British Columbia (U.B.C.) School of Social Work letterhead stationery used, but letters of endorsement from Greater Vancouver Mental Health Services (GVMHS) and Alcohol and Drug Programs (ADP) were included as well.  D. DATA ANALYSIS  Frequency distributions, Pearson's correlation coefficients,  Spearman's correlation  coefficients, phi coefficients, Cramer's V, and chi-square tests of significance were tabulated  using  the  U.B.C.  Computing Centre's SPSS:x statistical  analysis  program. The phi coefficient is a useful measure of association for use with two dichotomous variables, as it can be given a proportional reduction in error (PRE) interpretation. Cramer's V was used to measure associations between nominal data with more than four categories, because as a chi-square based measure it also can be used to determine levels of significance. Spearman's rho was selected for use with fully ordered ordinal data, as it can identify both positive and  44  negative relationships, and be given a PRE interpretation. Pearson's r was used for interval level data not only because it can be given a PRE interpretation, but also because its mathematical similarity to both phi and Spearman's rho makes comparisons between them possible.  The relationships between substance use and/or abuse and gender, age, boarding home admittance policies, boarding home size, average length of stay, psychiatric diagnoses, and prescribed medications were analyzed, as were the relationships between the abuse of alcohol and the abuse of other drugs, and the boarding homes' response to residents' substance use and/or abuse and their professed support for various programs. In addition, frequency distributions were examined to estimate the incidence and prevalence of dual diagnosis substance abuse in the various homes, and the degree of support evidenced for the various in-home or out-of-home treatment services.  E. METHODOLOGICAL DIFFICULTIES IN RESEARCHING THIS TOPIC  The  greatest  methodological problem of this study concerns the quality of  esimates. An attempt was made to increase the reliability of data by including three groups of respondents: directors, staff, and residents. It was assumed that surveying all three groups would cause the individual biases and inaccuracies of individual respondents and collective interest groups to balance each other out. In like fashion, it was hoped that selection bias would not be a problem, as attempts were made to survey the entire population of Vancouver area mental health boarding homes.  45 The identified population of boarding homes were contracted services run by fairly small independent agencies (fourteen homes operated under the auspices of larger umbrella organizations), so the staff and directors did not face as many formal restrictions regarding the release of information, as they would have in many larger human service organizations.  Nonetheless, there were a number of factors that threatened to jeopardise the reliability of the data. First, there were some issues arising from the method of data collection: mailed survey questionnaires often generate low response rates, and the researcher is unable to clarify problems of interpretation, and explore inconsistencies efficiency  as they occur. These problems threatened the accuracy and  of prevalence estimates. A number of measures were adopted to  increase the rate of response, and the quality of estimates, t And yet, despite these precautionary measures, very few residents (3%) participated in the study. Thus, attempts to increase the accuracy of estimates by reducing selection bias were not entirely successful. Further, respondents were self-selected, rather than randomly selected. Accordingly, resident reports have been used as descriptive data, and attempts have not been made to generalize findings based on these reports to the entire population of residents.  While the rate of response for staff is not known (information detailing the total number of staff members employed in the identified population of boarding homes was not available), there was a very high response rate from directors (78%), tRefer to the "Survey Instruments" section of this chapter for a more detailed discussion of the problems associated with mailed questionnaires, and subsequent measures adopted to improve their efficiency.  46  and thus, facilities. And while the effects of individual bias, agency bias, and selection bias, can never be entirely annulled, neither the efficiency of survey methods, nor the accuracy of the estimates are any more problematic than is usual for studies of this kind. Of course, this study was not entirely free from the objective bias of the researcher. However, by avoiding the use of research assistants and interviewers, other than the primary researcher, there was a high level of consistency in the evaluation of data from different sources. Furthermore, closed-ended and open-ended questions were used, so that I could benefit from the objectivity of the former and the subjectivity of the latter. Of course, the survey sample may not be representative of mental health boarding homes in other areas or municipalities, and so caution must be exercised when making generalizations to other populations.  VI. R E S E A R C H FINDINGS  A. P R E T E S T A N D SUBSEQUENT  QUESTIONNAIRE  REVISIONS  Following receipt of a letter of approval from the University of British Columbia Ethical Review Committee (Appendix 1), a pretest of two boarding homes selected randomly from the population of Vancouver area mental health boarding homes was conducted to test the survey instruments. This section outlines the pretest, and  details  some  of the  ensuing questionnaire revisions.  been included here rather than simply making vague  These revisions  references  have  to unspecified  "changes" to accentuate the value of conducting a pretest. This section does not contain results of the primary study; these are detailed in the ensuing sections. The  resident  respectively.  populations Only  of  these  pilot  homes  two homes  were  selected  were  for the  fourteen  pretest  and  twenty,  due to the small  number of homes in the population (n = 39), and the assumption that modifications to the  survey instruments subsequent  to the pretest  would be such that the  pretest sample could not be included in the larger study. Indeed, a number of revisions were made to the survey instruments.  According to the guidelines of the U.B.C. Ethical Review Committee, introductory letters (Appendices 2, 3, and 4) were mailed to the two boarding homes, along with questionnaires  for the  approximately  week  one  directors and staff.  following  their  receipt  The directors were of  the  telephoned  mailed packages,  and  arrangements were made to visit the two facilities, both to collect the mailed questionnaires and to personally administer the resident questionnaires. It was at  47  48  the point of telephone contact that the first difficulties ensued! The directors of both facilities indicated that the residents in their respective boarding homes were elderly persons who did not abuse drugs or alcohol, and that, therefore, this study was not applicable to their homes. Nonetheless, one of the directors immediately agreed to participate, by completing "at least part" of the director questionnaire. And while the other director was not quite as amicable, and berated the entire study as a "waste of taxpayers' money," upon further consideration, he/she too agreed to participate (perhaps I should clarify now, as I did then, that this study was funded entirely by the researcher, who received no monies from the public purse).  Both of the pretest  facilities  were large old wooden homes  that blended  inconspicuously into their environs; both had clearly defined lines of authority, with traditional staff/resident role expectations. The residents of the first home I visited had been informed of my intentions by the director, and were all gathered in the living room awaiting my arrival. I told the gathered residents about my study and, after stressing the voluntary nature of their participation, invited them to contribute their own views and expertise. My oratory was met, for the most part, with seemingly blank stares. Only two of the assembled residents (all were elderly and two were over the age of ninety) made any comments: one resident remarked that she "[did not] think that there [was] anything wrong with having a drink sometimes;" and the other resident asked me if I "could come back later to play cards?" Both comments were appropriate, if somewhat brief. The residents in the second home had not convened as a single group, though many were sitting in scattered groups of two or three in  49 the  large  grassy  backyard.  Two residents  agreed to fill out questionnaires  who  had been  conversing together  with me; none of the other residents  showed  any interest. I also met personally with the director and one staff member from this  home,  answered  and  the  the  director  questionnaire  of  the  questions  other very  home.  None  thoroughly.  of  the  respondents  Thus,  the  information  gained through oral discourse was invaluable.  A  number of revisions  pretest.  were  made to the  survey questionnaires  following the  I should clarify at this point that the question numbers cited in this  section refer to the pretest questionnaires (Appendices 5, 6 and 7) rather than to the revised questionnaires  (Appendices 8,  9 and 10) used in the actual study.  The first question on the director and staff questionnaires, which asked for the date,  was  left  unanswered  in  all  cases.  Though  it  certainly  had  not  been  intended as such, both the director and staff respondents from one of the homes believed that this question had been designed to test their awareness, rather than to simply elicit the date. Consequently, this first question had unfavorably colored the respondents' impressions of the entire questionnaire. Furthermore, due to the relatively short time span of the data collection in this study, the approximate date  of completion for any given questionnaire  was  easily  determined without  reference to the exact date. This question was deleted from the questionnaires.  Question number five of the director questionnaire which enquired after residents' average  length  of  stay,  was  also  left  unanswered.  Interval  level  data does  increase the researcher's flexibility during data analysis. However, nominal data is better than no data. Thus, in a later version, respondents were asked to check  50  the appropriate category rather than fill in the blanks. This change may have reduced the range of responses considerably.  Question number six of the director questionnaire was not answered by either of the directors, but the director of one of the homes did provide some interesting comments. This director stated that diagnoses were "just labels, and [she didn't] like labels." The staff respondent from this same home proffered a similar sentiment. I had not intended that this question indicate that either I or the respondent supported the routine use of popular diagnostic labels. Rather, I had hoped to establish if there was a relationship between diagnoses and substance use or abuse, and between diagnoses and residency in mental health boarding homes. In response to the director's comments, I added a diagnoses are not seen as relevant  category. In addition, the director who made the preceding comment  was not familiar with the terms unipolar affective disorder or bipolar affective disorder, so  the more common terms: depression (though not entirely synonymous  with the term it replaced), and manic depression, were used.  Question number seven of the director questionnaire also caused some confusion. At least two of the respondents were unable to distinguish between major and minor  tranquilizers. Consequently, these two categories were synthesized into a  single category. Despite these revisions, it appears that some respondents still found the medication categories confusing.  Numerous changes were made to question twenty of the director questionnaire and question thirteen of the staff questionnaire. First, the subheading: what is  your job title,  was deleted completely. None of the respondents answered this  question, and the use of distinct director, staff,  and resident questionnaires  rendered this question somewhat redundant. However, "staff' could have been cooks, cleaners, nurses, or "aides." Also, rather than asking respondents for their date of birth, I asked a less sensitive question: what is your age? and included four age categories to choose from. Thus, while the range of responses was narrowed, the response rate was increased. Additionally, the subcategory that inquired after respondents years of schooling was changed from an interval to a dichotomous yes/no answer format. A work experience category was added both in recognition of the intrinsic value of practical experience, and to reduce the level of  intimidation experienced by  those  respondents  without  formal academic  credentials.  Just as many changes were made to the director and staff questionnaires, so too were many changes made to the resident questionnaire. Perhaps the most glaring oversight was the overall length of the resident questionnaire; the resident questionnaire was longer than either the director or the staff questionnaires, and the two pretest resident respondents clearly found the length unwieldy.  Question five was deleted entirely. Neither of the two pretest respondents were able to answer this question about their psychiatric diagnoses. Furthermore, neither the director nor the staff who participated in the pretest thought it was a suitable question, both because they thought it highly unlikely that the residents would know the answer, and because they thought it might cause them some undue apprehension. Question seven was substantially altered, by asking  52  respondents to simply indicate if they used any medications at all rather than indicating which of a specified list of medications they used.  Questions fifteen, sixteen, and seventeen, which dealt with boarding home policies, were deleted entirely, as they were also included on the director (questions seventeen, nineteen,  and ten)  and staff  (questions  five,  twelve,  and four)  questionnaires. Like its counterpart on the director and staff questionnaires, the subsection of question nineteen that asked respondents for their date of birth was changed from an interval to an ordinal level format, by including a list of numeric ranges for respondents to choose from. The subsection that asked respondents what level of education they had completed was similarly changed.  The formats of a number of additional questions on director, staff, and resident questionnaires were also altered, either by switching from interval to ordinal, or ordinal to nominal levels of data collection, or by switching from a horizontal to a vertical layout, or by including directional arrows to guide respondents to the appropriate categories. The pretest segment of this study was clearly invaluable, and resulted in extensive changes that improved the quality and relevancy of the survey questionnaires.  The following section  is  essentially  an "introduction to the results." This  introductory section includes a general description of the survey sample, that is, the members of the total surveyed "population" that actually participated in the study. Following this introductory section, the research results will be examined in more detail, with specific reference to the identified research questions.  53  B. PRELIMINARY DESCRIPTION OF THE SURVEY SAMPLE As mentioned in the previous section, two Vancouver area mental health boarding homes were surveyed in a pretest. Due to the extensive changes that were subsequently made to the survey questionnaires, the two pretest facilities were excluded from the main study. Thus, the main study involved a sample size of thirty-seven boarding homes, and twenty-nine (78%) of these thirty-seven facilities participated in the study. While there was one director participant from each of the twenty nine homes, three of the directors completed questionnaires intended for staff members. Accordingly, questions that were only included on director questionnaires were not answered by these three respondents.  Out of the thirty-seven boarding homes, eight (22%) homes declined to participate for a variety of different reasons. For instance, the coordinator of one group of four homes stated that the persons living in the facilities were tenants with self contained appartments, rather than residents of conventional (staffed) boarding homes.  These  coordinator's  four facilities  role  did not have  involved liaison between  any staff the  tenants  members, and the and the umbrella  organization rather than on-site participation. Though a survey of these facilities would have provided useful information, they were dropped from the study at the coordinator's request (thus, it can be seen that the coordinator's role did indeed involve direct manipulation of the tenant's interests).  The director of another facility refused to participate because "this/her spouse had] asked [him/her] to scale down [his/her] duties," and he/she simply did not  54  have the time to get involved. However, this director's insistence that I approach neither the staff nor the residents of the facility suggests that his/her refusal may have involved more than temporal concerns. Indeed, personal communications with the (now retired) director of the Mental Health Residential Services, indicated that the residents of this particular facility were among those most likely to have dual diagnosis substance abuse problems. A similar reason for not participating was expressed by the director of another facility, who said: "I'm a working operator so I have to look after the residents. I haven't had the time [to complete the questionnaire]." In addition to temporal concerns, the director of another facility cited a lack of substance use by residents as the reason for not participating in the study. And finally, the last director who refused to participate did so for quite a different reason: in this case it was not the director but, rather, the residents, who decided at a weekly house meeting that they  would not participate. In this latter case, the residents were not only  consulted regarding their participation as individuals, but were also consulted regarding the boarding home director's participation.  It became apparent very early in the study (indeed, during the pretest) that very few residents would agree to participate. However, it should be noted that in many cases it was the directors, and not the residents, who determined that residents  would not participate. The following comment was by one such director,  who decided for the residents: "It's the age group. We had one person in the last six months who was a street person who did have problems ... no, I don't think it would do any good [to survey residents]. They are mostly in their own little worlds and like to be left alone. We have one fellow [who might be able  55 to answer a questionnaire], but he's too paranoid and grandiose to be of much use." It is not the accuracy of the preceding statement that is at issue here, but rather, it is the simple fact that no effort was made to consult the residents. Thus,  we cannot  fall  back  on the often  used  conclusion  that  low resident  response rates are due to "non-compliance."  There were 358 residents in the twenty-nine homes surveyed in this study, and sixty-four in the eight homes that were not surveyed, equalling a total resident population  of  Furthermore,  422.t  Only  the ten residents  ten  residents  (3%)  completed  who did participate were  questionnaires.  concentrated  in four  facilities: one resident from each of two facilities, two from a third facility, and six from a fourth facility. With one exception, those residents who did agree to participate were from facilities where a high degree of resident autonomy was encouraged (and expected).  This is not surprising, as these residents  were not  only likely to have been among the most cognisant, but were also most likely to have been given the opportunity to participate. Additionally, these persons who are encouraged (or allowed) to make their own decisions are more likely to be accustomed to, and comfortable about, taking control over their lives,  and are  less likely to be intimidated by someone like myself.  Unlike residents, twenty staff members, from twelve facilities, participated in the study.  While  it  is clear  that  I initially overestimated  the number of staff  tThese figures do not include the two pretest facilities. The reference to sixty-four residents in non-participating facilities is an estimate, based on figures obtained from Greater Vancouver Mental Health Services, Mental Health Residential Services. These figures were found lacking with respect to three other facilities, so the true number of residents in these eight non-participating homes at the time of the study is not known.  56  members likely to be employed in mental health boarding homes, it is not clear exactly how many staff were employed in these facilities at the time of this study, t In fact, several facilities did not have any clearly defined staff positions, either because they were small family run operations, or because of their emphasis on independent living. Additionally, many of the staff members were employed as cooks, or cleaners, who either did not have the expertise or the motivation to participate in the study. Thus, it remains difficult to establish just what the response rate for staff members was.  One thing is clear concerning the response rate: the enthusiasm of directors was a key determinant of the support generated in boarding homes. As mentioned previously, it was the directors who decided, in seven out of eight cases, that their respective facilities were not to be included in the study. In like fashion, the directors of many of the participating facilities had a strong influence on whether or not the staff and/or residents of the various homes became involved. Of course, the staff and/or residents of some facilities refused to participate despite  the directors' enthusiasm, but without the directors' support they were not  even given the opportunity to decide the issue for themselves. While it is true some consumer driven facilities did involve residents in the decision making process, these were the exception rather than the rule.  The next  five  sections present results that are specifically related to the  main research questions. Each  of  these  five  five  questions is considered separately. The  tMy initial estimates were based on staffing models in group homes for physically disabled and mentally handicapped adolescents, which are not congruent with those of the mental health boarding homes surveyed in this study.  57 section headings delineate  which research question is currently being considered.  Accordingly, the first results to be reviewed are those relating directly to the prevalence/incidence of dual diagnosis substance  abuse in mental health boarding  homes. Responses by directors, staff, and residents are considered. It is important to  note  that  the  participating  sample  of  residents  is  too  small,  and  too  unrepresentative- of the population^ of residents, to provide statistically meaningful answers. Thus, resident rsponses have been included at the end of each section, as descriptive points of interest.  C. PREVALENCE/INCIDENCE OF SUBSTANCE USE AND/OR ABUSE  The  first purpose of this study was  substance (76%)  abuse  of  the  to estimate the extent of dual diagnosis  in Vancouver area mental health boarding homes. twenty-nine  members, from twenty-three  directors,  and  fifteen  (75%)  of  the  Twenty-two twenty  staff  (79%) different facilities (95% confidence interval for  the population percent=64%-94%)$ reported that at least one resident consumed alcohol.  The  consumed  total number of  alcohol was  percent=27%-37%). eleven  (41%)  115  residents  (32%)  Ten directors  different  facilities  (95% (34%) (95%  who,  according to  confidence and  four  confidence  directors' reports,  interval for staff  the population  members  interval  for  (20%), from  the  population  percent=22%-60%), reported that at least one resident used marijuana. According to director's reports (n=27), a total of fourteen residents  (4%) used marijuana  tThe resident group was not a random sample, but was self selected. Thus, external validity is likely quite low. ^Although confidence intervals have been included here, it is important to remember that the research sample was not ramdomly selected. Thus, the representativeness of the sample to the population is unknown.  58 (95%  confidence  interval  for  the  population  percent=0%-11%),  although  one  additional director who did not report any cases of marijuana use did indicate that he/she suspected, but could not prove that a number of residents did use that substance. Data was missing in two cases. One director (3%) reported that one resident used opiates; there were no staff reports of opiate use. One staff member (1%) reported that there was an occasional LSD user, although this was not corroborated by the director of the same facility. On the other hand, both the  director  and  the  staff  member  from  another  facility  substantiated  the  presence of an amphetamine user among the residents. There was no barbiturate or PCP use reported. One director identified the use of inhalants by a resident; inhalant use was not reported by any of the staff members. Three directors and two staff members reported that substances  other than the ones listed in the  questionnaires were also used. Only one of these two staff members was from a facility  whose  director had similarly reported the  category. Thus, the use of "other" drugs was  use  of drugs in the other  reported in four (14%)  different  facilities (95% confidence interval for the population percent= l%-27%). Of course, individual substances  respondents  were  responsible  for determining specifically  which other  warranted mentioning, and it is probable that opinions varied greatly  in this respect.  Substances  that were mentioned in the other category included:  antihistamines, antiemetics, cough syrup, Midol, and Gravol. The total number of residents who, according to directors' reports, used "other" drugs was three (.8%). Data was missing in one case. who used any of the specified  Figure 1 shows the total number of residents substances,  according to directors' reports. It is  clear that alcohol is the most frequently used substance, marijuana, very few residents use illicit "street" drugs.  and aside from some  Figure 1. PREVALENCE OF SUBSTANCE  USE IN MENTAL HEALTH BOARDING HOMES  Number of Residents  30  is -»(d o _ o  3* a> —  €»  a. <£. 3 a q>  s  o  9L Z c  c  03  3  cr CD  q  SS o  cn c  IT »  •  - ca  3 cr »  £  o  o  3  CD cn  CD 3  O  m c  C/>  m zr o  c m (C/>D z ? CD  CO  >  CD O  —* m CD" OL  CO c cr  >  CO  S> o CD  CD O > a  z o m  60 While I had not included cigarettes or coffee in the specified list of substances, two  respondents  commented  specifically  about  one  or the  other  of these  two  drugs. One staff member included the following comments: Incidentally, coffee and cigarettes ('minor' (?) drugs) are mega-consumed by these people - but the cigarette  smoking especially  seems to be  one of life's few pleasures for these people - hard to watch the chain smokers without wanting to gag yourself - staff  will usually gently  caution against too many cigarettes, and only allow decaffeinated coffee to be served in the house after 10:00 o'clock.  The other respondent,  a director, provided the following rationale for the high  prevalence of cigarette use by residents: I  could count  the  number  [of residents]  who  don't smoke  on one  hand. You can look at it in light of Marxist philosophy. They own the means of production, control the time of production, and determine the  level  status  of production. Cigarettes  symbol. They  are  a  social  are  a form  medium ...  of currency, and a a way  of initiating  conversations with others.  While the above rationale does make sense (of course, cigarettes also seem to be physiologically addictive), I question the legitimacy of the statement that "these people" like to smoke (unless the term was used to refer to the residents of one specific Personal  facility, rather than to persons observations  in acute  very many psychiatric patients  care  with psychiatric problems, in general).  (hospital)  psychiatric settings indicate  smoke cigarettes,  that  but observations in community  mental health boarding homes indicate that very many ex-psychiatric patients do not smoke.  Certainly, in some boarding homes  virtually every resident  smokes  cigarettes,  but it is equally true that in other boarding homes  virtually every  resident does not smoke. The prevalence of cigarette use may be a product of the  environment (for example,  high stress levels and inactivity in acute  psychiatric hospitals, or anti-smoking policies in boarding homes).  care  On the other  hand, high levels of cigarette use may be associated with other variables (such as age, ethnic background, or alcohol consumption) that influence the selection of environments (by the individual or by others). As such, the environment may be a product of cigarette use. In any case, very few respondents included cigarettes or coffee  as viable substances  for the purposes  of this  study  ... nor was it  intended that they do so.  In order to explore the immediacy of residents' substance use, respondents were asked to indicate how many residents had consumed illicit street drugs or alcohol during the two week period prior to the questionnaire's  completion, t  Based on  directors' reports, three boarding homes (12%) had at least one resident who had used illicit drugs during the past two weeks (95% confidence  interval for the  population percent=0%-25%). Data was missing in three cases (n = 26). Illicit drug use was not reported by any of the staff members, despite the fact that three of them were from a facility whose director had identified illicit drug use by two residents. There is a clear discrepency between the director and staff reports for that facility.  There was considerably more alcohol use during the specified two week period. The directors (n = 27) of fourteen (52%) different facilities (95% confidence interval tFor the purpose of this discussion, the phrase the past two weeks refers to the two week period directly preceding the completion of any given questionnaire.  62 for the  population percent=33%-71%),  and seven  staff  members  (n=20,  35%),  reported that at least one resident had consumed alcohol one to five times during the past two weeks. Directors' reports were missing in two cases. While seven of the directors indicated that three or more residents had consumed alcohol one to five times during the past two weeks, were  not  more  than two  residents  according to the staff reports, there  in any given facility who had consumed  alcohol that frequently. In one home, all three staff respondents  reported that  only two residents had consumed alcohol, while the director of that same facility indicated that six residents had consumed alcohol. And yet,  while there  is a  clear discrepancy between reports by directors and staff, one reason that director reports were not substantiated by staff members is because, in four out of seven cases, the facilities with reportedly more than two drinkers did not have any staff members (thus, none completed questionnaires). Based on directors' reports, a combined total of fifty-four residents (16%) consumed alcohol one to five times during  the  past  two  weeks  (95%  confidence  interval  percent= 12%-20%). Data were missing for eighteen  for  the  population  residents from two facilities  (n = 340).  Two directors indicated that at least one resident had consumed alcohol six to ten times  during the  past two  weeks;  there  were  no reported cases of residents  consuming alcohol more than ten times during a two week period. It is difficult to determine if the three residents who reportedly consumed alcohol six to ten times, did so  on six  to ten different days,  or drank  repeatedly  on a fewer  number of separate occasions. Similarly, it is not clear exactly how much alcohol was consumed on any given occasion. Thus, it can not be ascertained that the  63 consumption was  of an abusive  nature, based  on the  Organization guidelines. A combined total of fifty-seven alcohol  at  some level  during  the  specified  two  specified  World Health  residents (17%) consumed  week periodt  (95%  confidence  interval for the population percent= 13%-21%),  While three residents had (according to directors' reports) used illict street drugs during the past two weeks, only two residents had abused illict drugs. As one would expect,  the  director who reported that residents  abused illict drugs had  also reported that residents used illicit drugs. And yet, this director stated that there were two residents who had abused illicit drugs during the past two weeks, while only one resident had used illicit drugs during the same time period. Thus, one  of the  residents  seems to have  abused drugs without using them! It is  possible that this respondent was referring to three different people: one that had used  drugs,  and two  that  had  abused  drugs.  Thus,  the  conflict  may  have  involved the interpretation rather than the report (of course, it may simply have been an error). The strongest relationship between reports of drug use and drug abuse was  between  drug abuse and marijuana use (Phi = .32).  appear to be any significant  relationships between the  There do not  use and abuse of any  specific drug.  Only  a slightly  higher incidence of alcohol abuse  was  reported. Two directors  indicated that one resident in their respective facilities had abused alcohol during  t Staff reports have not been included here, as their inclusion would have resulted in a certain amount of overlap; some residents would have been counted twice. However, one case of staff reported alcohol use could have been safely added, as the director from the same facility reported that no one had used alcohol, thus alleviating the chance of duplication.  64 the past two weeks, and two directors indicated that two residents had abused alcohol  during  residents  the  same  (95% confidence  time  period. Thus,  there  were  reportedly  six  interval for the population percent=0%-7%),  (2%)  who had  abused alcohol (n = 358), from four (14%) different facilities(95% confidence interval for the population percent= l%-27%). Questionnaires were also received from two staff  members  from  each  of  two  different  homes  where  alcohol  abuse  had,  according to director reports, occurred. In one of these two facilities, one staff member indicated that one resident had abused member  reported that  specified  two  residents  abused  week  none of  period; the  alcohol. In  the  the  residents  alcohol, while the  had  director, on the other  facility,  abused  other neither  other  alcohol  during  the  that  two  hand, stated of  the  staff  staff  members  reported that any alcohol abuse had occurred, though the director had indicated that  one  of  the  residents  had abused  alcohol.  Thus,  there  are  discrepancies  between reports by directors and staff once again, with .more directors reporting that more residents  use and/or abuse substances.  With alcohol abuse and drug  abuse categories  combined into a substance abuse category, eight (2%)  (95% confidence  interval for the population percent=0%-7%),  residents  from four facilities  (14%) had reportedly abused substances.  Associations between the use of various different substances  could not be made,  as reports by directors and staff did not identify individual users, but rather, referred either to the presence or absence number  of  substance  users/abusers.  of substance  However,  it  can  use/abuse, be  or the total  determined  that  all  reported cases of "drug" use were from facilities that also had reported cases of alcohol  use.  There was  a  significant  relationship  between  facilities  that had  65 reported cases of marijuana use and reported cases of alcohol use, according to directors' reports (Chi-Square, with the Yates correction<.05). significant relationship between the estimated and yearly marijuana use between substance  (rho = .65,  There was also a  prevalence of monthly alcohol use  sig<.01).  The only significant  realtionship  use and substance abuse was between weekly alcohol use and  drug abuse (rho = .58,  sig<.01). Suprisingly, this association was between alcohol  use  rather than between alcohol use  and drug  course,  it is  abuse, not  surprising to find that  and alcohol abuse. Of  reported drug  abusers  also  consume  alcohol. Although not statistically significant at the 95% level, negative associations were  noted  between  weekly  alcohol  use  and  the  "alcohol,"  "drug,"  and  "substance" abuse variables. Frequent consumption does not appear to be a good indicator of abuse.  A cursory examination of the data suggests that there are very few  substance  abuse  However,  problems  several factors  in  Vancouver area  mental  health  boarding homes.  suggest that the prevalence of substance  abuse may have been  underreported. First, directors' reports indicate that at least fifty-seven residents, from sixteen different facilities consumed at least some level of alcohol during the two  week period directly preceding the  completion  of questionnaires.  Directors'  reports further indicate that 115 residents (32%) consumed at least some level of alcohol  during the  year.  Figure  2  shows  a  large  discrepancy  between  the  number of people who consumed alcohol during a two week period, and during a one year period, and  the  number  who  abused alcohol  during  a  two week  period A tlf staff responses are added to the directors' reports, controlling for possible duplications by only selecting staff responses from facilities whose director did not  66 Figure  2.  SUBSTANCE USE VERSUS SUBSTANCE ABUSE  Number of Residents  cr> CO  < xi " o o-  TJ O  6^  »  3J  CD  •a o  CT c  c ID  iS  Is CJO.  o o  >  H O  3]  > CT cz cn  CD Q» c/> a. m crt CD < m ZD o CO o O c  —^  o  cn >  i—  o o CD CD  3  CD "O  CO  o  Q. cr)  >  CD C (/>  m  67 Furthermore,  as  previously  mentioned,  one  of  the  facilities  that  had  a  "reputation" for housing residents with substance abuse problems was not included in  the study. And while the director of one additional facility with a similar  reputation did complete a questionnaire, I was  strongly discouraged from either  visiting the facility or surveying the staff or residents. In both these cases, it is possible  that the prevalence of substance  abuse  in the facilities  influenced the  respective directors' descisions to limit the information I received.  In  addition, the internal validity of reports of substance  abuse may have been  adversely affected by internal or external pressure to present the facilities in a favourable  light.  Several  directors  expressed  concern  that  Greater Vancouver  Mental Health Services (GVMHS) might have access to their responses.  All of  the facilities that were surveyed rely heavily on GVMHS for their funding, t and are  therefore  Similarly,  the  very  concerned  private  administratively  owners  responsible  for  about  meeting  that  agency's  or umbrella organizations the  various  facilities,  contract  that  have  demands.  control and are  formal  or informal  regulations governing the daily operations of their boarding homes. For instance, the Mental Patients' Association has a formal list of house rules. The first two rules are: 1.  No  alcohol  (in  the  house  or  immediate  vacinity)  nor  arriving  home  intoxicated. 2.  No abuse of non prescription drugs.  t(cont'd) identify any cases of substance use, the number of residents who reportedly use alcohol increases slightly to 121 (34%). tWhile the bulk of agency operating expenses are covered by GVMHS "contract" money, the generation of additional funds for "nonessential" things through private fundraising is also commonplace.  68 The Coast Foundation Society also has a formal, documented policy regarding the consumption  of  alcoholic  beverages.  The  following  information  outlining  some  suggested changes to this policy was circulated to the "Management Committee" in September of 1989: Coast  Foundation  lifestyle.  Society  promotes  the  maintenance  of  a  healthy  Individuals should be aware that a mixture of alcohol and  medication may have adverse affects. Therefore: 1.  As a general rule, alcoholic beverages will not be consumed in Community Care Homes, in the Clubhouse/Administration, and in the  public areas of  the apartment buildings. Upon approval by the appropriate division manager or designate, there may be special events where alcohol is present. 2.  No supervised outings should be planned specifically for the consumption of alcoholic  beverages.  Coast  employees  will  not  drink  alcoholic  beverages  during their scheduled working hours.  The  directors  accuracy  for  and/or  staff  efficacy,  in  members an  attempt  of to  some  facilities  present  either  may  have  themselves  sacrificed or  their  facilities in a favourable light, t The comment by one director that he/she "had to  check  out  the  politics  of  the  thing" before  participating in  the  study  is  indicative of this tendency to protect one's personal, or agencies' interests.  Another factor that may have adversely effected the estimates of substance abuse tit is important to clarify at this point that the two examples of agency policies used here were selected because of their clarity, and not because the directors of either the Mental Patients' Association or the Coast Foundation Society boarding homes purposely provided me with misleading information. On the contrary, respondents from facilities affiliated with these two organizations were, for the most part, among the most enthusiastic and cooperative.  69 has to do with the survey questionnaires, rather than the respondents. On the original draft of the questionnaires, respondents were asked how many residents had  abused substances  question was  during a one month period. Following the  pretest,  the  simplified. In an attempt to increase the response rate, and the  accuracy of responses,  respondents were asked to focus on the past two weeks,  rather than the past month. While the response rate (for this particular question) and the accuracy of responses  may have been increased, the efficiency  estimates may have been jeopardised. This problem was  of the  summed up nicely by  one director, who stated that he/she did not "think two weeks [was] long enough, because [they had had] some problems about a month and a half ago, but not during the past two weeks ... in the last month and a half one person drank and got in a fight ... also in the last month and a half [one person took illicit drugs and] got in a fight; the police were called and the [resident was] taken to the hospital."  Another director stated, regarding substance abuse by residents, that: I don't have that. I used to. There used to be a young girl [here] who was not only a drug addict and alcoholic but also a street person. She took off last year and was raped and almost killed. I don't know if you remember, but a lot of prostitutes were being attacked back then ... I just started operating this [home] in October [1987] and have  already  had two  serious  problems [related to substance abuse]. Similarly, the director of another facility stated that they "had a fellow in the home two years ago who caused trouble [fighting with another resident] in the home, so [he] was expelled." Although this same director reported that none of  70  the current residents used any of the specified substances, he/she included the following comment: I have one residents [sic] only that drinks when he go home to his mother, who is an alcoholic, deft [sic] and mute. His brother who he was very close to committed suicide and his father did too and he has tried it as well ... He come home very drunk, sometimes police bring him home very drunk ... If he is drunk he just sleep. But one time he was fighting with one of our residents. He was warned he will stay in Look Out - if he do it again. Thus, it would seem that despite the fact that this respondent indicated that none of the residents used alcohol, one of the residents, at least, not only used but also abused alcohol on occasion.  Another director who similarly reported that the residents neither used nor abused substances stated that "at one time one guest did get very drunk, we had a bad time." And in two additional cases, although no drug or alcohol abuse was reported, directors indicated that they believed a resident abused prescription drugs. These cases of suspected prescription drug abuse were reported despite the fact that this study did not address the issue of prescription drug use directly; that  is an area for future research!  In response to the obvious problems of reliability and validity associated with questionnaires, respondents were encouraged to elaborate on their responses to "closed ended" questions. These supplementary comments indicated that, while a number of facilities had had problems directly related to residents' substance use, these  problems had not occurred within the  specified  two  week period.  Respondents  from  eleven  abused substances  different  facilities  (38%)  reported that  residents had  during a period of time exceeding two weeks.  For example,  one director stated that "there was one fellow [in the home] who [had] signed a contract not to drink, because his drinking was causing problems for the other residents." Another director said that "sometimes beers  and come  home drunk  when they  get  people will go out for a few their checks." Neither of these  directors reported that there had been any substance during the past two weeks.  abuse in the facility ...  Certainly, the act of going out for a few drinks  does not necessarly constitute  abusive behavior, but the potential for substance  related  probably  problems to  occur is  very  high,  and the  same  behavior in  another facility might result in expulsion for substance abuse. In another slightly different example, a staff member from one facility indicated that, while there were not any substance abusers in the facility, he/she had "experienced substance abuse at [another facility], when he/she was employed there ... especially [with] marijuana." And yet, the director of the specified other facility (the name has been withheld to maintain confidentiality) reported that there were not any cases of substance abuse.  Thirteen  directors (45%)  and seven  staff  (35%)  from fifteen  different facilities  (52%) reported that they had tried to get help for a resident with a substance abuse problem; and yet ten of these directors and one of these staff members, from eleven different facilities, had not reported any cases of substance abuse. Similarly, there were no reports of current substance abuse in eight of the eleven facilities where past cases of abuse were reported. Only 20% of the respondents (from 27% of the facilities) who had indicated that they had tried to get help  72 for a resident with a substance abuse problem, indicated that a resident had had substance  abuse problems within the past two weeks. Figure 3 compares the  number of boarding homes where substance  abuse occurred during the specified  two week period (four facilities), the number where it occurred during a longer, one year time period (eleven facilities), and the number of boarding homes where attempts were made to get help for a resident with a substance abuse problem (fifteen  facilities).  There is a clear discrepency between these different reports.  Nonetheless, there appear to be statistically significant relationships, between staff and  director's  reports  of  reports  of  attempts  alcohol  use  marijuana  to  help  residents  (Chi-Square<.02, use  with  following  (Chi-Square<.01,  Furthermore, there  was  also a fairly  director's attempts  to help residents  substance the  Yates  correction).  When  Yates  following  the  problems and correction), and  Yates  correction).  significant relationship between staff and with substance  abuse  reports that at least one resident abused substances the  abuse  directors' reports  problems, and their  (Chi-Square = .07,  were  viewed  in  following  isolation,  the  significance levels dropped considerably. Only the relationship between attempts to get  help  and reports of marijuana use  retained  a  high level  of  significance  (Chi-Square<.05, following the Yates correction).  In  summary,  directors substance  or  while staff  abuse  reports  have  at  problems,  reported cases of substance  it  from  52%  of  some  time  attempted  can abuse.  not  be  the  denied  facilities to that  The apparently low  indicate  get  help  there  that  for  were  incidence  of  either  residents' very  few  substance  abuse in mental health boarding homes will not come as a surprise to many persons  working in the  mental health  field. And yet,  while  substance  related  Figure 3. PREVALENCE/INCIDENCE OF SUBSTANCE ABUSE  Number of Boarding Homes  O X 171  r— "U  74  problems are likely far greater among the "street people," or tenants of derelict rooming houses in the city's poorer quarters, there are clear indications that diagnosis substance abuse is health boarding  homes.  a problem in  at  dual  least some Vancouver area mental  And if even one resident in any given facility has  problems related to substance use then it is potentially cause for concern.  a. Resident Responses  Resident reports regarding the prevalence of substance abuse are considered below. Six of the ten residents indicated that they consumed alcohol on a monthly basis, two reported that they drank alcohol on a yearly basis, and two reported that they never drank alcohol. One of the persons who reportedly consumed alcohol monthly also indicated that he/she used marijuana on a yearly basis. There was no other substance use indicated by the residents. Only one of the resident respondents lived in a facility that strictly forbade alcohol use; not suprisingly, this resident was one of the two people who reportedly never drank alcohol. Residents from facilities that did not allow any level of alcohol use were not as well represented as were residents from facilities that tolerated at least moderate alcohol use.  None of the residents reported that  they  had abused substances, although three  of them indicated that at least one other person in their boarding home had. Two of these residents were from the same facility (neither the director nor the third resident who responded from this facility corroborated the reports of substance  abuse).  Similarly, the other report of substance  abuse was not  75 corroborated either by the five coresidents who responded or the director. It is difficult to determine if the contradictory reports by residents within the same facility were due to differences of opinion, or differences in available information.  Self reports of substance abuse are notoriously unreliable. Thus, residents were asked if they had ever received treatment for substance abuse, if they had ever tried to get help for substance abuse, and if they had ever been told they had a substance abuse problem, in an attempt to test (and increase) the internal validity of prevalence estimates. While none of the residents reportedly had a substance abuse problem, three reported that they had substance abuse, three reported that they had abuse, and three reported that they had  received treatment  tried to get  been identified  help  for  for substance  as substance abusers. Not  surprisingly, it was the same three residents (from the same facility), who had both tried to get treatment for, and been told that they had, substance abuse problems. However, only two of these residents had actually received treatment; one of the residents who had received treatment was from a different facility. Nontheless, if we accept that the three questions: 2)have you  tried to get help; and  3)have you  l)have you received treatment;  been told you have a problem,  are  accurate indicators of substance abuse, then we can speculate that three residents actually did have substance abuse problems, despite their claims to the contrary. The key word here, of course, is if.  76 D. DEMOGRAPHIC CHARACTERISTICS OF RESIDENTS  The  second research question that this  study  posed concerned the demographic  characteristics of Vancouver area mental health boarding home residents, and the relationships between substance  these  use and/or  characteristics  abuse. For instance,  and the prevalence/incidence of are  men more  likely to  abuse  substances than women? Information concerning gender was available for a total of  151 male residents (48% of the residents for whom data were available) from  nineteen different homes,  and 162  female  residents  (52% of the  residents for  whom data were available) from twenty different facilities, equalling a combined total of 313 persons (87% of the residents in the sample). Data were missing for forty-five residents from three facilities. Seven homes had no men, six homes had no women, and thirteen homes had both men and women. Figure 4 shows the number of male and female residents in the participating boarding homes. There appears to be a fairly equal balance between the number of men and the number of women residing in mental health boarding homes. This distribution of men  and women differs from that reported by Davis (1987),t who found that  73% of referrals to boarding homes involved men. Of course, the Davis study did not focus on persons who had been accepted into, and were residing in boarding homes. Perhaps there is a higher rate of referral rejection for men, or a higher turnover of male residents, which would account for the discrepant figures. Based on  director's reports, the data from this  study do reveal a moderate inverse  relationship between the number of males in boarding homes and the residents' average length of stay (Cramer's V = .5), but this relationship is not statistically  tThe Davis study is referred to in more detail in Chapter IV.  Figure 4. RESIDENT GENDER  RESIDENT  GENDER  The Number of Male and Female Boarding Home Resident;  Data wefe missing tor loriy-live residents trom irvee dilterem laoiities (N=313)  78 significant. Data were missing in three cases.  According between  to the  director's  reports,  there  appeared  to  be  a  number of men (n=151) in boarding homes  positive  relationship  and the  number of  weekly drinkers (n=12, rho = .35, p<.05), and the number of women (n=162) and the number of yearly drinkers (n=57, r = .69, p<.01). Data were missing in six cases. There was also a fairly strong positive relationship between the number of women in boarding homes and the total number of people in any given facility who  consumed  alcohol  (r = .72,  p<.01).  Data  were  missing  in  four  cases.  According to these findings, the more men there are in a boarding home the greater the frequency of alcohol consumption, while the more women there are the greater the number of alcohol consumers. No relationship of any import was noted between residents' gender and the prevalence of substance abuse.  Age was another demographic variable that was identified. According to directors' reports,  the  average  age  of  residents  in the  different  facilities  ranged from  twenty-five to sixty-five, with a mean of forty-four, standard deviation of thirteen, and median of forty-eight across all facilities for which data were available. Data were missing in four cases. Figure 5 shows the distribution of residents' average age within each of twenty-five facilities, f As can be seen, fourteen (56%) of the facilities have an average resident age of fifty or less, while eleven (44%) have an average resident age of fifty-one or more. The strongest correlations between the  average  age  of  residents  in  any  given  facility  and  the  prevalence  of  substance use and/or abuse in that facility were between age and monthly alcohol tThe "count" on boarding homes.  the  horizontal axis  of figure 5  represents  the  number of  CD  W  s  o a o i—i  Q  A V E R A G E RESIDENT A G E Director Reports of the Average Age of Residents: By Facilities  < O to >< PQ W O  < w o < OS  w > CO  z,  w Q  cn W Qi  LEGEND Sid Dev - 13 09 Mean = 44 2 N • 25  UH  O Z  25 27 29  31  33 35 37 39  41  43 45  47  o I-H  H pc; P Q H  Average Resident Age Data are missing from four facilities (n-25) The displayed curve >s the normal curve for the distribution  49 51 53 55 57 59 61 63 65  80 consumption (rho = -.45,  sig<.05)  sig<.01),  the  and  between  and  average  yearly marijuana consumption (rho = -.51, age  of  residents  and  the  prevalence  of  marijuana use, with the daily, weekly, monthly, and yearly categories of marijuana use combined into one total number of users category (r = -.54, p<.05). Data were missing in six cases. While neither of these correlations were particularly strong, they  do  suggest  alcohol  on  a  marijuana  on a yearly basis tends to decrease as  the  age  residents'  increases.  between the  that  average  the  consumption  There do not  of  appear  age of residents  to  be  any  monthly  basis  and  of boarding home  meaningful  and the prevalence/incidence  relationships of substance  abuse.  One concern that has been expressed regarding the use of drugs and alcohol by persons with  with psychiatric problems is that these substances will interact poorly  prescribed medications. Accordingly, this study has examined both the  frequency, and the variety of medications used by Vancouver area mental health boarding home residents. Director reports indicated that 102 residents (37%) used tranquilizers, 38  (14%)  133  (49%)  used neuroleptics, forty-nine (18%)  used lithium, 116  (43%)  used  used antiparkonsonians,  antidepressants,  1 (.4%)  used some  other medication, and four (2%) used no medication at all. t Data were missing for  85  residents  residents use  from seven  the  specified  facilities  (n = 273).  medications.  Figure  Neuroleptics,  6  shows  how  many  antiparkonsonians  and  tranquilizers are the most frequently used. A strong relationship seems to exist between  yearly alcohol use  antidepressants  and  the  use  of  tranquilizers  (r = .78,  p<.01),  (r = .65, p<.05), and antiparkonsonians (r = .87, p<.01). There does  tThe medications used categories are not mutually exclusive, resident could be using a wide variety of different medications.  as  any  single  00  MEDICATION  USE BY RESIDENTS  The Number of Residents Who Take the Specified Drugs: Director Reports 273  n  :  Medications Taken by Residents Director reoorts only Data is missing in seven cases (n>273) Med'cei'on names have been abbreviated  1  82 not appear to be a significant relationship between medication use and substance abuse.  The  literature suggests that dual diagnosis  more  transient  group  than  their  substance  non-substance  abusers are generally a  abusing counterparts, t  attempt to test the above premise, the residents'  In an  average length of stay in  boarding homes was tested against their use and/or abuse of substances. It is hardly surprising that directors only selected the months and years categories, and in no case indicated that residents stayed, on the average, for a period of weeks. The  vast majority of facilities (23 of the twenty-six homes for which data were  available, or 88%)  indicated that the residents  stayed, on the average, for a  period of one or more years. Data were missing from three facilities, t  There was some alcohol use in all of the facilities with an average length of stay  measured in months (n = 3),  cases of marijuana use  and 25% of the facilities that had reported  had an average  length of stay  measured in months,  compared to 6% of those that had not. Nonparametric statistics did not reveal significant relationships between residents' average length of stay and substance use and/or abuse. In any case, it is difficult to make clear connections between length  of stay  in boarding  homes  and drug  use  and/or abuse,  because  the  average length of stay is not sensitive to the individual's length of stay. Thus, it is difficult to establish how closely the individual's length of stay is influenced by  tRefer to the section on homelessness in Chapter III for a discussion of this point. tin all three cases the directors had completed staff, rather than director questionnaires, and the question concerning the average length of stay was not included on the staff questionnaires.  83 his/her substance use. In retrospect, it is apparent that categories such as: less than  one year, one to two years  less a day, two to five years, and greater  than  five years, would have provided more variability in the data.  Another  question  that  this  study  addressed  concerned  the  size of boarding  homes. Is the size of a boarding home,- measured by the number of residents living in the facility, related to the occurrence of substance use and/or abuse in that  facility?  The  assumption  between care givers  behind  and residents  this  question  would become  was  that  the  relationship  less personal as the size of  homes increased. While information regarding the size of mental health boarding homes and outcome hospital wards  has  for residents been  is  not  available,  found to influence  the  the  course  size of hospitals of peoples'  and  psychiatric  disturbances. Ulman (1967), for instance, found that patients were released from small hospitals (1974),  large  more often wards  tend  result in less spontaneous responsibility;  there  is  than from large to  create  hospitals,  and according to Moos  towards  a more rigid structure,  pressure  relationships  and decreased  less support from staff  patient independence  and less attention  and  to personal  needs on large wards; and the staff on large wards feel an increased need to control  and  manage  the  patients.  Mishler's  (1981)  conclusion  that  the  term  "hospitalitis" provides a more accurate explanation of peoples' behavior than the term "schizohprenia" may not be too far off the mark.  The  minimum number of residents in any given facility was two (there were two  homes of this size), the maximum number was forty-seven, the mean was 12.35, the  standard  deviation  was  9.2,  and  the  median  was  10.  As  previously  84 mentioned, the total number of residents in the twenty-nine participating facilities was  358.  Figure 7 shows the  distribution of residents  across  all twenty-nine  facilities. As can be seen, the resident populations follow a normal distribution quite closely, with a limited number of uncharacteristic "outliers."  Alcohol use appeared to be the only substance use variable that was related to boarding home size (r = .6, p<.01). Of course, the more residents there are the greater the  chance becomes that  there  will be substance  users  in any given  facility. Oddly enough, neither marijuana use nor substance abuse are related to boarding home  size.  Thus,  the  interesting  point here  is  not  that  there  is a  positive relationship between boarding home size and alcohol use, but that there are  not  any  observable  relationships  between  boarding home  size  and either  marijuana use or substance abuse.  And what of diagnoses? Is the  psychiatric diagnoses of boarding home residents  related to their use,  or abuse  non-use,  of drugs and/or alcohol? According to  directors' reports, 191 residents (68%) had been diagnosed as schizophrenics,! 34 (12%) had been diagnosed as manic depressives, depressives,  17 (6%) had been diagnosed as  20 (7%) had been diagnosed as personality disordered, 20 (7%) had  been diagnosed as organically disordered, and 20 (7%) had been given some other diagnosis. $ None of the directors selected the diagnoses are not seen as relevant category,  although one cf them did state that this category  was "particularly  tThe study by Davis (1985) reviewed in Chapter III indicated that 54% of his sample of boarding home referrals had a diagnosis of schizophrenia. tThe diagnoses included in the other category include: mental retardation (seven cases), schizoaffective disorder (four cases), eating disorder/bulimia (two cases), Parkinson's disease (two cases), alcohol syndrome (two cases), and one case each of Alzheimer's disease, cerebral palsy, and multiple sclerosis.  BOARDING HOME SIZE The Number of Facilities With the Specified Number of Residents Director Reports  LEGEND Sid Dev - 9 04 Mean * 12 3 N - 29  95  12 U 5 17 195 22 24 5 27 29 5 32 34 5 37 395 42 44 5 47 49 5  number of residents Daia is available lor an t w e n i y - n m e facilities T h e C u r v e is the normal c u r v e (or i n e d'SlnbuIiOn  86 important with people with mood disorders, [because they] can understand what's happenening better." There was  reportedly at least one person who had been  diagnosed as schizophrenic in every boarding home for which data were available. Data were missing for 76 residents (n = 282) from six homes (n = 23). Figure 8 shows  the  number  of  people  who  had  been  given  the  specified  diagnoses.  Schizophrenia is considerably more comon than any of the other diagnoses. There seemed to be significant relationships between the following variables: the number of  people  diagnosed  as  schizophrenic  and  the  number who  consumed  alcohol  (r=.61, p<.05); the number of people who had been diagnosed manic depressive and the number who consumed alcohol (rho = .55, sig<.01); and the number of people who had been given a diagnosis of personality disorder and the number who consumed alcohol (rho = .42, sig<.05).  It is somewhat paradoxical that depression was the only diagnostic category that seemed  to  be  related to  the  reported number of people  who  abused alcohol  (rho = .63, sig<.01), while this same diagnostic category was not related to the number of people who used alcohol. While these findings do support those in the literature, the data refer to the total number of residents in a given facility that have been given each of the specified diagnoses. It must be remembered that the relationships between diagnoses  and substance  noted  individuals, but  here  patterns.  do  not  apply  to  use and/or abuse that have been rather,  delineate  more  general  00  DIAGNOSES OF MENTAL HEALTH BOARDING HOME RESIDENTS The Number of Residents with the Specified Diagnoses 282-,  —  schizo  ,  manic dep  depression  Psychiatric Diagnoses  Director reports only Data are missmg m six cases N-282  personality  organic  other  88 a. Resident Responses  Resident responses, concerning demographic characteristics, are described below. Of the ten residents who participated in the study, five were men and five were women.  The  However,  males  drinkers drank drank  same  alcohol  number  appeared  of  to  females  consume  (4)  alcohol  alcohol on a monthly basis, on  a  yearly basis.  and  There  males  more  while  consumed  frequently;  two  appeared  (4)  to  of the be  alcohol.  all four  male  female drinkers  only  a  moderate  relationship between gender and alcohol consumption, Cramer's V = .52). The only resident that reportedly used marijuana was male.  Four  of  the  residents  who  completed  questionnaires,  according  to  their  own  reports, were under the age of thirty, four were between the ages of thirty-one and forty-nine, one was between the ages of fifty and sixty-four, and one was over the age of sixty-four. Thus, eight of the residents were under the age of fifty.  Six  of the  eight residents who  were under the  age  of fifty  consumed  alcohol on a monthly basis, and they all consumed at least some level of alcohol. On  the  other  hand, neither  of the  residents over the  alcohol. There appeared to be a moderate  age  of fifty  consumed  reationship between alcohol use and  resident age, with the data listed in ordinal form (Spearmans rho = -.59, sig<.05). Additionally, with alcohol use recoded into yes/no categories, and age recoded into 0-49/50-99 categories, there  was  a very strong relationship between the  "age"  and "alcohol abuse" variables (Phi=l., Fisher's Exact Test<.05). The one resident who reportedly used marijuana was in the thirty or less age range. According to the reports of this small sample of residents, younger persons are more likely to  89  use, and thus abuse substances. Of course, as has been previously acknowledged, the  small  sample  of residents  who participated in this  study  are not  representative of all Vancouver area boarding home residents, and findings can not be generalized across the respondent/nonrespondent boundaries.  Resident's employment status was  another demographic variable that was  explored in this study. Three of the ten residents reported that they were employed. All three of the employed residents lived in the same facility, and all three consumed alcohol. Neither the single marijuana user nor the two abstainers were employed. The employment status of residents did not appear to be related to the prevalence/incidence of substance use and/or abuse, for the residents who participated in the study.  A variable that is somewhat similar to employment is education. Does a person's level of education affect his/her use of drugs or alcohol? Perhaps highly educated persons are more likely to be aware of the potential dangers of substance use. Four residents had completed some secondary school, one had graduated from secondary school, one had completed some post secondary school, and three had graduated from a post secondary program. Data was missing in one case (the resident who admitted to marijuana use did not answer this question). The relationship between education and substance use and/or abuse was weak.  The last resident characteristic to be considered here concerns the use of  90  prescription drugs. Seven of the resident participants took medication,t one did not take medication, and one did not know if he/she took medication. Data was missing in one case. The two people who either did not take medication or did not know if they  took medication (one person in each case) consumed alcohol,  while five  residents  of the  strong associations  on medication drank alcohol, and two did not. No  were noted between medication use and either substance use  or substance abuse.  E. DEMOGRAPHIC CHARACTERISTICS OF DIRECTORS AND  The  third  research  characteristics homes.  of  question  the  posed  directors  Do the demographic  and  in  this  staff  study  concerned  members  of  the  mental  characteristics of care givers  STAFF  demographic  health boarding influence  their  perceptions of the "problem"? As previously noted, individual respondents have very  different  consumption. give  views concerning the Is  there  an observable  and their gender? Of the  study, twenty-one (72%)  acceptability  of moderate  relationship between the  twenty-nine  levels of alcohol responses  people  directors who participated in the  were women and eight (28%)  were men. Of the staff  members for whom data were available, twelve (63%)  were women, and seven  (37%) were men. Data was missing in one case. Not only do more women work in Vancouver area mental health boarding homes than men, but an even greater number of women occupy the top positions. Perhaps this is due to the nursing backgrounds  of many  of these  persons,  and the  preponderance  tMedications identified by residents included Lithium cases), Stelazine, Rivotril, and an "anti depressant."  (two  of  women in  cases), Halcion  (two  91 nursing.  In order to measure the strength of the relationships between gender and reports of  resident  substance  use  and/or  abuse,  the  interval  level  data  from  the  prevalence of substance use categories were recoded into ordinal data (0 users =1, 1-6  users = 2,  7-12  users = 3,  13-20  users = 4,  21  or  more  users = 5).  appeared to be a significant relationship between the directors' gender number of people  identified  Women identified more women relationship  as alcohol users (Cramer's V = .56,  more alcohol users than did men.  directors'  gender  and the  Of course  number  of  and the  Chi-Square<.05). ... there were  than men. Nonetheless, there did not appear to be a between  There  significant  cases of substance  abuse they reported; nor was there a significant relationship between gender and substance  use  and/or  abuse  when  both  director  and  staff  responses  were  considered together.  Another demographic variable that  was  tested in relation to reported cases of  substance use and/or abuse, was the respondent's age. was  reportedly  thirty-one  to  thirty  forty-nine  forty-nine and sixty-five  or less age  years  range,  of  age,  One (3%) of the directors  twenty-four  and four (14%)  (83%)  were  were between the  in  the  ages of  (n=29). Five staff members (26%) selected the thirty or  less age category, eleven (58%) selected the thirty-one to forty-nine age category, and three (16%)  selected the fifty to sixty-four age category.  Data was  missing  in one case (n= 19). Only a weak association was found between directors' age and the number of alcohol users they identified (Cramer's V = .32). No noteworthy relationships were noted between the age of directors or staff and the number of  92 marijuana users and/or substance abusers they identified.  Education was another variable that was explored. Does the level of directors' and  staff  members' education effect  their  perceptions  regarding residents'  use  and/or abuse of substances? Seventeen (59%) of the directors and eight (42%) of the staff members had a college diploma or university degree; twelve directors (41%) and eleven staff members (58%) reportedly did not have a college diploma or  a university degree.  Data  was  missing from  one  staff  member. Tests of  association did not reveal any significant relationships between staff and directors' education and substance use and/or abuse.  Two other questions, also designed to elicit the respondents' level of education, or in this case, training, were included in the questionnaires. These two questions  training in the  asked director and staff respondents if they had received any areas of  substance abuse, or dual diagnosis substance abuse. Six directors  (21%) and five staff members (26%) had, and twenty-three directors (79%) and fourteen staff members (74%)  had not reportedly received any training in the  area of substance abuse. Data was  missing from one staff member. Similarly,  five directors (17%) and three staff members (16%) had, and twenty-four directors (83%)  and sixteen  staff members (84%)  had not received any training in the  area of dual diagnosis substance abuse. One director indicated that he/she had received substance abuse training at one of the other boarding homes surveyed in this  study.  However, the  director of this  other boarding home  he/she had not had any training in either substance substance  abuse,  and in reference  to the  abuse  indicated that  or dual diagnosis  latter of these two  areas,  said: it  93 "would be nice to have this."  A significant relationship was noted between directors who reportedly had received both  substance  abuse  Chi-Square<.05).  and dual diagnosis substance  Four  of  the  six  directors who  abuse  had,  training  and only  (Phi=.67,  one  of  the  twenty-three who had not received training in the area of substance abuse, had also received training in the area of dual diagnosis substance abuse. Similarly, 80% of the directors who had, and only 8% of those who had not received training in the area of dual diagnosis substance abuse, had also received training in the more general area of substance abuse. Though not significant at the 95% level,  directors without  substance  abuse,  However, there  training  reported fewer  in  either  substance  cases of substance  abuse use  or  dual diagnosis  by residents  were not any note-worthy relationships between  the  (Phi=l). "training"  and "substance abuse" variables.  F. BOARDING HOME  The  POLICIES  fourth research question concerned boarding home policies as they relate to  substance use and abuse. Do Vancouver area mental health boarding homes have  policies  Forty-four indicated  regulating  (90%) that  of  their  the  the use of drugs participating forty-nine  facilities  did indeed have  and alcohol  by  directors  staff  policies  and  residents?  concerning the  members use  of  substances by residents; four respondents (8%) indicated that their facility did not have such a policy, and one (2%) respondent indicated that he/she did not know if  the  facility  had  a  policy  concerning substance  use.  When  only directors'  94 responses  are  considered  (n=29),  it  appears  that  twenty-five  (86%)  of  the  facilities have policies concerning substance use and/or abuse, and four (14%) do not.  Seven directors indicated that their "policy" was to totally prohibit substance use by residents; thirteen directors indicated that their policy was to prohibit the use of substances  within their facilities; one director stated that the policy was to  prohibit drunkenness; and one director said: "[we] try to monitor and as much as  possible  prevent use,  but this  is  not  a prison ... [the  facilities]  primary  function is [that of] a home." While comments delineating the house policy were not included by all residents, from the available data it is reasonable to conclude that  at  least  twenty  facilities  (69%)  had policies  that prohibited the  alcohol or drugs on the premises, and at least twenty-two  use  of  facilities (76%) had  policies that restricted the use of substances on the premises.  The one staff respondent who indicated that he/she did not know if the facility had a policy, was from a facility that did not appear to have substance use of any kind (which helps to explain his/her lack of insight). The director of this same facility, and one additional staff member, indicated that the boarding home did in fact have a substance use policy, which consisted of screening applicants prior to their admisssion, to ensure that no one who was likely to use or abuse substances was admitted to the facility.  According to directors' reports (n = 29), 50% of the facilities that did not have a substance use policy had at least one resident who consumed alcohol, and 50%  95  did not. None of the policy free homes reported any cases of marijuana use, amphetamine use, or inhalant use. The relationship between the existence of a policy and the prevalence of substance use by residents was not statistically significant, with or without the inclusion of staff reports. Similarly, there did not appear to be a significant relationship between the presence or absence of a boarding home policy concerning substance use, and the incidence of substance abuse. Of  course, it is not surprising that the mere existence of a policy is not  related to the prevalence/incidence of substance use and/or abuse. It is the exact nature of the policy that counts.  One way that boarding home policies were further explored was by asking respondents what their response to substance use and/or abuse was when (or if) it occurred. Table 2 lists the reported likelihood that directors and staff would respond any of a specified number of ways to alcohol consumption by residents. The perceived appropriateness  of the  specified  responses is  considered by  respondents in relation to alcohol consumption in the boarding home, outside of the boarding home, and in either location.  Twelve directors (41%) and eight staff  (40%) said that they would not do anything about residents drinking alcohol outside of the home. This  point of view was summed up nicely by one director,  who said: When a resident leaves the home for whatever purpose [he/she is] then governed by the laws of the community - if a resident's behavior impacts upon the home or other residents then intervention by staff is expected. Another director expressed a similar sentiment when he/she said:  96 Table 2. DIRECTOR AND STAFF RESPONSES TO ALCOHOL CONSUMPTION BY RESIDENTS Responses to Drinking In-Home, Out-of-Home, and in Either Location Response To Drinking  Location Of Drinking  Would Not Do Anything  In-Home Out-of-Home Either Location  12 (41%) 5 (17%)  Ask to Stop  In-Home Out-of-Home Either Location  2 ( 7%) 8 (28%)  In-Home Out-of-Home Either Location  6 (21%) 1 ( 3%) 5 (17%)  8 (40%)  Refer To Substance Abuse  In-Home Out-of-Home Either Location  2 ( 7%) 1 ( 3%) 4 (14%)  1 ( 5%) 5 (25%)  Refer To Self Help  In-Home Out-of-Home Either Location  1 ( 3%) 2 ( 7%) 3 (10%)  2 (10%) 4 (20%)  In-Home Out-of-Home Either Location  6 (21%) 1 ( 3%) 2 ( 7%)  In-Home Out-of-Home Either Location  2 ( 7%) 4 (14%)  4 (20%)  In-Home Out-of-Home Either Location  5 (17%) 2 ( 7%) 9 (31%)  3 (15%) 2 (10%) 2 (10%)  Refer To Mental Health  Evict  Control Money  Other  Respondent ID Director  -  Staff 8 (40%)  10 (50%) 1 ( 5%)  4 (20%) 7 (35%)  Numbers refer to the number of respondents who would reportedly respond the specified ways in the specified circumstances Director n = 29, Staff n = 20  97  As long as its not abused I feel residents have the right to go have a drink. They are adults and have the right to make their own decisions as long as it does not create violent/abusive behavior towards themselves or others. Another director, who also stressed the result rather than the act of drinking, stated that "there are happy drunks and angry drunks. Angry drunks are sent to their room." Also, concerning drinking outside of the home, another director said: "it is not my business - but if it [became] a problem with budgeting or health I would help them in those areas."  On the other hand, six directors (21%) and four staff members (20%) indicated that they would evict residents for drinking alcohol in the home, one director (3%)  said that he/she would evict residents for drinking alcohol outside of the  home, and  two directors  (7%)  and seven staff members  (35%)  reported that they  would evict residents for drinking alcohol either in the home or ouside of the home.  However, some of the respondents who indicated that they would evict  residents for drinking, qualified their choice by stating that drinking would only result in eviction "if [the] behavior continued," or if a "contract had been broken," or "as a last resort." Figure 9 shows the boarding homes' responses to substance use by residents. In addition to the "in-home," "out-of-home," and "both in-home and out-of-home" categories, a "neither" category was added to show how many respondents reportedly would not respond in the specified manner regardless of where the drinking took place. As can be seen, none of the directors would do nothing about residents drinking within their facilities. Thus, we can assume that all of the directors would do something about alcohol  00  BOARDING HOME R E S P O N S E TO S U B S T A N C E U S E BY RESIDENTS w  Do Directors Respond the Specified Ways?  00  PQ <r, W  o  2 <: CO  CQ co O <V U  W  CO O OH  CO  w  OS  in  a>  e  o o> c  X  ia  < oo  CD  W  S o  X a  z  X)  E  => Z  Do Nothing  Ask To Stop Mental HeeUh Subst Abuse  M  Q OS < O CQ  Response To Substance Use Categories are not mutually exclusive N-29  Sell Help  Evici  Control Money  Olher  99 consumption within their facilities. But what would they do? The highest selected response to "in the home" drinking was asking residents to stop, and yet only seven  directors selected  majority  of  directors  specified  ways,  this  indicated  regardless  twenty-three  directors  twenty-three  (79%)  response.  (79%)  of  that  As Figure  they  where  the  would not  would not  would  9 clearly not  drinking  refer  respond in  took  residents  control residents  depicts,  money,  place.  to  a  the  any For  self  vast  of  the  instance,  help group,  and twenty-two  (76%)  would not refer residents to a substance abuse counsellor. Not surprisingly, many directors (55%) selected the "other" category.  Several respondents selected the other category simply as a means of elaborating on, or qualifying another selection. However, some respondents truly did specify responses  that were  questionnaires.  decidedly different from  For instance,  in one  facility  those that were when  residents'  specified in the substance  use  is  "overdone," they are asked to sign a contract restricting or prohibiting further consumption.  Several  other  facilities  review  the  boarding  home  policy  with  residents who drink alcohol or consume drugs.  As would be expected, the prevalence of substance use in any given facility is closely linked to the likely response of the director and staff members of that facility. Eleven of the twelve facilities that do not do anything about residents drinking  alcohol outside  of  the  home,  and all five  facilities  that  do not do  anything about residents drinking alcohol either inside or outside the home, have at least one resident who consumes alcohol.  100 Significant relationships were noted between facilities that reportedly had at least one  alcohol  consuming  resident,  and  facilities  that  either  did  nothing about  residents' alcohol consumption (Phi = .51, Chi-Square<.05), or facilities that referred residents who drank to mental health counsellors (Phi = .51, Chi-Square<.05).t At least one resident consumed alcohol in 94% of the facilities that reportedly would not do anything about alcohol consumption by residents, compaired to 50% of the facilities  that  consumption  by  reportedly residents.  would  do  something  Coincidentally,  the  (unspecified)  crosstabulation  about  alcohol  distributions  for  facilities that referred clients to mental health counsellors for drinking alcohol was exactly the opposite of that mentioned above in relation to facilities that did not do anything about residents consuming alcohol; there was an inverse relationship between referrals to mental health counsellors and reports that there was  at  least one alcohol user in any given facility.  Another aspect of boarding home policies concerning substance facilities  use involves the  admittance practices. Certainly, there are not likely to be substance  abuse problems in facilities to which substance using persons are routinely denied access.  Of course,  it does not necessarily  follow that there  are likely to be  substance abuse problems in facilities that do accept substance using applicants. Only one director (4%) indicated that he/she never admitted people with histories of substance abuse into the facility ("if the abuse [was] current.") Thus, while additional comments by this respondent suggested that people with histories of substance abuse probably were never knowingly admitted into the facility, his/her  tThe response variables were recoded into yes/no values (rather than differentiating between substance use in the home, out of the home, and in or out of the home).  101 qualifying statement also suggests that the term history of substance abuse quite possibly meant different things to different people. Another respondent had this to say  about admitting people with histories of substance  abuse into the facility:  "This boarding home does not accept clients with a recent history of drug or alcohol abuse. It is extremely difficult to deal with straight psychiatric problems, and even harder to deal with compounded problems."  Seven (25%) directors indicated that they rarely accepted appplicants with histories of substance abuse. Eleven (39%) directors indicated that they sometimes accepted applicants with histories of substance abuse, with one of them stating that this decision depended "on [the] time elapsed since [the] substance abuse." Four (14%) directors indicated that they  often admitted people with histories  abuse into their facilities. And finally, only five history of substance  of substance  (18%) directors reported that a  abuse did not influence their decision to accept or reject  applicants to their facilities. Data was missing in one case.  Tests  of  acceptance  association  were  policies and the  conducted  between  the  boarding  prevalence/incidence of substance  home  use  referral  and/or abuse,  with the acceptance policies recoded from five to two values. The values never, and  rarely were combined to form one do not accept category, and the values  sometimes, often, and does not influence our decision were combined to form one do accept category.  There was  acceptance  and  (Phi=.44,  policies  the  a moderate relationship noted between referral  presence  of  marijuana  use  in  boarding  homes  Chi-Square=.07); none of the facilities that did not accept applicants  with histories of substance abuse reported any cases of marijuana use. Thus, all  102 eleven  facilities  with histories abuse abuse,  with at least one of substance  in facilities while  four  that  abuse.  did not  of the  reported marijuana user There were accept  facilities  applicants  no reported cases of substance  applicants  that  accepted  with  histories  reportedly did accept  of  substance  applicants with  histories of substance abuse had at least one resident who was currently abusing substances. substance  Put differently, all of the facilities that reportedly had at least one abusing resident also indicated that they did accept applicants despite  their histories of substance abuse.  Another aspect of boarding home substance use and/or abuse policies concerns the tendency to permit, or not to permit, the  consumption of acholic beverages at  parties or other special functions. Four directors (14%) indicated that they did allow  alcohol  consumption  at  special  functions,  seven  (25%)  said  that  they  sometimes allowed alcohol consumption at special functions, and seventeen directors (61%) said that they did not allow alcohol consumption at special functions. With the above three values (yes, no and sometimes) recoded into two values (yes/no), it  appears  that  alcohol  consumption  was  permitted  facilities, and was not permitted in seventeen (61%) missing in one case.  in  eleven  (39%)  of  the  of the facilities. Data was  Figure 10 shows the number of facilities that do, do not,  and sometimes allow alcohol consumption at special parties. The majority do not\  One director had this to say about serving alcohol at special functions: The serve  residents alcohol  vote [at at  the  house monthly  meetings] on whether formal  [candle-light]  or not to dinners  we  have, and it seems to me that it is about 50/50. They voted in  103  Figure 10. ALCOHOL CONSUMPTION AT SPECIAL HOUSE FUNCTIONS  ALCOHOL USE AT SPECIAL FUNCTIONS The Number of Homes That Allow Alcohol Consumption at Special Functions  Someiimes  7 / 2b%  Data was missing in one case N=28  104 favor  of alcohol last  don't abuse want  to  the  drink  month and against  privilege.  Our residents  alcohol very  it this  month. They  don't really  much. We had one  seem to  woman who  bought a lot of alcohol once, but she didn't drink it, she just bought a case [of hard liquor] and kept it [in her room].  Another director, who sometimes allowed alcohol consumption at special functions, and who expressed an interest in starting a "pub night," commented that: "[The] owners [of the boarding home] do not want any drinking in the facility, [but] I have worked in other homes where there was a pub night and it [was] quite successful. I don't think that it is harmful for someone to have a glass of wine once a month." An interesting contradiction became  apparent here; on the one  hand this director advocated a pub night and thought an occasional glass of wine was  fine,  while  on  the  other  hand  he/she  indicated  that,  for  people  with  psychiatric problems, substance use and substance abuse were synonymous terms. Following the logic of a classical syllogism, advocating substance use in this case is tantamount to advocating substance  abuse.  One other director who indicated  that alcohol consumption was allowed at special functions said: "We had a party here  last  week and I made  an alcoholic punch, and about one  half  of the  residents drank the alcoholic punch and the rest drank a nonalcoholic punch."  Surprisingly,  the  association  between  boarding  homes  that  allow  alcohol  consumption at special parties, and reports of alcohol use, is very low (Phi = .24). This  weak  forbidding  association alcohol  is  due,  consumption  no doubt, within the  to  the  facility,  practice in many while  permitting  homes  of  moderate  consumption outside of the facility. There does not appear to be a relationship  105 between substance abuse and the practice of allowing or not allowing residents to drink alcohol at special functions.  We  have  established  uncommon, in very interesting  paradox  that,  while  substance  (especially  few cases is this use considered between  the practices  alcohol)  use is  not  abusive. This reveals an  and professed  beliefs  of some  respondents. Though many respondents make a clear distinction between the use and  abuse of substances, many of them also believe that substance use and  substance abuse are synonymous terms (in reference to people with psychiatric problems). Eight (47%) of the staff members and thirteen (46%) of the directors indicated that substance use and substance abuse were synonymous terms; six staff members (35%) and seven directors (25%) indicated that use and abuse were not synonymous terms; two staff members (12%) and seven directors (25%) indicated that the term substance use was sometimes synonymous with the term substance  abuse;  one director  (4%) indicated  that  he/she  did not know if  substance use and abuse were synonymous terms; and one staff member (6%) provided  a comment that could not be coded into the above categories.! Data  were missing from one director (n = 28) and three staff (n=17). Figure  11 shows  the percentage of directors, staff, and residents who did, did not, and sometimes thought  that  Additionally,  substance  use and substance  the no and sometimes  values  abuse  were  are combined  synonymous to form  terms. a fourth  category, as it can be assumed that respondents who selected the "sometimes" category do not believe that substance use and substance abuse are synonymous terms, but rather, are only so under special circumstances.  tThis respondent's reaction to the specified statement was: "it needs help."  106 Figure  11.  ARE SUBSTANCE USE AND SUBSTANCE ABUSE SYNONYMOUS TERMS?  P e r c e n t a g e of  JO  ii »3: O O  ro  2  >>  •oo 3  *  U3J3  CO  CO 9 «n  Q. O  Respondents  z  cm  II ro  ° a  —  o2 oo cr — m oo  CO  -<C/> Z H  3  z z  o >  a  O 3 CL —  ll  a5 * a•  ,o  <* <t '  <A =.£ o a  •o «9 »-=  o * o o 3 « cr 3 5 ° <» a 5 o 0. o> c is  -<o  m Oc cen com 2  O  Q.  33 CD to CL CD 3  mz  CO  2) CD T3  O —n </>  C/> H > Z o  m  107 The following comments are examples of those that were coded as disagreeing with the statement that substance use and abuse are synonymous terms: 1.  "Usually the care team says to residence [sic] one or two beer is OK. I tend to support this view, although very few at our residence drink."  2.  "Every case I've  seen has been so individual. I do not believe there is  always a worsening of psychiatric symptoms with substance use." 3.  "In the majority of people they aren't any more affected than other 'well' people."  4.  "I disagree. Many of our residents have had one beer when going out with friends and their behavior [has] not [taken] on any radical change."  5.  "Use is different than abuse. I disagree with the above statement. If one has a psychiatric problem it does not necessarily mean [one] will be [an] alcohol abusers. Use of alcohol is an individualized experience and what one person can tolerate another person can not."  6.  "I think  it's  nonsense.  I do warn  clients  about possible  dangers about  medications and booze, and ask them to tell me if they've been drinking."  Similarly,  the  agreeing with  following comments the  statement  that  are examples substance  of those that were use  and  substance  coded as abuse  are  synonymous terms: 1.  "I agree  that  even  small amounts of substances  can worsen psychiatric  symptoms. One of our clients became extremely difficult to handle after having a few drinks." 2.  "Given the seriousness of symptoms of schizophrenia and affective disorders, any added chemical substance makes them worse. In my twelve years of  108 experience I would say that well over one half of those [residents] under thirty had a history of substance abuse prior to diagnosis."  And,  the  following  comments  are  examples  of  those  that  were  coded  as  conferring that substance use is sometimes abusive and sometimes is not. 1.  "If a person is an alcoholic, yes, but if not a small amount may only make  them happier, but I believe  it must be different in some  cases  according to what medications they take." 2.  "Moderation  is  OK, but most  people  with psychiatric problems seem  to  include compulsive behavior patterns and therefore over do it." 3.  "Sometimes yes causes  a  - sometimes  "worsening" of  no - if the consumption/use of alcohol/drugs  the  psychiatric symptoms,  and  if  the  person  continues to consume/use, then it becomes abuse." 4.  "Usually true, but not necessarily - in the case of marijuana. Probably true for other substances."  5.  In my  experience,  most  people  use  substances  to  get  relief from their  symptoms (i.e. voices, anxiety). However, some [people] seem to be using them (as well as prescribed drugs) for self abuse. Some seem to be able to tolerate  small  amounts  of  alcohol  as  well.  Some  seem  psychotic  on  marijuana. I believe that the responses are highly individual." Regarding  the  inherently  abusive  nature  of  substance  use  by  people  with  psychiatric problems, there appear to be two polarized groups, one at each end of the agreement/disagreement continuum, with an additional group characterized by ambivalence. Of course, as some of the respondents' comments suggest, this "ambivalence" seems to be the result of careful attention to the complexities of  109 individual  circumstances  (which  render  "black  and  white"  generalizations  ineffectual), rather than the result of "wishy-washy" indecision.  In order to test the relationship between substance  the estimated  prevalence/incidence of  use and/or abuse, and respondents' opinions regarding the inherently  abusive nature of substance use, the latter variable was recoded from five to three categories. The / disagree and I sometimes agree values were combined into one category, as were the I don't know and can not code categories. Thus, the data were coded into the three categories of: I don't agree, I do agree, and I don't know. Only the first two values (/ don't agree that substance use and abuse are synonymous terms, and I do agree that they are synonymous terms) were included in tests of association.  Some statistically significant relationships were found between director's attitudes concerning presence (Phi=.55,  the inherently or  absence  abusive  of  substance  Chi-Square<.05).  directors did not believe  While  nature  of substance  using  residents  all fourteen  that use and abuse  in  use, the  and the reported various  of the boarding homes were  facilities whose  synonymous terms had at  least one resident who consumed alcohol, the same was only true for six of the thirteen facilities  whose directors did believe  terms. Thus, it appears that residents  use and abuse  were synonymous  are more likely to consume alcohol in  facilities whose directors do not believe substance use and abuse are synonymous terms. A similar relationship was noted between  the presence of at least one  marijuana user and the opinion that, for persons with psychiatric problems, any level of substance use is abusive because it causes a worsening of psychiatric  110 conditions  (Phi = .59,  Chi-Square<.01).  While  only  one  (8%) of  the  thirteen  facilities whose directors indicated that use and abuse were synonymous did not have any marijuana using residents, nine (64%) of the fourteen facilities whose directors indicated use and abuse were not synonymous had at least one resident who used marijuana. However, there did not seem to be a relationship between directors' attitudes concerning the inherently abusive nature of substance use, and the incidence of substance abuse in boarding homes.  Respondents were  also asked if  going out for a drink could be a positive  accomplishment for people with psychiatric problems, because at least they were doing something. Only one director (4%) and two staff members (11%) indicated that going out for a drink of alcohol was a positive accomplishment. Six directors (21%) and two staff members (11%) indicated that it was sometimes a positive (64%) positive  accomplishment to go out for a drink of alcohol; eighteen  and fourteen  staff  members  (74%) indicated that  drinking  directors  was not a  accomplishment; and three directors (11%) and one staff member (5%)  provided comments that could not be coded into the above categories. Data were missing in two cases (one director and one staff member).  Figure 12 shows how  many respondents did, did not, and sometimes thought that going out for a drink could be a positive accomplishment for people with psychiatric poblems, because at least they were doing something. Additionally, the yes and sometimes values were combined to form a fourth category. Even with these two values combined into a yes/sometimes category, considerably more people indicated that going out for a drink could not be a positive accomplishment, than thought that it could be a positive accomplishment.  C A N G O I N G O U T F O R A DRINK O F A L C O H O L BE A POSITIVE ACCOMPLISHMENT? Percentage of Directors, Staff, and Residents 100  «i  Responses Percemages do not eauai 100 'i don't know" cateqory was not included, and some responses could not be coded 0>f <n-25),Siatf(n-i8VRes (n-10)  112  The following comments are from respondents who indicated that going out for a drink could be a positive accomplishment: 1.  "I think it can be positive that some people with psychiatric problems choose to go out for a drink; since it is a popular social tradition going out for a drink may help strengthen a person's feeling of membership in his culture."  2.  "Having found that most residents do enjoy the occasional bit of pubbing, I see it as a positive step in normal social activity. I stress occasional because I've noticed some residents use alcohol 'to get away from the voices.' Abuse as such seems to lead to a false sense of independence and drifting away from structured programs."  3.  "For some residents, this is applicable because they are going out into the community; resocialization. As long as it is not abused I feel residents have the right to go have a drink. They are adults and have the right to make their own decisions as long as it does not create violent/abusive behavior towards themselves or others."  4.  "I have no problem with people social drinking, or going out for a drink like anyone else, as long as it doesn't create other problems."  5.  "It depends on the individual's behavior when he or she drinks. I have known psychiatric patients to be quite sociable and relaxed and without any problems - as a matter of fact 'Pub Night' is usually held once a week (Saturday) in most psychiatric units - and it appears to be beneficial."  As previously mentioned, the majority of respondents indicated that they did not think that going out for a drink of alcohol was a positive accomplishment for  113 people  with psychiatric problems. The following comments  are examples of this  point of view: 1.  " Going out is a positive accomplishment for many - but consuming alcohol is  unnecessary  and potentially  very dangerous  in combination with many  other drugs. Just as I would refrain from drinking if on prescription drugs (when  drinking  alcohol  has  been  advised  against),  I  would  (and  do)  encourage these people I work with to refrain from drinking." 2.  "Do not agree. Alcohol is just another form of a drug, and in no way do I regard it as a positive influence, especially with regard to a person who already has psychiatric problems. Alcoholism is just another disease."  3.  "This is not true because in the majority they do not know when to stop. Medication for their psychiatric problems cannot be given when alcohol is consumed.  Therefore, their problems become worse.  Medication and alcohol  cannot be mixed!!" 4.  "Absolute destructive,  rubbish. by  'Doing  alcohol  use.  Something' The  last  should toxic  be  drug  self-enhancing, that  psychiatric  not (the  majority) patients require, is indeed alcohol." 5.  "Nonsense."  6.  "Usually the consumption of alcohol and its effects on [a] person who takes psychotropic medication is highly intensified and therefore not advisable."  7.  "I'd say that it could be dangerous for a psychiatric patient to drink as it may cause a problem with a bad reaction to the medication. Also some psychiatric patients also have an alcohol problem and need to abstain."  8.  "It is a statement born out of frustration or uncaring. Certainly, going out for 'a drink' may be perceived as 'normal' behavior - but we strive for  114 healthy , normal behavior." 9.  "Not much ... actually, I am opposed to it and somewhat angry. Alcohol interferes with medication and physiologically is detrimental to mental health as most residents who drink do so to excess, t  In addition to those respondents who clearly agreed or did not agree with the statement  that  going  out  for  a  drink  of  alcohol  could  be  a  positive  accomplishment, there were several people who indicated that it sometimes was, and sometimes was not true. The following comments are examples of responses that were somewhat ambivalent and were coded into this sometimes category: 1.  "Alcohol in moderation can be helpful to feel comfortable in social situations although it is 'crutch'."  2.  "Depending on the individual this statement can be correct, as it is with any sector of our society. The one difference is with people whose beneficial results from medications, is altered dramatically by alcohol."  Respondents' reactions  to the statement that going out for a drink of alcohol  could  accomplishment,  be  association  a  positive  carried out between this  substance use and substance the  specified  statement  were  recoded  to  simplify  variable, and the estimated  the  tests of  prevalence of  abuse. Those respondents who clearly agreed with  and those  that  thought  it was sometimes true  were  combined into one category, and the can not code and I don't know values were similarly combined. tThis comment was made by a director who indicated that there were nine residents in the facility who drank alcohol. And yet, despite his/her belief that most residents who drink "do so to excess," no cases of substance abuse were reported (perhaps due to the specified two week time span for reports of abuse).  115 Only a weak relationship was noted between directors' professed agreement with the statement that going out for a drink could be a positive accomplishment, and their reports of marijuana use in a given facility (Cramer's V = .36); though not significant at the 95% level, a stronger relationship was noted when alcohol use was  substituted  for marijuana use  (Cramer's V = .43,  Chi-Square = .07).  In the  latter case, all seven (100%) of the directors who reported that drinking could be positive,  also  indicated that  at  least one resident in their respective  consumed alcohol, compared to thirteen (72%) out  for  residents  a  drink  was  not  a  positive  are more likely to drink  facilities  of those who believed that going  accomplishment.  alcohol in facilities  Thus,  it  appears  that  whose directors' believe  drinking alcohol can be a positive accomplishment.  An even stronger relationship was noted between reports of alcohol use and the belief that substance use was inherently abusive, controlling for those respondents who  believed  that  (Cramer's V = .66,  going  out  for  a  drink  of  Chi-Square<.05). Six of the  alcohol  could not be  respondents  (43%)  positive  who thought  substance use was inherently abusive, and who did not believe going out for a drink of alcohol could be positive, reported that none of the residents in their facilities drank alcohol. On the other hand, only one of the respondents (7%) who indicated that substance the residents  use was not necessarily  in their facilities  abusive reported that none of  drank alcohol. There does not appear to be a  significant relationship between directors' attitudes  in relation to residents  going  out for a drink of alcohol, and the estimated incidence of substance abuse.  One might expect there to be a strong relationship between respondents' attitudes  116 concerning the positive or negative nature of going out for a drink, and their attitudes concerning the inherently abusive or nonabusive nature of substance use. However, answers  there  was  to these two  a  considerable questions.  amount  of  variation between individuals'  The following excerpts  are examples  of this  variation, with respondents' answers to both questions juxtaposed: 1.  Example number one: a.  "An  occasional  drink  is  not  harmful  unless  contraindicated  by  medications - frequent use of alcohol or over indulgence is a problem." b. 2.  "[I] agree [that substance use is the same as substance abuse]."  Example number two: a.  "I strongly disagree with the above statement  [that going out for a  drink can be a positive accomplishment]. My experience tells me that there are more motivators than just alcohol." b.  "Use is  different than abuse.  I disagree with the  above  statement  [that substance use is the same as substance abuse]. If one has a psychiatric problem it does not necessarily mean they will be alcohol abusers. Use of alcohol is an individualized experience and what one person can tolerate another can not." 3.  Example number three: a.  "[I] wouldn't really agree with this statement  [that going out for a  drink can be a positive accomplishment] as they could have a coke rather than alcohol and still be doing something." b.  "Usually the care team says to residence [sic] one or two beer is OK. I tend to support this view although very few of our residence [sic] drink."  117 4.  Example number four: a.  "I believe  that people with psychiatric problems combined with the  desire to drink usually have an awareness of their psychiatric problem and  drink in hopes of masking the problem or attempt to have some  temporary relief. I believe it to be a definitely negative experience." b.  "Every case I've seen has been so individual. I do not believe there is always a worsening of psychiatric problems with substance use."  Another way of determining what is done in individual facilities, about substance use and/or abuse by residents is to establish what, if any, programs are offered. Are  there  mental  any substance  health  boarding  abuse  homes?  programs  Only  three  operating  i n Vancouver  directors (10%)  and one  area  staff  member (5%) indicated that there were substance abuse programs operating in their respective homes. All four respondents were from different facilities. While there were additional respondents from all four of these facilities, none of these other  respondents  corroborated  the  reports  that  there  were  substance  abuse  programs. Only one of the facilities that reportedly had an in-home substance abuse program had any reported cases of substance abuse.  The following in-home programs were identified: 1.  "Lectures - during current events."  2.  "Mainly education of the dangers of alcohol in conjunction with medication."  3.  "Drug awareness  life skills; drug education regarding illicit and medicinal  drugs and applications to daily living." The fourth facility with an in-home substance abuse program really had none at  118 all! Although the director indicated that there was an Alcoholics Anonymous group operating in the facility, from conversations with the director and the resident who attended the program, it was clear that the Alcoholic's Anonymous program was held in a community hall, sometimes, and a church, other times, and the boarding home ... never.  a. Resident Responses  Resident responses to questions concerning boarding home policies are outlined below. Residents were also asked to indicate what they thought staff and/or directors would do about alcohol consumption by residents. Three of the residents indicated that they would be  asked  to  residents' indicated that the staff or director would that they would be referred to either a counsellor;  evicted; one  drinking alcohol; seven  not do anything;  mental health  one indicated that they would be referred to  two reported that they would be controlled;  stop  or a  substance abuse  Alcoholic's  indicated that their  one indicated  Anonymous;  money would be  and two residents thought that the staff and/or director would have  some other response  to residents' alcohol consumption. One of the residents who  indicated that he/she did not think the staff or director would do anything about his/her alcohol consumption commented that: "if it was affecting things or people around me, I'm sure that it would be stopped. We are adults after all."  A strong relationship was noted between residents' reported belief that nothing would be done about their drinking and their own alcohol consumption (Cramer's V = .87, Chi-Square<.05). Six of the seven residents who thought nothing would  119  be done about their drinking consumed alcohol monthly, and the other resident consumed alcohol yearly. On the other hand, while one of the three residents who thought the staff or directors would do "something" drank alcohol yearly, two never consumed alcohol.  Thus, while causality can not be established,  there does seem to be a  noteworthy relationship between the prevalence of alcohol use among this small resident sample, and their perceptions concerning the likely response of staff and/or directors to alcohol consumption by residents.  Residents were also asked if they thought substance use and abuse were synonymous terms. Five of the residents stated that use and abuse were synonymous terms, one indicated that they were not synonymous terms, two said that they were sometimes synonymous terms, and two stated that they did not know  if they  were  synonymous terms. Residents' attitudes  concerning the  inherently abusive nature of substance use did not appear to be related to their self reports of alcohol use.  As with the directors and staff members, the majority of residents (six) indicated that going out for a drink of alcohol was not a positive accomplishment for people with psychiatric problems. The remaining four residents indicated that going out for a drink could sometimes be a positive accomplishment. While only four residents reported that going out for a drink could be positive, eight of them indicated that they consumed alcohol themselves. Of course, it does not necessarily follow that persons who consume alcohol (in certain unspecified  120 situations) would agree that going out for a drink of alcohol, just to be doing something, was a positive accomplishment.  One resident who reported that going out for a drink of alcohol was  not a  positive accomplishment, said: "that is such a negative and destructive attitude. There are other things one can do." This person reportedly drank alcohol once or twice a month. Similarly, another resident who stated that "alcohol [was] never positive," indicated that he/she consumed alcohol, albeit only once or twice  a  year. A somewhat more consistent! response was obtained from another resident who reportedly drank alcohol once or twice a month, and who commented that "going out to drink [was] not [positive] all the time, but maybe [was] once a month." Similarly, another resident said: "I think any social activity is good as long as the participant conducts him or herself with moderation and acts in a responsible manner."  For this  small sample of residents,  concerning estimated  the  positive  prevalence  of  relationships were  nature of going out alcohol use  noted between  for a drink  (Cramer's V = .67),  attitudes  of alcohol and the  and between  attitudes  concerning the inherently abusive nature of substance abuse and the prevalence of alcohol use, controlling for those who do not think that going out for a drink of alcohol can be a positive  accomplishment (Cramer's V=.58).  Residents who  drank alcohol reportedly believed that going out for a drink of alcohol could be a positive  accomplishment, and did not believe  that substance  use  and substance  tReferences to "consistent" and "inconsistent" responses are not intended to imply that statements of one sort are "better" than statements of the other sort. Festinger's (1957) study of "cognitive dissonance" provides evidence of our frequent attempts to justify, or rationalize the inconsistencies in our own lives.  121 abuse were synonymous terms. The relationship between residents' attitudes about going out for a drink,  and reports by residents  that  at  least  one  of their  house-mates abused substances, did not appear to be statistically significant. Thus, it  does  not  substances,  appear  were  that  residents  who  indicated  that  a  house-mate  unduly influenced by their general attitudes  abused  regarding alcohol  consumption.  G. PROGRAM  The  OPTIONS: WHAT, IF ANYTHING, SHOULD B E DONE?  fifth and final research question addressed in this study tried to determine  whether or not special services should be offered in response to substance abuse in Vancouver area mental health boarding homes. Accordingly, respondents were  asked if they  reduce  substance  thought  abuse  any of a specified  in boarding homes.  list of programs might help 3  Table  shows  the  number of  directors, staff, and residentst who reportedly thought the specified services would be  useful  in  response  to  dual  diagnosis  substance  abuse  in  mental  health  boarding homes. A number of points deserve mentioning here. For instance, the relationship between respondents' reports that self help groups would be useful, and  their actual use of self help groups as referral sources, was very low. On  the  other  hand,  respondents' would  refer  there  professed  appeared  to  be  support for individual  substance  using  residents  a  note-worthy  relationship  between  counselling and reports that to  mental  health  they  counsellors  (Chi-Square = .06). One staff member had this to say about individual counselling:  tAlthough resident responses have been reviewed seperately at the end of each section, they have been included here (in Table 3 and Figure 13) so that the three respondent groups can be juxtaposed.  Table 3. SUPPORT EVIDENCED FOR SPECIAL SERVICES Reports Concerning the Probable Usefulness of Specified Services in Responi Dual Diagnosis Substance Abuse in Mental Health Boarding Homes  Specified Programs  Self Help Group Drug Education Life Skills Individual Counselling Group Counselling Family Counselling Job Training Housing Search Substance Free Recreation Other  Director 19 22 22 23 12 12 14 12 19 3  Respondent ID Staff  (68%) (79%) (79%) (82%) (43%) (43%) (50%) (43%) (68%) (11%)  Categories are not mutually exclusive. Director n = 28, Staff n=19, Resident n=10  16 15 15 15 9 8 10 8 14 2  (84%) (79%) (79%) (79%) (47%) (42%) (53%) (42%) (74%) (11%)  Resident 9 7 7 7 6 4 6 4 5 1  (90%) (70%) (70%) (70%) (60%) (40%) (60%) (40%) (50%) (10%)  123 There  are  increasing  numbers  of  people  (professionals,  para-professionals, 'lay persons') and facilities and programs for people in the Mental Health system. What seems to be lacking is extensive one-on-one  by  professional  psychiatrists/counsellors.  Care Teams have such huge case-loads  The Community  that each psychiatrist doesn't  have time to do much more than save a client's life (important) and control  medications.  There  are  many  clients  (depressive,  sexually  abused, from alcoholic or dysfunctional families) whose quality of life could be greatly improved with individual counselling.  There was group  a significant relationship between respondents' professed  counselling  and  their  tendency  to  refer  substance  using  support for residents  to  substance abuse consellors (Chi-Square<.05). Reports that family counselling would be useful were significantly related to reports that residents would be referred to substance  abuse  counsellors  (Chi-Square<.05),  and  mental  health  counsellors  (Chi-Square<.05). Data were missing in two cases (one director and one staff member).  Figure  13  graphically depicts  the  support  evidenced  by  directors,  staff,  and  residents for the specified services. The greatest amount of support was generated for self help groups, drug education programs, life skills programs, and individual counselling. Some differences,  and similarities can be noted between the  favoured by the different respondent groups. Both residents the  services  and staff evidenced  greatest amount of support for self help groups, while directors preferred  individual counselling. All three respondent groups showed a high level of support for drug education, life skills, and individual counselling. It is interesting to note that the same percentage of staff and residents favoured family counselling and  RESPONDENT  SUPPORT  D I R E C T O R ,  A N D  S T A F F ,  FOR SPECIFIED  R E S I D E N T  R E P O R T S  :  100 T  OR  TREATMENT  P E R C E N T A G E S  1  80 •  PREVENTATIVE  IN  SERVICES  SERVICES  T H E S E C A T E G O R I E S ARE NOT M U T U A L L Y EXCLUSIVE DIRECTOR ( N = 2 8 ) , S T A F F (N=19), RESIDENT (N=10)  125 housing search programs. One of the directors who selected the other category specified that "a lot of people abuse substances as a way of coping with their present and past - real counselling might be of great benefit." Apparently this respondent did not think that individual, group, or family counselling qualified as real counselling. Perhaps he/she was referring specifically to psychotherapy.  Directors and staff members were also asked if they wanted any of the previously specified programs offered within their facilities. Table 4 shows the number of directors and staff who reportedly thought the specified in-home services would be useful in response to dual diagnosis substance abuse in mental health boarding homes. Directors seemed to favour drug education, life skills, individual counselling, and substance free recreation programs, while staff seemed to favour life skills, substance free recreation, and drug education programs. Although substance abuse was only reported in four facilities, the directors of seventeen different facilities (59%) indicated that they would like a drug education program in their home. Thus, it does appear that dual diagnosis substance abuse is recognized as being a potentially relevant problem in over one-half of the surveyed mental health boarding homes.  As would be expected, the number of respondents who indicated that the specified services would be useful, generally exceeded the number who indicated that they would like those same services to be offered within their facility. There was, however, one exception. While only 79% of the staff members reportedly thought a life skills program would be useful, 84% wanted to have a life skills program in their respective facilities. And yet, despite this paradox, there was a  126 Table 4. SUPPORT EVIDENCED FOR IN-HOME SERVICES Reports Concerning the Probable Usefulness of Specified In-Home Services in Response to Dual Diagnosis Substance Abuse in Mental Health Boarding Homes Specified Programs Self Help Group Drug Education Life Skills Individual Counselling Group Counselling Family Counselling Job Training Housing Search Substance Free Recreation Other  Respondent ID Director 4 (14%) 17 (59%) 17 (59%) 17 (59%) 6 (21%) 3 (10%) 5 (17%) 10 (34%) 16 (55%)  Staff 2 (11%) 11 (58%) 16 (84%) 9 (47%) 4 (21%) 1 ( 5%) 3 (16%) 8 (42%) 12 (63%) 1 ( 5%)  Categories are not mutually exclusive. Director n = 29, Staff n=19 (with the exception of the "self help" category, where n=18)  127 statistically  significant  Chi-Square<.01,  after  relationship the  Yates  between correction).  these  two  Similarly,  variables significant  (Phi = .64, relationships  were evidenced between the variables drug education and drug education in the home (Phi = .47, Chi-Square<.05 after the Yates correction), individual counselling and individual counselling in the home (Phi = .54, Chi-Square<.05 after the Yates correction),  housing  search and  housing  search in  the  home  (Phi = .49,  Chi-Square<.05 after the Yates correction), and recreation and recreation in the home (Phi = .64,  Chi-Square<.01 after  fairly high level of consistency  the  Yates  correction). Thus,  there  is  a  between respondents' reported opinions regarding  the general usefulness of various programs, and their desire to have these same programs offered within their respective  facilities. This consistency  there is a reasonably high level of internal validity associated  suggests that  with these two  variables.  Not only were respondents asked if they thought any of the specified programs would be useful in response to substance  abuse; they were also encouraged to  identify and comment freely about any additional services they thought should be offered to help reduce drug and/or alcohol related problems of mental health  boarding home  substance  abuse  as  residents.  Although very  few  people  actually  identified  a current problem in their facility, many suggested ways  that the problem could be reduced. There was a wide range of comments, and rather than code them into discrete categories (not an easy task), I have ordered them according to general themes, One  such  theme  concerns  and have included a number here, "as is."  respondents  programs. One director stated that:  professed  suport  for  drug education  128  Mandatory attendance at an evening substance abuse information group geared towards psychiatric clients [would be useful]. Attendance at this group would be necessary to continue residing within the facility. At present there are no such classes offered. Evening classes are necessary as most clients attend day programs ... there is a total lack of any groups dealing with this [dual diagnosis substance abuse] problem. And any group that does have some input runs during the hours of nine to five, when most clients are in structured programs, workshops, or employed. There is a need for evening and weekend drug education and support programs. Four additional directors, four staff members, and three residents also professed their support for drug education programs. Of course, one way of increasing the level of participation in a program is by taking the program to the consumer, thereby maximizing the ease of use and accessibility of the service. Such an approach was espoused by one of the boarding home directors, who stated that "there should be in-house counselling on drug use and psychotropic medication ... there is a real need for service in this [dual diagnosis substance abuse] area."  Another director commented that it would be useful to have: Speakers coming into homes to talk about alcohol and drugs mixing with prescribed antipsychotic medications ... there was a marked difference in people here after we had a psychologist come in [to provide Cognitive Therapy] for about one week, but the effects died down because the program was not continued ... there should be more psychologists working in this area.  Self help groups constituted another general theme. While three staff members advocated an Alcoholics Anonymous program, one of the directors stated that:  129  "We don't like sending people to Alcoholics Anonymous because of its religious foundation. A lot of people with psychiatric problems are obsessed with religion anyway, and we have found that Alcoholics Anonymous has confused them even more because it encourages them to continue their religious delusions. Then we have to try and sort it all out here." Additionally, one of the staff members who did think Alcoholics Anonymous was a useful service, had this to say about that program: "I think a program like Alcoholics Anonymous without the religion might be useful because some people get turned off by the religion. It is a very good support group though, and maybe it is because of the religion that it is so successful. I mean, what do you replace the religion with? It's hard to replace God!"  A more comprehensive bevy of services was recommended by the director of another facility, who commented that: [There should be] more opportunities for involvement and self-fulfillment; improved workshop facilities and opportunities; drug education and awareness programs; more accommodation for drug free residents to live and work together; job programs to provide improved earning capacity; and Ministry involvement to ensure drug free boarding homes increase. Over the years we have accommodated many individuals that represented previous drug affliction (alcohol included here as the drug that it is). And the majority of those debilitated by drugs, as well as some form of psychiatric diagnosis, favorably responded to a drug free living environment, while accommodated [here]. The need for more community mental health services was also espoused by one of the staff members, who said that "there should be group homes where  130  alcoholics can live and be supervised, as they probably need medication but would over do it on their own [and so] should be strictly supervised."  The  need  for  government  support was  also espoused  by two additional  respondents: one stated that there should be "more subsidized or paid alcohol and drug free activities," and the other indicated that there should be "more money for community based recreation and social activities." Without specifically referring to persons with psychiatric problems, the director of another facility adressed the need for government, and thus, societal, preventative interventions to curb the flood of drug abuse that pervades all segments of Canadian society: If the 'profit' were taken out of drugs (made 'legal'), and much stiffer penalties for 'trafficing' [were enacted], there probably might be less drugs sold. Although 'alcohol' is 'legal,' it is a great source of revenue for the government, therefore, it is the responsibility of the government to care for the treatment programs and [the] education of 'alcoholics.' If there was no profit to be made in both cases probably there would not be any 'supply' - or at least much less.  One respondent expressed the following belief that substance abuse services for people with psychiatric problems should be located on the street, rather than in residential boarding homes: I'd like to see diagnosis and system (street chose to follow  a more active street level outreach program, for early more conducive towards group activity ... a support level) for discharged psychiatric residents who do not the 'system'.  131 A number of respondents indicated that there should be more interaction between mental  health  and  drug  and  alcohol  services.  The  following  comments  are  indicative of this view point: 1.  "Mental health service and drug and alcohol should work closer together. Special facilities for dual diagnosis people with  acute  substance  abuse  symptoms  [are needed] because  does  not  fit  into  a person  the standard  programs in boarding homes." 2.  "It would be extremely helpful if a counsellor would be available through Mental Health who would be knowledgable about mental illness as well as substance  abuse  and  the  correlation there  of.  This  person  should  be  available for individual counselling of mental patients." 3.  "I think drug and alcohol counsellors should have more training about sike [sic] patients."  4.  "[They should] increase the interaction between Drug and Alcohol programs and the homes - increase the flow of educational information between Drug and Alcohol and the homes and Community Care Teams and the residents (clients)."  5.  "The dual diagnosis project at Greater Vancouver Mental Health services will be very helpful."  Three respondents indicated that there was not much point in offering substance abuse services to  people with psychiatric  problems.  One  such  person,  a  staff  member, commented that "you can't stop people from drinking if they want to [drink]. No one can ever do that and people have been trying to for centuries." A second staff member said: "education for residents [should be offered to reduce  132  the drug and alcohol problems in mental health boarding homes], although for most adult psychiatric patients I don't see much of a solution unless someone with a problem is willing to deal with it much the same as Alcoholics Anonymous believes." And lastly, the third respondent, a director, made the following comment: I don't think there is a way [to reduce residents' substance abuse problems]. If someone wants help - there are already places who are willing to help. I think most people who have problems with drinking or drugs are on welfare, so they should be given food vouchers instead of money so they can not spend it on drugs or alcohol ... I don't think you can do anything about people drinking. You can try to talk to them but they don't usually listen to you. You can offer people services but they probably won't accept them.  So, what services  should  be offered to help reduce the drug or alcohol related  problems of Vancouver area mental health boarding home residents? One final comment, by a staff member of one of the facilities, summed up his/her own thoughts about this question quite nicely, when he/she adroitly replied: "Hmmm..."  The services we have considered thus far have been geared towards the of mental  health boarding homes,  but what of the  residents  directors and staff  members?! Programs for directors and staff members could, after all, actually be construed as programs for residents; the residents would ultimately benefit from the increased skill and expertise of the caregivers. With this in mind, the  tWhile the services/programs considered in this study are largely focused on it is also imperative that we focus on the broader political and economic issues that contribute to problems at a societal level. individuals,  133 directors and staff  members were  asked if they  would like to be offered  a  workshop on dual diagnosis substance abuse, and if so, what they would like it to include. Seventeen directors (61%)  and nine staff members (47%) indicated  that they would like to be offered a workshop, seven directors (25%) and 4 staff members (21%) indicated that they might like to be offered a workshop, and four directors (14%)  and six staff members (32%) indicated that they would not like  to be offered  a workshop. Thus,  we  can ascertain that  twenty-four  directors  (86%) and thirteen staff members (68%) expressed some interest in the possibility of being offered a workshop. Data was missing in two cases (one director and one staff member). Figure 14 shows the number of directors and staff who do, do not,  and might want to be offered  a workshop, with the  addition of a  combined category which includes both the "yes" and "maybe" values. The data are displayed in percentages directors and staff.  so that direct comparisons can be made between  Most of the respondents were interested in a workshop; and  comparatively few were not.  One staff member who indicated that he/she might like to be offered a workshop, clarified his/her position by stating that, enough problems with substance  while he/she did not think they had  abuse to warrant a workshop, he/she was still  "interested in it." Considerably more directors (86%)  than staff members  (68%)  expressed interest in a workshop. Perhaps this imbalance was due to the unequal distribution of staff  participants across all facilities; while there  was  one, and  only one director from each of the participating facilities, there was more than one staff respondent from some homes, and none from others. Or perhaps staff members were not as committed to the facilities as the directors were, or were  SUPPORT FOR A DUAL DIAGNOSIS S U B S T A N C E ABUSE WORKSHOP Percentage of Directors and Staff Who Want a Workshop ,oo, 90-  Yes  No  Maybe  Responses D a l e w a s missing Irom one s t d " member  (n-19)  and one d " e c t O ' ( n « 2 8 )  Yes-Maybe  135  less concerned about providing "favorable" responses.  Specifed workshop topics have not been coded into discrete categories, but rather, have been grouped according to common themes. Drug education services was the most frequently selected workshop topic. Of course, "drug education" meant different things to different people, and included a wide range of topics. Several  people  indicated that  they  thought  drug education  should include  information concerning problem identification, or as one respondent put it, "how to spot the problem when you don't smell or see drugs." How indeed? Of course, the complexity of this task would depend largely on one's definition of abuse.  If the consumption of even small amounts of substances,  moderation, is considered abusive,  then detection  used in  can be very difficult; if  consumption is only considered abusive if it results in observable problems then detection can be a simple matter. The detection of substance use and/or abuse becomes even more difficult when unusual or suspect behaviors are automatically attributed to peoples' "mental illness." One staff member indicated that he/she not only wanted to know how to detect substance abuse, but also wanted to know how to respond to it. This person wanted a workshop to include "drug education, appropriate [ways to] approach individuals who are addicted, [and] the types of behavior to expect from these individuals."  Another popular workshop topic involved identifying community resources where substance  abusing residents  could be referred. One director stated that a  workshop "would have to be practical, including information about how to deal with individuals who abuse substances, and what resources were available." Many  136  facilities are not equipped to handle substance abuse problems, either because the care givers are unwilling or unable to do so. It is not surprising that client referrals are so popular. Indeed, with the ever increasing specialization of services and service  providers, and the  near extinction  of the  "urban generalist"  practitioner, referrals have become the norm rather than the exception.  Many  respondents  requested  that  prescription and nonprescription  information concerning the  substances  interaction of  be included. It would be helpful to  focus on the effects of specific combinations of drugs, rather than simply stating that drugs and drugs do not mix. Several respondents thought a workshop should provide opportunities to develop their counselling skills. Both the personal skills to intervene directly, and the ability to access other resources would benefit boarding home service providers. This sentiment is summed up nicely by the following comment: Although alcohol abuse is not a major problem here, it has been in the past. More information on this subject would increase staffs ability to relate empathically to someone with a drug or alcohol problem. It would also alert us to potential problems and enable [us] to informally counsel clients or direct them [to a professional counsellor] ... this study has [already] led us to reevaluate just what we would do if someone did come home drunk.  Another director specified that he/she wanted information about "how [treatment programs] could be integrated into the boarding home, [and] what happens when people continue to use or abuse substances ... they are currently dumped out and probably end up in hospital." A nicely itemized workshop agenda was  137 provided by one of the staff members, and it included: 1.  An explanation of terms.  2.  Case studies introduced as examples.  3.  A talk on history/predictors etc.  4.  Role playing working with these people.  5.  Specific items/indicators to look for in clients.  A  number  of  respondents  looked  beyond  the  isolated,  personal  poblems  of  identifying and responding to individual problems after they arise, to the larger contextual,  societal  problems of identifying and responding to common problems  before they arise. The comment by one director that workshops should focus on "pro-active interventions" is indicative of this "macro" perspective. Of course, both proactive and information  reactive interventions  concerning  the  are  indicators  needed.  and  health  In  addition  effects  of  to  requesting  substance  abuse,  prognoses after treatment, and the pros and cons of treatment options, one staff member  requested  information  concerning  the  possible  social,  psychological,  physical, and/or other causes for the abuse. While not addressing this particular issue, one director had this to say  about the possible  causes of psychoses: "I  wonder how many peoples' psychotic episodes are really triggered by drug use. I lived in Africa  before  I moved here  and we  did not have  any schizophrenia  there, and there was no drug use. But here, marijuana use is very widespread, as are psychiatric problems."  Of course, it does not logically follow that because many Canadians both smoke marijuana  and  are  schizophrenic,  and  no  Africans  allegedly  either  smoke  138  marijuana  or  are  schizophrenic,  that  marijuana use  causes schizophrenia.  Nonetheless it is clear that the symptoms of certain forms of psychoses are often extremely difficult to differentiate from certain drug induced states, and the chemical structures of certain naturally occurring neurotransmitters are startlingly similar to those of certain drugs, t Perhaps the relationship between substance use and psychoses is stronger than we think.  Three respondents provided rather unique comments in response to the what would you like a workshop to include  question. First, one director indicated that  what he/she really wanted to see included in a workshop, which he/she did not want to be offered anyway, was "a good lunch." A bit of humor is refreshing, it is true, but we must not underestimate the importance of a nutritionally balanced diet. A good lunch, indeed! The second respondent, another director, took a more serious approach and indicated that he/she thought a workshop should contain information regarding the history, and pros and cons of the dual diagnosis substance abuse diagnostic category. This diagnoses  interest in the new dual diagnosis  was shared by the third respondent (director), who said: "I have heard  of this dual diagnosis label and I sometimes wonder if it isn't just another attempt to create another service provider." Indeed, is the creation of the dual diagnosis label legitimately in the client's best interests?  tRefer to Chapter III for a more detailed discussion of these chemical similarities, and the similarities between certain drug induced states and "naturally" occurring psychoses.  139 c. Resident Responses  Resident responses to questions exploring what, if anything should be done about substance  use  and/or abuse  in mental health boarding homes are  summarized below, t Self help groups (specified as "Alcoholics Anonymous" on resident questionnaires) generated the most support, followed by drug education, life skills, and individual counselling. One resident stated that he/she thought Cognitive Therapy would be helpful (the director from the same facility favoured the same form of therapy). Another resident stated that there should be "compulsory education about what happens when drugs and alcohol are mixed with medication." It is interesting that a resident advocated a compulsory program, as that approach is more often advocated by professionals or other service providers (especially when the offered service fails to otherwise "draw them in") rather than by service consumers. An "exercise" program was advocated by one of the residents, and an additional resident stated that "programs specifically dealing with prescription drug abuse [would be useful, such as] education [about] alternative ways to deal with problems." However, as a third resident succinctly pointed out, before substance abuse services can be effective, people have to admit they have substance abuse problems.  It is not enough to determine what programs might be useful in response to substance  abuse in mental health boarding homes; it is also important to  determine what programs might be accepted and used. Thus, it is important to tRefer to Table 3 for a complete itemization of residents' reported opinions regarding the relative usefulness of the specified programs, in relation to dual diagnosis substance abuse.  140  try and establish which programs the residents themselves would be willing to use. Accordingly, residents were asked to indicate if they currently attended any of the specified programs, or if they would attend them if they were made available.  Five residents indicated that they attended at least one of the  specified programs. The programs that residents reportedly used were: a self help group, Alcoholics Anonymous, individual counselling (specified by two people), job training, assistance obtaining independent housing, life skills, and "a very good relationship with [a] doctor." One person indicated that he/she would attend Alcoholics Anonymous (this same  person was currently attending Alcoholics  Anonymous). Another resident indicated that he/she would attend both a drug education and a substance free recreation program; although this respondent reportedly did not have a substance abuse problem, he/she indicated that that had not always been the case. Although one additional resident indicated that he/she would attend one of the specified programs, this person specified that he/she would only do so "if [he/she] needed them." This person did not apparently feel that he/she needed them at present.  The last resident who indicated that he/she would attend one of the specified programs reported that he/she would, in fact, attend all of them, and had this to say: I drink in moderation. Alcohol does not affect my life. I am always a phone call away from Alcoholics Anonymous if I need it. I really believe its helped a lot of people. It's there when I need it. My work history hasn't been the best but I know beyond a reasonable doubt it hasn't been alcohol. Maybe cigarettes, but they help my stress levels and I am attempting to quit.  141  While this resident had apparently been told that he/she had a drinking problem, he/she did not concur with that assessment, because  he/she was able to  "moderate" him/herself. Clearly, this was a person who did not believe that abuse and use were synonymous terms, and in response to that question had replied: "Moderation is the key."  Although one additional resident indicated that he/she would not attend any of the specified programs he/she also said: "I feel my drug problems are a thing in my past (twelve years ago). But for sure, if I ever slipped only once, I would seek help immediately." The following account tells of this resident's struggle with both psychiatric and substance abuse problems: I had been a prescription junkie for eighteen years - since a back injury started me on pain killers. It wasn't long before I was on tranquilizers and sleeping pills. When I was diagnosed as manic depressive at twenty-nine years of age I'd had enough and tried to kill myself. It wasn't until I found a caring and dedicated counsellor through my doctor that I gained the knowledge and confidence to get off pills and realize my potential as a productive and alive individual. I've just moved into three-quarter way housing after spending two years in a group home and will be going back to school and work soon, hopefully in the mental health field.  The following chapter summarizes the data, explores the findings, puts forth a program proposal, discusses the limitations of the study, and makes suggestions for future research.  VII. CONCLUDING REMARKS  A. SUMMARY OF FINDINGS  The  primary purpose of this study has been to estimate the prevalence/incidence  of substance abuse in Vancouver area mental health boarding homes. The data suggest that substance abuse is not a large problem in these facilities. Of 358 residents,  from  twenty-nine  different  facilities,  only  six  had reportedly abused  alcohol, and two had abused illicit drugs. Thus, there was a combined total of eight  (2%)  substance abusers. The  term  "substance  abuse"  was  clearly  operationalized according to World Health Organization (1986) specifications,! so it is assumed that respondents' understanding of what behaviors constituted abuse were fairly constant. However, the following factors suggest that the prevalence of substance abuse may have been underreported: 1.  The specified two week period may have been too short, and consequently narrowed the scope of the data considerably.  2.  "Political" pressure to present a "clean" image of substance may  have  influenced  some  respondents'  reports,  and  free facilities  influenced  others'  decisions not to participate at all. 3.  Alcohol was consumed by 115 residents (32%), and 57 (16%) had consumed alcohol during the past two weeks.  4.  Director and staff  respondents  from  fifteen  facilities  (52%)  indicated that  they had tried to get help for a resident with a substance abuse problem. 5.  And similarly, cases of substance  abuse were reported in eleven different  tSee the introductory section on "definitions" Organization definition of substance abuse. 142  for  a  complete  World Health  143 facilities (38%), without reference to the specified two week period.  While  it  cannot  be  assumed  that  those  residents  who  consumed alcohol  also  abused alcohol, the combined data do indicate that the prevalence of substance abuse may be higher than is indicated by reports of substance abuse during the specified  two  residents  in the  have substance of  dual  week  period. Nonetheless,  surveyed boarding homes,  relation  to  the  total  number of  it appears that very few  residents  abuse problems. Thus, while there may be considerable numbers  diagnosis  substance  boarding home residents these hospitals,  in  abusing  patients  referrals consist  very few  persons  in  primarily  with substance  acute  care  hospitals,!  of persons abuse  and  discharged from  problems seem to be  entering, or residing in, Vancouver area mental health boarding homes.  In addition to estimating the prevalence/incidence of substance has explored different factors,  abuse, this study  such as demographic characteristics, to map out  the significant associations between these factors and the prevalence of substance use and/or abuse. The following associations were found to be significant: 1.  There are significant relationships between the number of men in boarding homes and the frequency of alcohol consumption (p<.05), and the number of women in boarding homes and the number of alcohol consumers  (p<.01).  However, while this appears to imply that more women drink alcohol than men,  and men drink  more often  than  women,  the  data  directors and staff members refer to totals and averages  obtained  from  and can not be  extrapolated to individual residents, but rather, provide evidence of general tRefer to Chapter III for a review of studies that estimate the prevalence of dual diagnosis substance abuse in psychiatric acute care hospital settings.  144 trends. 2.  Significant relationships were noted between residents' average age and the prevalence of marijuana use (p<.01) and monthly alcohol use (p<.05). The data  do not  support findings  in the  literature  that  age  is  significantly  related to substance abuse. In any case, a higher prevalence of substance abuse  among  younger  experimentation,  and  age  "rites  groups  of  may  passage,"  be  more  than it  is  to  the the  result  of  presence  or  absence of psychiatric problems. 3.  The data show  significant relationships between tranquillizer use  yearly consumption of alcohol (p<.01), antidepressant  and the  use  and the yearly  consumption of alcohol (p<.05), and antiparkonsonian use  and the yearly  consumption of alcohol (p<.01). 4.  Additionally, alcohol use  significant and the  manic depression  associations  were  noted between the  following psychiatric diagnoses:  prevalence of  schizophrenia (p<.01),  (sig<.01), and personality disorder (sig<.05). There was  also a significant relationship between the prevalence of alcohol abuse and the  diagnosis  literature t  of depression  regarding  the  (sig<.01). relationships  The data between  support findings substance  in the  use/abuse  and  diagnoses.  As  was  expected,  the  policies  of  boarding homes  were  associated  with  the  estimated prevalence of substance use. Ninety-four percent of the homes that do not do anything about residents' alcohol consumption had at least one resident who consumed alcohol (Chi-square<.05).  There was  also an inverse relationship  tRefer to Chapter III for a summary of studies showing relationships between dual diagnosis substance abuse and specific psychiatric diagnoses.  145 between reports by directors that they would refer substance using residents to mental  health  counsellors,  (Chi-square<.05).  and  the  estimated  Not surprisingly, significant  prevalence  relationships  of  were  alcohol noted  use  between  directors' beliefs that substance use and substance abuse are synonymous terms, and the presence of at least one resident who consumed alcohol (Chi-Square<.05), or  marijuana  (Chi-Square<.05).  All of  the  facilities  whose  directors  did not  believe that substance use was inherently abusive had at least one resident who consumed alcohol, and 64% of these same facilities had at least one resident who consumed marijuana (compared to only 6% of those facilities whose directors did believe the two terms were synonymous).  No  significant  relationships  were  noted  between  directors'  opinions regarding  residents going out for a drink of alcohol, and the prevalence of either substance use or substance their  abuse. However, a significant relationship was noted between  reports of alcohol consumption and their belief that  substance  use and  substance abuse were synonymous terms, controlling for those who did not believe that  going  out  for  a  drink  of  alcohol  could  be  a  positive  accomplishment  (Chi-Square<.05). Thus, it appears that more residents drink alcohol in facilities whose  directors  believe  that  going  out  to  drink  alcohol  can be  a  positive  accomplishment, and do not believe that substance use and substance abuse are synonymous terms.  In  addition to  estimating  what  the  prevalence  of  substance  abuse  was,  and  testing different associations, this study also attempted to determine what, if any, services  should be  offered  in response  to  dual  diagnosis  substance  abuse  in  146 Vancouver area mental health boarding homes. Not very many people working in Vancouver area mental health boarding homes appear to have received training in either substance abuse or dual diagnosis substance abuse, and most of those people who did have training in one area also had training in the other. Further, directors who did have training in these two areas were from facilities that reportedly had substance using (though not abusing) residents.  Respondents evidenced support for a number of different services. Drug education, life skills, individual counselling,  and self help programs generated the most  support. With a few exceptions, comments by respondents supported findings in the literature that suggest existing community mental health services do not adequately meet the needs of dual diagnosis substance abusing persons.! As was expected, fewer of the respondents wanted the specified programs to be offered within  their facilities than were in favor of them being offered somewhere, in a  more general sense. It is one thing to believe that a service might be useful, and another thing to have that service in your own parlor.  Nonetheless, there was a fairly high level of consistency between respondents' expressed support for programs, in general, and support for programs offered in the home. The in-home programs that received the highest levels of support were drug education, life skills, recreation,  and individual counselling. The highest level  of support for any given program, according to the comments of respondents, was for drug education. Similarly, drug education was the most frequently selected workshop topic (83% of the directors and 65% of the staff members indicated tA summary of studies that suggest existing services are inadequate is contained in the discussion of homelessness and deinstitutionalization in Chapter III.  147  that they would be interested in attending a workshop on dual diagnosis substance abuse). These findings are congruent with those in the literature that indicate that drug education forms a component of almost all substance abuse treatment strategies.!  B. DISCUSSION  We have already established that, while many facilities reportedly had problems related to dual diagnosis substance abuse, few individual residents reportedly had dual diagnosis substance abuse problems. However, as previously noted,t three of the resident participants had received treatment for substance abuse, three had been told they had a substance abuse problem, and three had tried to get help for a substance abuse problem. Thus, while resident reports (in this study) can not be reliably used to make statistical inferences, it is worth noting that a whopping "30%" of the residents seem to have had substance related problems at some time.  On the other hand, it does not necessarily follow that people who have received treatment, or been told they have a problem, or tried to get help for substance abuse, actually have substance abuse problems at all. The one resident who had neither tried to get help, nor been told that he/she had a problem, but who received "treatment" nonetheless is a case in point. This resident seems to have attended Alcoholics Annonymous (AA) meetings for social, and more specifically, tRefer to Chapter III for a review of different treatment approaches. tChapter VI, section C, summarises findings of this study regarding prevalence estimates.  148  spiritual reasons. Drawn to the religious framework, this resident reportedly relied on AA meetings as an adjunct to Sunday church services (this statement was corroborated by the director of the same home). Thus it would seem that while this person attended an alcohol treatment program, he/she had never tried to get treatment for an alcohol problem, had never been told that he/she had an alcohol problem, and, it would seem, did not have an alcohol problem. Similarly, although it may be ascertained that someone has been told they have a substance abuse problem, it is difficult to determine how objective, and thus, how reliable the report is; put simply, just because someone says it is true does not mean it necessarily is.  Additionally, as for residents having received treatment, the data do not indicate when  the treatment occurred. In like fashion, it is not clear how long ago the  residents were told they had a problem, or tried to get help. Each of these events could have happened in the distant past. Strong advocates of the biomedical view on substance abuse and addiction (that it is an incurable, progressive disease state), may suggest that the issue of time is purely "academic." However, while some individuals may have a genetic predisposition to abuse substances,  whether or not the individual consumes substances, and  whether or not there are problems associated with that consumption, is largely the result of environmental conditions (whether they be social, political, physical, economic, or cultural environments). Behaviors must be viewed in their context!  We commonly focus on the identified "client," "patient," or "resident," when examining the prevalence of problem behaviors in a given population, without  149 recognizing or acknowledging that emotions, cognitions, and behaviors are only defined  as problematic in relation to the "normal" emotions, cognitions, and  behaviors of others. Thus, psychiatric or substance abuse "problems" only become such, within a given cultural context, when they contravene societal, and thus individual, expectations.! The socio-cultural characteristics of specific populations must be taken into account, and we must always ask ourselves: normal for what? And normal  for whom? And does normal  refer  to  the average  characteristics of a population, or an ideal standard?  Our perceptions effect our interpretations, which are in turn effected by our experiences.  Thus, it was assumed that the demographic characteristics of  directors and staff members might influence their tendencies to "see" substance use as abusive in a given context. Although no significant relationships were found between the specific (identified) characteristics of staff and directors and their reports of substance abuse, considerable variations were noted between their respective perceptions regarding dual diagnosis substance abuse.  While the term "substance abuse" was clearly operationalized according to World Health Organization guidelines, it is clear that the "personal meanings," or "affective connotations"$ associated with this term varied greatly among individual respondents. For example, a staff member in one facility stated that: "no one lets people drink in mental health facilities anywhere, and there is only one way to deal with [drinking]. If [they] drink, then [I say] there's the door." This !Refer to Waxler's (1979) study, for a discussion of the influence of sociocultural contexts on the diagnosis and prognosis of schizophrenia. $Refer to Hayakawa (1973) for an insightful "expose" on the connotations of language.  150  individual was passionately opposed to any level of alcohol consumption, and consequently believed that the only way to respond to residents who drank was to evict them immediately. Obversly, the director of another home stated that he/she had "no problem with people social drinking [sic], or going out for a drink like anyone else, as long as it [didn't] create other problems." This individual believed that moderate levels of alcohol consumption were entirely acceptable. Clearly, if the former of these two individuals stated that a resident had a substance abuse problem, it would have a very different meaning than would the same statement made by the latter individual.  While not surprising that  there was  a positive relationship between the  prevalence of alcohol use and a facility's tendency to do nothing about alcohol use, it is somewhat more surprising that "referrals to mental health counsellors" was the only specified response variable with an inverse relationship to alcohol consumption. Perhaps facilities that refer residents to mental health counsellors have closer ties to Greater Vancouver Mental Health Services (GVMHS) than facilities that do not. It is conceivable that such a relationship could influence boarding home policy makers to neither accept applicants who consume alcohol, nor tolerate alcohol consumption by existing residents. However, just as mental health boarding homes rely on GVMHS for funding, so too does GVMHS rely on mental health boarding homes as resources for client referrals. It is, therefore, unlikely that GVMHS would encourage boarding homes to reject its own referrals.  Another unexpected finding was that there did not appear to be a relationship between the estimated prevalence of alcohol use and directors' tendencies to evict  151 residents who use alcohol. One would think that residents would be less likely to drink alcohol if it was likely to result in their eviction. Problems of interpretation may have influenced this non relationship between eviction policies and alcohol consumption. No doubt, virtually every facility evicts residents for drinking alcohol, under certain conditions.  The admittance policies of boarding homes were not significantly related to either substance use or substance abuse. This finding was not expected, as it was assumed that a primary determinant of the prevalence of substance abuse in facilities would be their tendencies to admit, or refuse admittance to, persons with histories of substance abuse. The data do not support findings in the literature that indicate that most boarding homes refuse to take persons with substance abuse problems. Perhaps, as the literature also suggests, the low prevalence of substance abuse is largely due to the refusal of dual diagnosis substance abusers to sacrifice their autonomy by staying in boarding homes, t The failure of the data to reveal a relationship between admitting policies and the prevalence of substance  use  and/or abuse,  may have been influenced by  incongruent interpretations of the relevant question by different respondents. There appeared to be some confusion over the temporal parameters of the phrase a history of substance abuse.  The statements that going out for a drink can be a positive accomplishment, and substance  use and substance  abuse are synonymous  terms,  were intended to be  tRefer to Chapter III for a summary of studies that examine boarding home admittance policies in relation to substance abuse, and persons' refusals to live in these facilities.  152  somewhat provocative, in an attempt to generate interest in the study and stimulate thought and discussion. As such, they were quite effective. However, it is possible that different individuals interpreted the statements in a variety of ways. The following comments by one director underscores the possible range of interpretations: There are a variety of ways to go out for a drink (social to abusive), there are a variety of reasons for drinking (social to alcoholic), there are a variety of reasons for going to bars (normal socializing versus alcoholism), etc. etc. etc. It is individualized as to how a person behaves while drinking, what happens after drinking, and why they went out for a drink.  Just as the director who made the preceding comment intimated that the motivations for, and results of drinking vary greatly, so too does the potential range of interpretations of the questions vary greatly. The following comments by another director show evidence of two different interpretations within the same answer: The process of planning a social event, going to it and being comfortable in public is important - [for example] developing leisure activities, social skills, friendships etc. When alcohol is involved, there is an added pressure of responsibility to use it appropriately, or not to use it at all because of medications. 'Mentally ill' or not, when alcohol is the activity it can't be viewed positively.  Thus, the statement going out for a drink of alcohol can mean going out for the sole purpose of consuming alcohol, or it can mean going out on a social excursion that will involve, among other things, drinking alcohol. On the one  153  hand, drinking alcohol is the activity, while on the other hand drinking alcohol is only part of the activity. Discrepant interpretations such as these may account for  some  of  the  apparent  inconsistencies.  Of course,  the  presence  of  inconsistencies does not negate the significance of respondents' comments, though it does create the potential for problems of internal validity when the data are coded into quantitative, discrete categories. In fact, as respondents' comments indicate, discrepancies between responses are in large part a reflection of the complexity  of responses, and the thoughtfulness of respondents, rather than the  unreliability of  responses and the inefficiency of respondents.  While there were reportedly substance abuse programs operating in four different facilities, there seem to have been a variety of different ideas about what, exactly, constituted a substance abuse program. On the one hand, it could be supposed that refusing to admit anyone with a history of substance abuse into a facility, or evicting residents who use or abuse substances, are actually substance abuse "programs." Certainly, these programs might solve the boarding homes' substance abuse problems. On the other hand, it could be supposed that doing absolutely nothing about residents' substance use or abuse problems is, in effect, a substance abuse "program." While true that these examples are extreme, the fact remains that respondents seem to have interpreted the phrase in the home substance abuse program  in a variety of different ways. It is probably safe to  assume that, if the word program were taken to mean a formal, regular planned service with an established agenda or structure, the number of programs was over reported; and if the word program were taken to mean an informal, irregular, spontaneous 'response' without an established agenda, the number of  154  programs was  under reported. Nonetheless,  at the very least it can be  ascertained that in some facilities, there is an awareness of, and an attempt to respond to, the potentially damaging effects of substance abuse.  A number of respondents made comments that support findings in the literature which reflect the general inadequacy of community based mental health services (perhaps a problem of quantity rather than quality) to meet the needs and, increasingly, demands of de-institutionalized ex-mental patients. Several respondents indicated that there was a need for our government to extend its present commitment (to providing specialized dual diagnosis substance abuse services), to the development of more community living facilities for persons with psychiatric problems. However, on the one hand facilities that would in large part  exclude  persons with substance abuse problems were advocated, while on the other hand facilities that would house  only  persons with substance abuse problems were  advocated. Perhaps a more integrated service would be best. A "tiered" boarding home  system,  where  people  can  move  to  increasingly  autonomous living  environments might be a viable alternative to the existing structure.  Many people have expressed concern that the combination of prescription and nonprescription drugs will either negate the effects of prescription drugs, or result in an undesirable "interaction effect." Thus, the high prevalence of prescription drug use by persons with psychiatric problems (and the  assumption that  substance use causes a worsening of psychiatric symptomology) has led some people to conclude that any level of substance use is, in fact, abusive. While generalizations of this sort often do contain an element of truth, they nonetheless  155 do their targets  a disservice.  Persons  with psychiatric problems are not only  members of a group, but are also individuals. One respondent stated that people with psychiatric problems should follow his/her example, and not consume alcohol while taking prescription drugs. While this logic is basically sound, it does not acknowledge the difference between temporary and permanent prescription drug use. For the respondent who made the preceding comment, not drinking alcohol while taking medication means not drinking for a few days, weeks, or possibly months, while  for  many  people  with  psychiatric  problems  it  means  a  lifetime of  abstinence.  The inclusion of data in this study regarding medication use is in  recognition  of  the  potential, rather  than  inherent,  problems  caused  by  the  interaction of prescription and nonprescription drugs.  One  question  that  has  been  raised in this  creating the "dual diagnosis substance  study  concerns  the  legitimacy of  abuse" label. Is the creation of the dual  diagnosis substance abuse label truly in the clients best interests? Kutchins and Kirk  (1987,  Psychiatric  1988a  &  Association's  1988b)  provide  Diagnostic  and  interesting Statistical  critques Manual  of  the  American  (DSM-III), and  the  diagnostic categories it contains. Why, for instance, was homosexuality, which was included in early editions of DSM, excluded from later editions? And why were the three new categories  of Paraphilac Rapism, Premenstrual Dysphoric Disorder  (PMS) and Masochistic Personality Disorder, which were  proposed additions for  DSM-III-R, either excluded, or revised and moved to an appendix? The answer, it seems, is "political pressure." Certainly, there were no sudden medical discoveries justifying these revisions. It was political pressure exerted by homosexuals and other interest groups that "cured" homosexuals of their "disease;" it was political  156 pressure exerted by the U.S. Justice Department, and feminist interest groups, that "cured" rapists of the "disease" that would have protected them from criminal  prosecution,  redefining  their  heinous  acts  of  aggression  as  the  uncontrollable symptoms of a disease, and thereby legitimizing their brutalization of women by transforming the perpetrator into the victim (or "patient"); it was political pressure exerted by feminists and other interest groups that "cured" women of their "disease," by normalizing PMS and ensuring that basic biological processes would not be stigmatized and labelled "abnormal;" and it was political pressure exerted by the Surgeon Generals Conference on Violence, and other interest groups, that "cured" women and other victims of domestic violence of their  "disease," ensuring that they retain their rightful status as victims, rather  than as mentally ill deviants who entreat others to beat and abuse them to satisfy their own masochistic tendencies.  Psychiatric diagnoses have been citicized and defended with equal alacrity by inumerable protagonists. Nonetheless, it is clear that mental disturbances are influenced by a wide variety of factors, and while the symptomology may be linked  to  microbiological aberrations, the  causes of these  aberrations are  multifactorial, and the meaning that the symptomology has depends on the social, cultural, political, and economic contexts within which they occur. Schizophrenia, for example, has no objective reality: it is the symptoms of schizophrenia that objectively exist, while "schizophrenia" is the label we use to compartmentalize these symptoms and symptom sufferers into the explanatory model of 'choice' in the western world, the biomedical disease model. "Reality" is constructed through, and does not exist independently of, human experience.  157  Certainly, with the creation of a dual diagnosis service industry, there is a danger that  the  interests  of the  individual  will  be  lost  in a  fog of  generalizations. Blanket statements like: "for persons with psychiatric problems substance use is synonymous with substance abuse," are indicative of our all too common tendency to strengthen the distinction between us and them, between the in group  and the out group, between the normal and the less than normal, by  pointing to the failure of the deviant subgroup to conform to the mainstream parameters of normality. Ours is  a society  made up of a plethora of  differentiated segments, and we struggle diligently to maintain the boundaries. The "mentally ill" have not fared well in this system of segmentation; crouched on the periphery, they have been steadfastly denied access to the exclusive world of the nondistinct normal. When even the well established psychiatric diagnostic labels are of questionable validity, should we be creating another unproven, untested, unsubstantiated, objectively indeterminate category?  And yet, on the other hand, for some people with psychiatric problems the combination of prescription and nonprescription substances is likely to cause some problems.! And substance use is likely to cause the thought patterns of persons whose thought patterns are already somewhat unusual to become even more so; and it is likely to cause some management problems for service providers; and it is bound to cause interpersonal, financial and legal problems for some. As long as we do not lose sight of the fact that it is not the act of substance use, but the consequences of that act, the occurrence of substance related problems, that constitutes substance abuse, then perhaps the label of dual diagnosis substance tRefer to Chapter III for a discussion of the "additive," "synergistic," and "antagonistic" effects that can result from coingesting different substances.  158  abuse can be used responsibly. Nonetheless, the potential for "dual diagnosis label abuse" is great.  It was suggested by a few respondents that there was really no point in offering services to dual diagnosis substance abusers, as they will not change their behavior in any case. Certainly, it is true that the motivation to change must not only come from within, but must also exceed the motivation not to change if  any meaningful change is to occur. When the costs of continuing a  certain behavior consistently exceed the rewards, then the stage for change is set. Of course, the balance between rewards and costs must be measured in the mind of the individual concerned. While an external, "objective" analysis may suggest that the costs of a certain behavior far outweigh the rewards, it is the perceptions of the individual  concerning the relative value of costs and rewards  that is of paramount importance.! Further, a key step in the process of becoming motivated to change one's dysfunctional behaviors involves recognizing that the behaviors are, in fact, dysfunctional. One can do something about a person's substance abuse problem, even if that person does not acknowledge that his/her substance use is problematic. True, the individual will probably not be motivated to change, and the problem behaviors may continue, so it may appear that all efforts to stimulate change have been fruitless. It is less expedient, when working with "unmotivated clients," to refer them to this, or that service, or to demand immediate change, than it is to consistently and systematically expose the inconsistencies between behaviors and beliefs, between consequences jThere is always a danger that we, as "professionals," will evaluate clients' from the comfort of our "armchairs," within our own frame of reference, without adequately considering how their standard of living and quality of life influences their behaviors, cognitions, and emotions.  159  and objectives, between external and internal realities, between objective and subjective truths, until the protective shield of rationalizations has been stripped away to reveal the problem within.  Of course, this does not suggest that problems always rest within the individual. Rather, we must redefine the term treatment, so that it transcends the narrow confines  of conventional treatment modalities. Just as drug abuse problems are  not unique to persons with psychiatric problems, neither can the causes of, nor the solutions to, dual diagnosis substance abuse be viewed in isolation. While not negating the need for individual or group oriented reactive measures, it is imperative that we develop preventative measures at a societal or cultural level if we are to effectively "cure" peoples' substance abuse problems.  C. RECOMMENDATIONS  The data do not reveal a sufficiently high prevalence of substance abuse in Vancouver area mental health boarding homes to justify the expenditures of time and money necessary to create a new service delivery system for residents who abuse drugs and/or alcohol. Perhaps the creation of "new" services should involve redefining the parameters of "normality," thereby opening up the doors of existing services to people with psychiatric problems. Estimations of prevalence do suggest that some level of service is warranted when viewed in relation to facilities rather  than individuals. While not enough residents abuse substances to  justify the creation of services for residents, enough boarding homes have had substance  abusing residents to justify the creation  of education services  for  160 caregivers.  It  is  the  reccommendation  program/workshop be offered  of  this  author  that  a  to the directors and staff  trial  drug  education  members of Vancouver  area mental health boarding homes. Such a service can be offered within existing services, thereby minimizing both the monetary and temporal investments needed. The  "dual diagnosis team" recently formed by Greater Vancouver Mental Health  Services  (GVMHS),  in  conjunction  with  Alcohol  and  Drug  Programs  (ADP),  provides an excellent medium for such a drug program.  Following are some general operations  that might prove useful in developing a  drug education service for mental health boarding homes. 1.  Select  the  appropriate  program personnel  (hereafter  referred  to  as  the  "project coordinators"). The director and personnel of the Greater Vancouver Mental Health Services  dual diagnosis  team would seem to be a logical  choice. 2.  Contact potential service consumers to inform them of the pending program, elict their support, and solicit their input. Consumer involvement participation, t increases also  the  increases  Involving  consumers  likelihood that the  "ownership" in the  in  the  planning  process  increases not  only  "appropriate" services will be developed, but  likelihood  that,  by  program, consumers  instilling  in  them  will be motivated  a  sense  of  to accept and  participate in resultant services. 3.  Develop a "mission statement." The mission of this  t Refer to Chapter III for a summary of studies information sharing on subsequent group participtation.  project should be to  delineating  the  effects  of  161  increase the quality of life for substance abusing mental health boarding home residents, by increasing the caregivers awareness of, and ability to respond effectively to, dual diagnosis substance abuse. Define the program goals and objectives. The primary goal of this proposed project is to increase the awareness of directors and staff members regarding the many complexities of dual diagnosis substance abuse. It is assumed that by so doing, the caregivers will be able to provide better services to residents with substance abuse problems. Following, is a list of program objectives. The degree to which these objectives are attained should be systematically monitored. a.  Increase participants' knowledge of the potentially adverse effects of substance use on an individuals' psychiatric symptomology.  b.  Increase  participants' knowledge of the  additive, synergistic, and  antagonistic effects that may occur when substances are taken in combination, with a particular emphasis on the interaction of specific prescribed and nonprescribed substances. c.  Increase participants' knowledge about alternative coping strategies.  d.  Increase participants' awareness of the pros and cons of creating a new (dual diagnosis substance abuse) service industry.  e.  Increase participants' knowledge about the possible "causes" of dual diagnosis substance abuse (and substance abuse in general), including physiological, societal, cultural, economic, and political factors and their global ramifications.  Develop the program content/agenda. Suggestions for agenda items are detailed at a later point.  162 6.  Select,  develop  effectiveness  of  or  adapt  the  measurement  project.  instruments  There are  a  number  designed  to  test  of measurement  the tools  available that have been designed for use in conjunction with drug education programs, though most of these have not been designed for populations with both psychiatric and substance abuse problems, and thus, would need to be modified to fit a dual diagnosis substance abuse program. 7.  Locate  a suitable  facility  to  run the  program in. One of the boarding  homes may be able to host the program. 8.  Develop and distribute information and registration packages.  9.  Identify and contact possible guest speakers to address specific concerns. It would be preferential to have  representatives  from  a variety of different  disciplines and resources, providing a variety of different viewpoints. the  Thus,  "education" participants received would not solely reflect the relatively  narrow interests of any one interest group. 10.  Arrange for videotaping of the useful  program. This would not only provide a  assessment tool, but could also serve future  educational goals, or  provide guidelines for the development of future services. 11.  Run the  program/workshop, administer selected assessment tools using an  A/B (pretest/postest) design. It would be useful to structure such "research" so that it is conducive to longitudinal data collection. 12.  Analyze collected data.  13.  Based  on  the  subjective  consumers,  and the  videotapes,  and  a  insights  "objective" cost  insights  analysis,  specified goals and objectives.  of the  project coordinators  derived from  determine  if  the  and  service  measurement  scales,  project  has  met  its  163 14.  Present  a  summary  of  findings  and  recommendations  to  the  executive  directors of GVMHS and ADP, and the service consumers.  The  program/workshop agenda  would  have  to  be  developed  by  the  project  coordinators, in conjunction with the service consumers, although this study has provided many suggestions regarding potential agenda items: 1.  How to detect substance abuse.  2.  When does use become abuse?  3.  What behaviors might one expect?  4.  How to  respond to  residents  who  abuse  substances.  Direct intervention  techniques could be strengthened by role playing or small group formats. 5.  The effects of specific combinations of drugs.  6.  The similarities between the  molecular structures  of specific  psychoactive  drugs and neurotransmitters. 7.  The effects of prolonged abuse of specific substances.  8.  What community support services  are available? Only two  respondents in  this study made any reference to the newly formed GVMHS dual diagnosis team! Increased access to existing services is needed. 9.  Identify the pros and cons of available treatment options.  10.  Discuss the pros and cons of the "dual diagnosis" label.  11.  Explore the motivating factors that influence people's choice to use or abuse substances.  12.  Suggest alternative, substance free, stress management and problem solving skills.  164  While there is a growing awareness among health care professionals that dual diagnosis substance  abuse is a significant problem, and that most existing  treatment services are not sensitive to the needs of this population, there is less certainty about what, exactly, should be done. It is hoped, of course, that a drug education project would help boarding home staff and directors better understand the many complexities of dual diagnosis substance abuse, and would increase the quality of services available to boarding home residents. But in addition, this project would be extremely valuable as a guide for health care professionals, boarding home personnel, and policy planners (and thus, dual diagnosis substance abusers), to help develop increasingly "consumer friendly" services for this troubled and much maligned population.  D.  LIMITATIONS OF THE STUDY AND SUGGESTIONS  FOR FURTHER  RESEARCH  One (unjustified) criticism of this study might be that it does not survey the population with the highest prevalence of dual diagnosis substance abuse, and that findings, therefore, can not be generalized to the majority of persons with such problems. While it is true that mental health boarding home residents with substance abuse problems are not representative of all dual diagnosis substance abusers, a similar point can be made of the homeless, jailed, or hospitalized people that have been the focus of previous research in this area. This study was designed to look specifically at boarding home populations, to estimate the prevalence of dual diagnosis substance abuse therein. Attempts have not been made to generalize findings  specific to this study,  to other populations.  165  Several comments are in order concerning the method of data collection used in this study. First, while survey questionnaires are generally assumed to be a quicker means of data collection than personal interviews, this assumption rests on the premise that respondents will complete and return the questionnaires promptly ... which they seldom do. Furthermore, the expense of compiling, copying  and mailing questionnaires  can be  considerable.  Certainly, mailing  questionnaires would be less expensive than hiring interviewers, however, in a study of this size the researcher, author, and interviewer are one and the same. Thus, the researcher would have only him/herself to pay. Additionally, not only is the breadth of information gained through personal interviews greater, but specific clarifications can be obtained when answers are ambiguous.  And finally, it is extremely difficult to ensure that the interpretations of questions remain constant among different respondents. For instance, directors and staff members were asked if they had received any "training" in substance use or  dual  diagnosis  substance  abuse. However, the word "training" was not  specifically operationalized, and individual respondents may have interpreted this word in a variety of different ways. Although advantageous in that it increases the  breadth  of  the  information  that  can  be  collected,  omitting  specific  operationalizing parameters makes it difficult to make comparisons between different respondents. One staff member commented that he/she had not had any training in either substance abuse or dual diagnosis substance abuse, but had "read up on it" and had "some introduction [to these areas] at university as well." Another respondent who indicated that he/she had received training stated that it was "on the job" training. It is probable that individual respondents'  166  definitions of "training" were quite varied, and that what one respondent might have included as an example of substance abuse or dual diagnosis substance abuse training, the next respondent may have dismissed as inconsequential. Additionally, the term "boarding home" was used as a "generic" term referring to all residential mental health living facilities used by the Residential Services Division of Greater Vancouver Mental Health Services for client referrals. However, many respondents  insisted  that clear distinctions existed between  "boarding homes," "group homes," and "independent" or "semi-independent" living facilities (although the exact nature of these distinctions varied from one person to the next). It is extremely difficult to obtain a uniform understanding of concepts among different respondents when using survey questionnaires. Thus, making direct comparisons between respondents can be problematic. A good rule of thumb when operationalizing terms, is to assume that if there is the slightest chance that interpretations will vary ... they will. A clear distinction must be made between questions that require a wide breadth of data and those that require the consistency conducive to comparisons between subjects.  A number of points deserve mention regarding the content of the questionnaires, rather than the process of data collection. First, the prevalence of substance abuse during a two week period may not accurately estimate the true extent of substance abuse. Perhaps it would have been more expedient to simply ask respondents if any residents had had substance abuse problems, without reference to any specific temporal parameters. Respondents who did identify cases of substance  abuse could be further prompted to provide additonal information  concerning prevalence, frequency, and temporality. Another problem involved the  167  question designed to estimate residents' "average length of stay" in boarding homes. The specified categories of weeks, months, and years were not sensitive enough to pick up much variation between facilities; 88% of the facilities had an average length of stay that was measured in years, and none had a length of stay that was measured in weeks. More variation in the data could have been obtained by using categories such as "months," "one year," "two to five years," "six to ten years," and "more than ten years."  Further research is needed to survey persons with psychiatric and substance abuse problems, whose needs are not being met by the mental health boarding home infrastructure. A common assumption is that many people with both psychiatric and substance abuse problems either do not want to live in mental health boarding homes, or are restricted from doing so by boarding home policies. This study suggests that the latter of these two assumptions may be true, when the abuse is current. Thus, it would logically follow that the former assumption may  also be true. After all, would you want to live with others who were  highly critical of your behavior?  The refusal of persons to use services or receive treatment is often attributed to the individual's  "noncompliance,"  and very seldom is attention paid to the failure  of the service provider to comply with the consumer's needs and/or demands. If the existing mental health boarding homes are not meeting the needs and/or demands of people with both psychiatric and substance abuse problems, then what needs to be done? Should we attempt to change the people to fit the service, or the service to fit the people? Are the authoritarian structures of  168 many of these facilities too restrictive for many people with both psychiatric and substance  abuse problems? Is it better to provide housing that emphasizes  people's autonomy and independence, even if it means allowing people to make their own mistakes?  Should there be increased freedom for persons with  psychiatric problems, with or without the addition of substance related problems; freedom of choice ... freedom to be crazy? Should some of the attention currently focused on dual diagnosis substance abuse be shifted to further examine the problems associated with prescription drug use and/or abuse? These and other questions are waiting to be explored. But for now, community mental health boarding homes provide a suitable forum for increasing the quality of service delivery, and the quality of life for substance abusers that do make it into the "system." Drug education programs are an essential step in the struggle to increase awareness of the many complexities of dual diagnosis substance abuse.  BIBLIOGRAPHY  1. Albert, W.G., and Simpson, R.I. (1985). Evaluating an educational program for the prevention of impaired driving among grade 11 students. Journal of Drug Education, 15(1), 57-72. 2. Atkinson, R.M. (1973). Importance of alcohol and drug abuse in psychiatric emergencies. California Medicine, 118(4), 1-4. 3. Bachrach, L . L . (1982a). 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Washington: American Psychiatric Press.  171 23. Davis, S. (1986). The "new young chronic" psychiatric patient: A study in Vancouver. Social Work in Health Care , 11(2), 87-100.  24.  Davis, S. (1987). The homeless mentally Social Worker, 55(1), 10-13.  ill: A report from Vancouver. The  25. Deutsch, A . (1949). The mentally ill in America.  New York: Columbia Press.  26. Ellinwood, E . H . (1976). Emergency treatment of acute adverse reactions to C N S stimulants. In P.G. Bourne (Ed.), Drug abuse emergencies: A treatment manual (pp. 115-122). New York: Academic Press.  27. Elpers, J.R. (1987). Are we legislating ^institutionalization? of Orthopsychiatry, 97(3), 441-446.  American  Journal  28. Erard, R. Luisada, P.V., and Peele, R. (1980). The P C P psychosis: Prolonged intoxication or drug induced functional illness. Journal of Psychedelic Drugs, 12, 235-251  29. Festinger, L. (1957). A theory of cognitive dissonance. Evanston: Row, Peterson.  30.  Fowler, R.C., Liskow, B . 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Kutchins, H . , and Kirk, S.A. (1987). DSM-III and social work malpractice. Social Work, May-June, 205-211. 44. Kutchins, H . , and Kirk, S.A. (1988a). The business of diagnosis: DSM-III and clinical social work. Social Work, May-June, 215-220. 45. Kutchins, H . , and Kirk, S.A. (1988b). The future of DSM: Scientific and health professional issues. The Harvard Letter, 5 (3), 4-6.  Medical School Mental Health  173 46. Khantzian, E . J . (1985). The self medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. American Journal of Psychiatry, 142 (11), 1259-1264.  47. Klerman, G.L. (1970). Drugs and social values. The International Journal of the Addictions, 5(2), 313-319. 48. Kovess, V . , and Lafleche, M . (1988). How do teams practice community psychiatry? Canada's Mental Health , 36(2/3), 9-16.  49. Kroeker, H . (1988). An assessment of service needs for clients who have a mental disorder and also substance abuse problems: A survey of service providers and resource persons/agencies in Greater Vancouver Mental Health Services and Alcohol and Drug Programs. Report presented to  the Alcohol and Drug Programs, and Greater Vancouver Mental Health Service Society, Vancouver. 50. Lamb, H.R. (1982). Young adult chronic patients: The new drifters. Hospital and Community Psychiatry, 33 (6), 465-468.  51. Lamb, H.R., and Grant, R.W. (1982). The mentally ill in an urban county jail. Archives of General Psychiatry, 39, 17-22.  52. Lamb, H.R., and Grant, R.W. (1983). Mentally ill women in a county jail. Archives of General Psychiatry, 40, 363-368.  53. Lightman, E.S. (1986). The impact of government economic restraint on mental health services in Canada. Canada's Mental Health, 34(1), 24-28. 54. Maisto, S.A., and Carey, K.B. (1987). Treatment of alcohol abuse. In T.D. Nirenberg, and S.A. Maisto (Eds.), Developments in the assessment and treatment of addictive behaviors (pp. 173-212). New Jersey: Ablex. 55. Marlatt, G.A. and Rohsenow, D.J. (1980). Cognitive processes in alcohol use: Expectancy and the balanced-placebo design. In N.K. Mello (Ed.), Advances in substance abuse: behavioral and biological research (pp.  155-199). Greenwich: A A l Press.  174 56. McKelvy, M. Kane, J . , and Kellison, K. (1987). Substance abuse and mental illness: Double trouble. Journal of Psychosocial Nursing, 25(1), 20-25. 57. Merricucci, L . , Wermuth, L . , and Sorensen, J . (1988). Treatment provider's assessment of dual-prognisis patients: Diagnosis, treatment, referral and family involvement. International Journal of the Addictions, 23(6), 617-622.  58. Meyer, R., and Hesselbrock, M. (1984). Psychopathology and addictive disorders revisited. In S.M. Mirin (Ed.), Substance abuse and psycopathology (pp. 1-18). Washington: American Psychiatric Press. 59. Milby, J.B. (1981). Addictive behavior and its treatment. New York: Springer. 60. Mirin S.M., Weiss, R.D., Sollogub, A., and Michael, J . (1984a). Affective illness in substance abusers. In S.M. Mirin (Ed.), Substance abuse and psychopathology (pp. 57-78). Washington: American Psychiatric Press. 61. Mirin S.M., Weiss, R.D., Sollogub, A., and Michael, J . (1984b). Psychopathology in the families of drug abusers. In S.M. Mirin (Ed.), Substance abuse and psychopathology (pp. 79-106). Washington:  American Psychiatric Press. 62. Mishler, E.G. (1981). Patients in social contexts. In E.G. Mishler (Ed.), Social concepts of health, illness, and patient care. Cambridge: Cambridge  University Press. 63. Moos, R.A. (1974). Evaluating treatment environments. New York: John Wiley and Sons. 64. O'Brien, C P . , Woody, G.E., and McLellan, A . T . (1984). Psychiatric disorders in opioid-dependent patients. Journal of Clinical Psychiatry, 45(12), 9-13. 65. O'Farrell, T.J., Connors, G.J., and Upper, D. (1983). Addictive behaviors among hospitalized psychiatric patients. Addictive Behaviors, 8, 329-333.  66. Pekarik, G., and Finney-Owen, K. (1987). Outpatient clinic therapist attitudes and beliefs relevant to client dropout. Community Mental Health Journal, 23(2), 120-130.  175 67. Pepper, B., and Ryglewicz, H. (1984). Concluding comments. In B. Pepper and H . Ryglewicz (Eds.), New directions for mental health services: The Young Adult Chronic Patient. San Francisco: Jossey-Bass.  68. Preskorn, S.H., and Goodwin, D.W. (1987). Medical management of the depressed alcoholic patient. International Journal of Psychiatry in Medicine, 17(2), 117-131. 69. Quine, L . (1981). Alone in the community. New Society , 11, 435-436. 70. Reich, R., and Siegel, L. (1978). The emergence of the bowery as a psychiatric dumping ground. Psychiatric Quarterly , 50(3), 191-201. 71. Reid, W.J., and Smith, A.D. (1981). Research in social work. New York: Columbia University Press. 72. Ridgely, M.S., Goldman, H.H., and Talbott, J.A. (1986). Chronic mentally ill young adults with substance abuse problems: A review of relevant literature and creation of a research agenda. Baltimore, Maryland:  Mental Health Policy Studies, Department of Psychiatry, University of Maryland School of Medicine. 73. Ridgely, M.S., Osher, F.C., and Talbott, J.A. (1987). Chronic mentally ill young adults with substance abuse problems: treatment and training  issues. Baltimore, Maryland: Mental Health Policy Studies, Department of Psychiatry, University of Maryland School of Medicine. 74. Rounsaville, B.J., Weissman, M.M., Kleber, H . , and Wilber, C H . (1982). The heterogeneity of psychiatric diagnosis in treated opiate addicts. Arichives of General Psychiatry, 39(2), 161-166. 75. Rounsaville, B.J., Dolinsky, Z.S., Babor, T.F. and Meyer, R.E. (1987). Psychopathology as a predictor of treatment outcome in alcoholics. Archives of General Psychiatry, 44(6), 505-513.  76. Safer, D. (1986). 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INTRODUCTORY LETTER TO DIRECTORS August, 1989 Mental Health Boarding Home Dual Diagnosis Project Dear Boarding Home Director,  I am a Master of Social Work candidate at the University of British Columbia, and  as part of my degree requirements I am conducting some research to find  out  how common drug or alcohol (substance)  use  is  among the  residents of  mental health boarding homes in Vancouver. A number of studies have shown that many "homeless" people have both psychiatric and substance abuse problems, and  hospital admittance records show that many people who enter acute care  psychiatric  wards  in hospitals  also  have  histories  of substance  use  or abuse.  However, very little is known about the extent of drug or alcohol use by mental health boarding home residents.  Your knowledge and opinions are very important. Not only do I need your help to establish the extent of substance  use  or abuse  in mental health boarding  homes (is it a problem?), but also to determine what, if any thing, should be done about it.  Quite often, people in different positions within the same agency have different opinions about the same thing, and so it would be extremely valuable to me if not only you but also the staff and residents of your boarding home would each agree to complete a questionnaire. In the next week I will phone you to try  180  APPENDIX 3. INTRODUCTORY LETTER TO STAFF June,  1989 Mental Health Boarding Home Dual Diagnosis Project  Dear Staff Member,  I am a Master of Social Work candidate at the University of British Columbia, and  as part of my degee requirements, I am conducting some research to find  out  how  common drug or alcohol  (substance) use  is  among the  residents  mental health boarding homes in Vancouver. A number of studies have  of  shown  that many "homeless" people have both psychiatric and substance abuse problems, and  hospital admittance records show that many people  psychiatric  wards  in hospitals  also have  histories  who enter  of substance  use  acute care or abuse.  However, very little is known about the extent of drug or alcohol use by mental health boarding home residents.  Your knowledge and opinions are very important. Not only do I need your help to establish  the  extent of substance  use  or abuse  in mental  health boarding  homes (is it a problem?), but also to determine what, if any thing, should be done about it.  Participation in this study is entirely voluntary. If you complete the questionnaire I will assume that you have given your consent to participate in this study, and will send a copy of the results to this boarding home in the autumn. It should not take  more than  45  minutes  to complete  182  this questionnaire,  and you can  APPENDIX 5. DIRECTOR PRETEST QUESTIONNAIRE (FOR DIRECTORS] DUAL DIAGNOSIS SUBSTANCE ABUSE IN VANCOUVER'S MENTAL HEALTH BOARDING HOMES: A NEED ASSESSMENT SURVEY This questionnaire alcohol  i s designed  to f i n d out what the extent of  and drug u s e i s by people who l i v e i n mental h e a l t h  homes, and to f i n d  out i f any d i f f i c u l t i e s a r i s e  T h e r e a r e no r i g h t  or wrong answers. Your answers a r e very  By  questions,  answering these  of my M a s t e r o f S o c i a l  boarding  from t h i s use. important.  you w i l l not only h e l p me f u l f i l l  Work degree requirements,  but w i l l  also  me make some program p l a n n i n g recommendations t o t h e G r e a t e r Mental Health It w i l l  only  take about f o r t y - f i v e minutes t o f i l l  Participation  i f you c o m p l e t e  agreed tell  which boarding  Vancouver  i s entirely  out t h i s voluntary,  asume t h a t you have  These q u e s t i o n n a i r e s a r e coded so that I can  home they came from. Do not p u t your name on t h e  i f y o u do n o t want to be i d e n t i f i e d . To ensure  confidentiality, access  i n t h i s study  this questionnaire I w i l l  to participate.  questionnaire  help  S e r v i c e s and the Vancouver Drug and A l c o h o l Program.  questionnaire. and  part  only  I and my U.B.C. t h e s i s a d v i s o r s w i l l  have  t o these q u e s t i o n n a i r e s . Please f e e l f r e e t o c o n t a c t me a t  224-4786 i f you have any q u e s t i o n s . T i m o t h y J . Hayvard,  B.S.W.,  U.B.C. Master of S o c i a l  • P l e a s e mark an 'X' a t the beginning of any q u e s t i o n s u n c l e a r o r c o n f u s i n g . Thank you f o r your h e l p . 1. What i s the d a t e  How many p e o p l e  Candidate  t h a t you f i n d  today? month  2.  Work  are l i v i n g  i n the boarding  day  year  home a t t h i s time?  3. What i s the a v e r a g e age of your r e s i d e n t s ? 4. What number of t h e r e s i d e n t s a r e : Male? (These s h o u l d e q u a l the number Female? g i v e n i n q u e s t i o n number 2) 5. What i s the a v e r a g e l e n g t h of stay f o r the r e s i d e n t s ? ( P l e a s e f i l l t h e a p p r o p r i a t e blanks) Days Weeks Months Years  186  187 P l e a s e i n d i c a t e how many of y o u r b o a r d i n g g i v e n the f o l l o w i n g diagnoses: Schizophrenia Unipolar A f f e c t i v e Disorder Bipolar Affective Disorder Personality Disorder Organic Disorder Other (please s p e c i f y )  home r e s i d e n t s  have  been  What number of the r e s i d e n t s are c u r r e n t l y taking the f o l l o w i n g medications? None. Major t r a n q u i l i z e r s . Minor t r a n q u i l i z e r s . Neuroleptics Antidepressants. Lithium. Antiparkonsonians. Other (Please s p e c i f y )  As f a r as you know, how many of the r e s i d e n t s l i v i n g i n the home take any of the f o l l o w i n g drugs the s p e c i f i e d number of times? For example, i f there were 10 residents i n the home, and three of them used a l c o h o l once or twice a week, one of them used alcohol once or twice a year, and the remaining 6 of them never used a l c o h o l , i t would look l i k e t h i s : every day a) A l c o h o l (Please f i l l  once or once or once or never twice a twice a twice a week month year  i n the appropriate numbers) every once or once o r once or day twice a twice a twice a week month year  never  a) A l c o h o l b) Marijuana c) O p i a t e s d) PCP/Angel Dust e) LSD/Acid f) Amphetamines g) B a r b i t u r a t e s h) Inhalants/Glue i) Other (If you i n d i c a t e d use of drugs i n the "other" p l e a s e i n d i c a t e what they are)  I don't know  I don't know  _  category,  188 9.  I have heard i t said that f o r some people with p s y c h i a t r i c problems, going out f o r a drink i s a c t u a l l y a p o s i t i v e accomplishment, because "at least they are doing something." What, based on your e x p e r i e n c e , i s your r e a c t i o n to that statement?  10. Does your boarding home have a p o l i c y concerning a l c o h o l or drug use by residents? No I Don't Know Yes (what i s i t ? )  11. What would you do i f you d i s c o v e r e d one of the r e s i d e n t s was d r i n k i n g a l c o h o l : (Mark as many as apply) a) Outside of your boarding home? Nothing, as long as they didn't over do i t Ask them to stop Refer them to a mental health c o u n s e l l o r Refer them to a substance abuse c o u n s e l l o r Refer them to a s e l f - h e l p group l i k e A l c o h o l i c s Anonymous Ask them to move out of the boarding home Control t h e i r money I don't know Other (Please s p e c i f y )  b)  In your boarding home? Nothing, as long as they d i d n ' t over do i t Ask them to stop Refer them t o a mental health c o u n s e l l o r Refer them to a substance abuse c o u n s e l l o r Refer them t o a s e l f - h e l p group l i k e A l c o h o l i c s Anonymous Ask them to move out of the boarding home Control t h e i r money I don't know Other (Please s p e c i f y )  1 2 . Have you ever t r i e d t o get h e l p f o r a r e s i d e n t with an a l c o h o l or drug problem? No Yes a)With whom?__  b)What was the outcome?  189 13. How o f t e n do y o u a c c e p t a p p l i c a n t s w i t h h i s t o r i e s o f s u b s t a n c e a b u s e i n t o y o u r b o a r d i n g home? (Check t h e c a t e g o r y t h a t f i t s b e s t ) Never _Rarely Somet imes Often A h i s t o r y o f s u b s t a n c e abuse does n o t i n f l u e n c e our d e c i s i on 14.  I have h e a r d i t s a i d t h a t f o r people w i t h p s y c h i a t r i c p r o b l e m s , s u b s t a n c e u s e i s t h e same as substance abuse, b e c a u s e "even s m a l l a m o u n t s of t h e s e s u b s t a n c e s cause a w o r s e n i n g o f p s y c h i a t r i c symptoms." What, b a s e d on your e x p e r i e n c e , i s y o u r r e a c t i o n t o t h a t statement?  15. T h i n k f o r a . m i n u t e a b o u t t h e p a s t two weeks. To t h e b e s t of y o u r k n o w l e d g e , how many t i m e s have t h e i n d i v i d u a l r e s i d e n t s i n your b o a r d i n g home t a k e n i l l i c i t " s t r e e t " drugs o r u s e d a l c o h o l ? ( P l e a s e i n d i c a t e t h e number of r e s i d e n t s who f i t i n t h e f o l l o w i n g categories). a) Amount o f Drug U s e D u r i n g The P a s t Two Weeks: 0 times  1 t h r u 5 times  6 t h r u 10 t i m e s  don't  11 t h r u 15 t i m e s  16 o r more t i m e s  know  b) Amount o f A l c o h o l Use D u r i n g The P a s t Two Weeks: _0  times  _don't  know  1 t h r u 5 times  6 thru  10 t i m e s  11 t h r u 15 times  16 o r more t i m e s  16. How many r e s i d e n t s h a v e had problems r e l a t e d t o h e a l t h , b e h a v i o r , f a m i l y , work, o r t h e l a w due t o drug o r a l c o h o l u s e d u r i n g t h e p a s t two w e e k s ? ( i f a p p l i c a b l e , would you b r i e f l y d e s c r i b e one o r two i n c i d e n t s f o r me?) a)  Number o f R e s i d e n t s W i t h Drug R e l a t e d P r o b l e m s . . Description.  b) Number o f R e s i d e n t s W i t h A l c o h o l R e l a t e d Description.  Problems.  190  17.  A r e a l c o h o l i c b e v e r a g e s a l l o w e d a t b o a r d i n g home C h r i s t m a s p a r t i e s a n d / o r o t h e r s p e c i a l f u n c t i o n s ? (Check t h e b e s t answer) _Yes No Sometimes  18.  What, i f . any, s e r v i c e s do you t h i n k s h o u l d be o f f e r e d t o h e l p r e d u c e t h e d r u g or a l c o h o l r e l a t e d p r o b l e m s o f m e n t a l h e a l t h b o a r d i n g home r e s i d e n t s ?  19.  A r e t h e r e any s u b s t a n c e abuse p r o g r a m s o p e r a t i n g i n your b o a r d i n q home? ( I f t h e r e a r e , p l e a s e s p e c i f y what they are) No I Don't Know Yes (What?)  20.  W o u l d you p l e a s e answer the f o l l o w i n g q u e s t i o n s about y o u r s e l f , t o h e l p me u n d e r s t a n d more about t h e p e o p l e who work i n m e n t a l h e a l t h b o a r d i n g homes? (Of c o u r s e , y o u r a n s w e r s w i l l be k e p t confidential). a) What i s y o u r j o b t i t l e ?  b)  What i s y o u r gender?  Male  c)  What i s y o u r d a t e of b i r t h ?  Day  d)  What l e v e l  completed?  e)  Have y o u No  f)  Have y o u r e c e i v e d any t r a i n i n g i n t h e a r e a of d u a l d i a g n o s i s s u b s t a n c e abuse? No Yes ( i f y e s , p l e a s e s p e c i f y what t h i s was)  o f e d u c a t i o n have y o u  Female Month  Year  r e c e i v e d any t r a i n i n g i n t h e a r e a o f s u b s t a n c e a b u s e ? Yes ( i f y e s , p l e a s e s p e c i f y what t h i s was)  191  2 1 . V a r i o u s p r o g r a m s have been s u g g e s t e d as r e s p o n s e s t o d u a l d i a g n o s i s s u b s t a n c e a b u s e . Which of the f o l l o w i n g s e r v i c e s do you t h i n k w o u l d be u s e f u l ? ( P l e a s e rank those p r o g r a m s t h a t you s e l e c t i n t h e i r o r d e r o f i m p o r t a n c e , w i t h "1" as t h e most i m p o r t a n t ) . a) b) c) d) e) f) g) h) i) _ j)  S e l f - h e l p group l i k e A l c o h o l i c s Anonymous Drug e d u c a t i o n p r o g r a m Life skills training Individual Counselling Group C o u n s e l l i n g Family Counselling Job t r a i n i n g program A s s i s t a n c e o b t a i n i n g independent housing R e c r e a t i o n programs t h a t a r e a l c o h o l and d r u g Other (Please s p e c i f y )  22.  W h i c h of t h e above w i t h i n the boarding a) f)  23.  W o u l d you l i k e t o be o f f e r e d a w o r k s h o p on d u a l s u b s t a n c e a b u s e ? ( S e l e c t o n l y one answer) Yes No  free  programs do you t h i n k s h o u l d be o f f e r e d home? ( c h e c k t h e a p p r o p r i a t e c a t e g o r i e s ) b) c) d) e) g) h) none  (Why?)  diagnosis '_  (Why?)  Maybe (Why?)  24.  I f a w o r k s h o p o r s t a f f t r a i n i n g s e s s i o n on d u a l d i a g n o s i s s u b s t a n c e a b u s e were a v a i l a b l e , w h a t w o u l d you l i k e i t t o i n c l u d e ?  192  25.  Please use t h i s space (and the other side of t h i s page) t o i n c l u d e any a d d i t i o n a l comments you would l i k e to make.  THANK YOU VERY MUCH FOR PARTICIPATING IN THIS STUDY.  194  2.  As f a r as you know, how many of the r e s i d e n t s l i v i n g i n t h e home t a k e any o f t h e f o l l o w i n g drugs the s p e c i f i e d number of t i m e s ? For example, i f t h e r e were 10 r e s i d e n t s i n t h e home, and t h r e e o f them used a l c o h o l once o r t w i c e a week, one of them used a l c o h o l once o r t w i c e a y e a r , and t h e r e m a i n i n g 6 of them n e v e r used a l c o h o l , i t would look l i k e t h i s : every day a)Alcohol  once o r twice a week  3  once o r twice a month  once or twice a year  1  never  don't know  ( P l e a s e f i l l i n the a p p r o p r i a t e numbers) every once o r once o r once or never day twice a twice a twice a month week year a) A l c o h o l b) M a r i j u a n a c) O p i a t e s d) PCP/Angel Dust e) L S D / A c i d f) Amphetamines g) B a r b i t u r a t e s h) I n h a l a n t s / G l u e i) Other ( I f you i n d i c a t e d use of drugs i n the " o t h e r " c a t e g o r y , p l e a s e i n d i c a t e what t h e y are)  3.  I have h e a r d i t s a i d t h a t f o r some p e o p l e w i t h p s y c h i a t r i c p r o b l e m s , g o i n g out f o r a d r i n k i s a c t u a l l y a p o s i t i v e accomplishment, b e c a u s e " a t l e a s t they a r e d o i n g something." What, b a s e d on y o u r e x p e r i e n c e , i s your r e a c t i o n t o t h a t statement?  4.  Does t h e b o a r d i n g home have a p o l i c y use by r e s i d e n t s ? No I Don't Know Yes (what i s i t ? )  concerning a l c o h o l o r drug  195 Are a l c o h o l i c beverages a l l o w e d a t b o a r d i n g home C h r i s t m a s p a r t i e s and/or other s p e c i a l f u n c t i o n s ? (Check the b e s t answer) Yes No Sometimes What would you do i f you d i s c o v e r e d one o f the r e s i d e n t s was d r i n k i n g a l c o h o l : (Mark as many as apply) a) O u t s i d e o f your b o a r d i n g home? Nothing, as l o n g as t h e y d i d n ' t over do i t Ask them t o s t o p R e f e r them t o a m e n t a l h e a l t h c o u n s e l l o r R e f e r them t o a s u b s t a n c e abuse c o u n s e l l o r R e f e r them t o a s e l f - h e l p group l i k e A l c o h o l i c s Anonymous Ask them t o move out o f the b o a r d i n g home C o n t r o l t h e i r money I don't know Other ( P l e a s e s p e c i f y )  b)  In your b o a r d i n g home? Nothing, as l o n g as t h e y d i d n ' t over do i t Ask them t o s t o p R e f e r them t o a m e n t a l h e a l t h c o u n s e l l o r R e f e r them t o a s u b s t a n c e abuse c o u n s e l l o r R e f e r them t o a s e l f - h e l p group l i k e A l c o h o l i c s Anonymous Ask them t o move o u t o f t h e b o a r d i n g home C o n t r o l t h e i r money I don't know Other ( P l e a s e s p e c i f y )  Have you ever t r i e d t o g e t h e l p f o r a r e s i d e n t w i t h an a l c o h o l o r d r u g problem? No Yes a)With whom?  b)What was t h e outcome?  . I have heard i t s a i d t h a t f o r p e o p l e w i t h p s y c h i a t r i c p r o b l e m s , s u b s t a n c e use i s the same as s u b s t a n c e abuse, because "even s m a l l amounts of t h e s e s u b s t a n c e s c a u s e a worsening o f p s y c h i a t r i c symptoms." What, based on your e x p e r i e n c e , i s your r e a c t i o n t o t h a t statement?  196 9. Think f o r a minute about the past two weeks. To t h e b e s t of your knowledge, how many times have the i n d i v i d u a l r e s i d e n t s i n your b o a r d i n g home t a k e n i l l i c i t " s t r e e t " drugs o r u s e d a l c o h o l ? ( P l e a s e i n d i c a t e the number of r e s i d e n t s who f i t i n t h e f o l l o w i n g categories) . a)  Amount o f Drug Use During The Past  Two  Weeks:  0 times  1 t h r u 5 times  6 thru  .don't know  11 t h r u 15 times  16 o r more times  b) Amount o f A l c o h o l Use During The Past  Two  10 times  Weeks:  _0 t i m e s  1 t h r u 5 times  6 thru  _don't  11 t h r u 15 times  16 o r more times  know  10 times  10. How many r e s i d e n t s have had problems r e l a t e d t o h e a l t h , b e h a v i o r , f a m i l y , work, o r t h e law due t o drug or a l c o h o l use d u r i n g the p a s t two weeks? ( i f a p p l i c a b l e , would you b r i e f l y d e s c r i b e one o r two i n c i d e n t s f o r me?) a)  Number With Drug R e l a t e d  Problems.  Description.  ;  b) Number With A l c o h o l R e l a t e d Description.  Problems.  ;  11.  What, i f any, s e r v i c e s do you t h i n k s h o u l d be o f f e r e d t o h e l p r e d u c e t h e d r u g o r a l c o h o l r e l a t e d problems o f m e n t a l h e a l t h b o a r d i n g home r e s i d e n t s ?  12.  Are t h e r e any s u b s t a n c e abuse programs o p e r a t i n g i n y o u r b o a r d i n g home? ( I f t h e r e a r e , p l e a s e s p e c i f y what t h e y are) No I Don't Know Yes (What?)  197 13.  14.  Would you p l e a s e answer the f o l l o w i n g q u e s t i o n s about y o u r s e l f , t o h e l p me u n d e r s t a n d more about the people who work i n m e n t a l h e a l t h b o a r d i n g homes? (Of c o u r s e , your answers w i l l be k e p t confidential). a) What i s your job t i t l e ?  b)  What i s your gender?  Male  c)  What i s y o u r date  d)  What l e v e l  e)  Have you No  f)  Have you r e c e i v e d any t r a i n i n g i n the a r e a of d u a l d i a g n o s i s substance abuse? No Yes ( i f yes, p l e a s e s p e c i f y what t h i s was)  of b i r t h ?  of e d u c a t i o n  have you  Female Day  Month  completed?.  r e c e i v e d any t r a i n i n g i n the a r e a of s u b s t a n c e abuse? Yes ( i f y e s , p l e a s e s p e c i f y what t h i s was)  V a r i o u s programs have been s u g g e s t e d as r e s p o n s e s t o d u a l d i a g n o s i s s u b s t a n c e abuse. Which of the f o l l o w i n g s e r v i c e s do you t h i n k w o u l d be u s e f u l ? ( P l e a s e rank those programs t h a t you s e l e c t i n t h e i r o r d e r o f i m p o r t a n c e , w i t h "1" as the most i m p o r t a n t ) . a) S e l f - h e l p group l i k e A l c o h o l i c s Anonymous b) Drug e d u c a t i o n program c) Life skills training d) Individual Counselling e) _ _ _ G r o u p C o u n s e l l i n g f) _ _ _ _ F a m i l y C o u n s e l l i n g g) Job t r a i n i n g program h) A s s i s t a n c e o b t a i n i n g independent housing i) R e c r e a t i o n programs t h a t are a l c o h o l and d r u g j) Other (Please s p e c i f y )  15.  Year  Which of the above w i t h i n the b o a r d i n g a) f)  free  programs do you t h i n k s h o u l d be o f f e r e d home? (check the a p p r o p r i a t e c a t e g o r i e s ) b) c) d) e) g) h) none  198 16.  Would you l i k e to be o f f e r e d a workshop on dual s u b s t a n c e abuse? ( S e l e c t o n l y one answer) Yes No  diagnosis  (Why?) (Why?)  .Maybe  (Why?)  17.  I f a workshop or s t a f f t r a i n i n g s e s s i o n on d u a l d i a g n o s i s s u b s t a n c e abuse were a v a i l a b l e , what would you l i k e i t t o i n c l u d e ?  18.  P l e a s e use t h i s space t o i n c l u d e any a d d i t i o n a l comments l i k e t o make.  THANK YOU VERY MUCH FOR  you w o u l d  PARTICIPATING IN THIS STUDY.  200 2.  How l o n g have you l i v e d i n t h i s b o a r d i n g home? ( P l e a s e f i l l a p p r o p r i a t e numbers as c l o s e as you can remember) Days Weeks Months Years  3.  How much l o n g e r do you p l a n t o l i v e Days Weeks Months Years  i n t h i s boarding  i n the  home?  4. I have heard i t s a i d t h a t f o r p e o p l e w i t h p s y c h i a t r i c p r o b l e m s , s u b s t a n c e use i s the same as substance abuse, because "even s m a l l amounts o f t h e s e s u b s t a n c e s cause a worsening o f p s y c h i a t r i c symptoms." What, based on your e x p e r i e n c e , i s y o u r r e a c t i o n t o t h a t statement?  5.  P l e a s e i n d i c a t e what p s y c h i a t r i c d i a g n o s i s you have been (Check the a p p r o p r i a t e c a t e g o r y below) Schizophrenia Unipolar A f f e c t i v e Disorder Bipolar A f f e c t i v e Disorder Personality Disorder Organic D i s o r d e r I Don't Know O t h e r ( p l e a s e s p e c i f y what)  6. Do y o u agree w i t h the above Yes No I Don't Know 7.  given.  diagnosis?  A r e y o u c u r r e n t l y t a k i n g any of t h e f o l l o w i n g m e d i c a t i o n s ? None. Major t r a n q u i l i z e r s . Minor t r a n q u i l i z e r s . Neuroleptics Antidepressants. Lithium. Antiparkonsonians. I Don't Know What M e d i c a t i o n I Am T a k i n g Other(s) (Please specify)  201 8. How o f t e n do you take any of t h e f o l l o w i n g d r u g s : ( P l e a s e c h e c k the a p p r o p r i a t e c a t e g o r i e s ) every once or once o r once or never I day twice a twice a twice a don't week month year know a) A l c o h o l b) Mariauana c) O p i a t e s d) PCP/Angel Dust e) LSD/Acid f) Amphetamines g) B a r b i t u r a t e s h) I n h a l a n t s / G l u e i) O t h e r ( I f you t a k e d r u g s i n t h e " o t h e r " c a t e g o r y , p l e a s e s p e c i f y what they a r e )  9.  How many of t h e p e o p l e l i v i n g i n your b o a r d i n g home have had p r o b l e m s w i t h t h e i r h e a l t h , b e h a v i o r , f a m i l y , work, o r t h e law due t o drug o r a l c o h o l use d u r i n g t h e p a s t two weeks? ( i f a p p l i c a b l e , would you b r i e f l y d e s c r i b e one o r two examples f o r me?) a)  Number With Drug R e l a t e d Description  b)  11.  o f Problems.  Number With A l c o h o l R e l a t e d Description  10.  Problems.  Problems.  o f Problems.  Have you had any p r o b l e m s r e l a t e d t o h e a l t h , b e h a v i o r , f a m i l y , work, o r t h e law due t o drug o r a l c o h o l use d u r i n g t h e p a s t two weeks? ( I f you have, w i l l you p l e a s e g i v e me one o r two examples?) a)drugs  No  Yes  Example(s)  b)alcohol  No  Yes  Example(s)  Have you e v e r No Yes  r e c e i v e d treatment (Where?)  f o r d r i n k i n g o r drug  use?  202 12. 13.  14.  15.  Have you ever No  tried  t o g e t h e l p f o r an a l c o h o l o r drug Yes  problem?  I f you answered 'No' t o the above q u e s t i o n , then s k i p t h i s q u e s t i o n and go t o q u e s t i o n 14. I f you answered 'Yes,' then who d i d you t r y t o g e t h e l p from? A Friend A F a m i l y Member A B o a r d i n g Home S t a f f Member A Counsellor A Doctor I Don't Remember O t h e r ( P l e a s e s p e c i f y what t h e i r r e l a t i o n s h i p was t o you)  Have you ever No Yes  been t o l d (By Who?)  t h a t you have an a l c o h o l or d r u g A Friend A F a m i l y Member A Counsellor A Doctor A Police Officer Other (What was t h e i r to you?)  A r e a l c o h o l i c b e v e r a g e s allowed a t b o a r d i n g p a r t i e s and/or o t h e r s p e c i a l f u n c t i o n s ? Yes No Sometimes  home  problem?  relationship  Christmas  I don't know  16.  A r e t h e r e any s u b s t a n c e abuse programs o p e r a t i n g i n y o u r b o a r d i n g home? ( I f t h e r e are, p l e a s e s p e c i f y what they a r e ) No I Don't Know Yes (What?)  17.  Does t h e b o a r d i n g home have a p o l i c y c o n c e r n i n g use by r e s i d e n t s ? No I Don't Know Yes (What i s i t ? )  a l c o h o l o r drug  203 18.  What do you t h i n k t h e b o a r d i n g home s t a f f would do i f t h e y f o u n d out t h a t you were d r i n k i n g a l c o h o l : (Mark as many c a t e g o r i e s as a p p l y ) a) O u t s i d e of t h e b o a r d i n g home? N o t h i n g , as l o n g as I d i d n ' t o v e r do i t Ask me t o s t o p R e f e r me t o a mental h e a l t h c o u n s e l l o r R e f e r me t o a s u b s t a n c e abuse c o u n s e l l o r R e f e r me t o a s e l f - h e l p group l i k e A l c o h o l i c s Anonymous Ask me t o l e a v e t h e b o a r d i n g home C o n t r o l my money I don't know Other (Please s p e c i f y )  z)  19.  In the b o a r d i n g home? N o t h i n g , as l o n g as I d i d n ' t o v e r do i t Ask me t o s t o p R e f e r me t o a m e n t a l h e a l t h c o u n s e l l o r R e f e r me t o a s u b s t a n c e abuse c o u n s e l l o r R e f e r me t o a s e l f - h e l p group l i k e A l c o h o l i c s Ask me t o l e a v e y o u r b o a r d i n g home C o n t r o l my money I don't know Other (Please s p e c i f y )  Anonymous  W o u l d you p l e a s e answer t h e f o l l o w i n g q u e s t i o n s a b o u t y o u r s e l f , t o h e l p me u n d e r s t a n d more a b o u t t h e p e o p l e who l i v e i n m e n t a l h e a l t h b o a r d i n g homes? (Of c o u r s e , your a n s w e r s w i l l be k e p t conf idential) . a) Do you have a j o b a t t h i s time? No Yes ( P l e a s e i n d i c a t e what i t i s )  b)  Are y o u :  Male,  c)  What i s your  d)  What l e v e l  f)  What i s your  date  or  of b i r t h ?  of education  Female Day  Month  have you c o m p l e t e d ?  e t h n i c background.  Year  204 20.  What, i f any, s e r v i c e s do you t h i n k s h o u l d be o f f e r e d to h e l p r e d u c e the drug o r a l c o h o l r e l a t e d problems of mental h e a l t h b o a r d i n g home r e s i d e n t s ?  21.  V a r i o u s programs have been s u g g e s t e d as r e s p o n s e s t o d u a l d i a g n o s i s s u b s t a n c e abuse. Which of the f o l l o w i n g s e r v i c e s do you t h i n k would be u s e f u l ? ( P l e a s e rank t h o s e programs t h a t you s e l e c t i n t h e i r o r d e r of i m p o r t a n c e , w i t h "1' as the most i m p o r t a n t ) . a) b) c) d) e) f) g) h) i) j)  22.  S e l f - h e l p group ( l i k e A l c o h o l i c s Anonymous) Drug e d u c a t i o n Life skills training Individual Counselling Group C o u n s e l l i n g Family C o u n s e l l i n g Job t r a i n i n g A s s i s t a n c e o b t a i n i n g independent h o u s i n g R e c r e a t i o n programs t h a t a r e a l c o h o l and drug Other (Please s p e c i f y )  Do you a t t e n d s p e c i f y what)  any  of the above l i s t e d programs? No Yes (What?)  ( I f yes,  free  please •  23.  Would you a t t e n d any of the above mentioned programs i f they o f f e r e d t o you? ( I f yes, p l e a s e s p e c i f y what) No Maybe Yes (What?)  24.  Which of the above w i t h i n the b o a r d i n g a) f) .  programs do you t h i n k s h o u l d be o f f e r e d home? (check the a p p r o p r i a t e c a t e g o r i e s ) b) c) d) e) g) h) none  were  205 . P l e a s e use t h i s l i k e t o make.  space t o i n c l u d e  any a d d i t i o n a l comments you would  THANK YOU VERY MUCH FOR PARTICIPATING  IN THIS STUDY.  207 5.  P l e a s e i n d i c a t e how many of your b o a r d i n g home r e s i d e n t s have been g i v e n the f o l l o w i n g d i a g n o s e s : Schizophrenia Manic D e p r e s s i o n Depression P e r s o n a l i t y Disorder Organic Disorder D i a g n o s e s a r e not seen as r e l e v a n t Other (please specify)  6. What number o f the r e s i d e n t s a r e c u r r e n t l y medicat ions? Tranquilizers Neuroleptics Antidepressants Lithium Antiparkonsonians None Other (Please s p e c i f y :  t a k i n g the f o l l o w i n g  ) 7.  P l e a s e i n d i c a t e i f any of the r e s i d e n t s u s e any of the f o l l o w i n g d r u g s : ( I f they do, p l e a s e i n d i c a t e how many p e o p l e f i t i n t o each of t h e s p e c i f i e d c a t e g o r i e s : ) once or once or once o r every twice a twice a twice a day week month year a)Alcohol No Yes ->( b)Ma r i juana No Yes " ->( " c)Opiates No Yes ->( d ) P C P / A n g e l Dust Yes No ->( e)LSD/Acid No Yes ->( f)Amphetamines No Yes ->( g)Barbiturates No Yes ->( h) I n h a l a n t s / G l u e No Yes ->( i)Other No Yes ->( >  ( I f you i n d i c a t e d use of d r u g s p l e a s e i n d i c a t e what they a r e :  i n the "other" category,  ) 8. I have h e a r d i t s a i d that f o r some p e o p l e w i t h p s y c h i a t r i c p r o b l e m s , g o i n g out f o r a d r i n k of a l c o h o l i s a c t u a l l y a p o s i t i v e a c c o m p l i s h m e n t , because " a t l e a s t they a r e d o i n g something." What, based on your e x p e r i e n c e , i s your r e a c t i o n t o t h a t s t a t e m e n t ?  208 Does your b o a r d i n g home have a p o l i c y c o n c e r n i n g a l c o h o l o r d r u g use by r e s i d e n t s ? No I Don't Know Yes (what i s i t ? )  0,  What would you do i f you d i s c o v e r e d one o f the r e s i d e n t s was d r i n k i n g a l c o h o l : (Mark as many as a p p l y )  a) Outside of your boarding home? .  Nothing, as l o n g as they d i d n ' t over do i t Ask them t o s t o p R e f e r them to a mental h e a l t h c o u n s e l l o r R e f e r them t o a substance abuse c o u n s e l l o r R e f e r them t o a s e l f - h e l p group l i k e A l c o h o l i c s Anonymous Ask them t o move out of the b o a r d i n g home C o n t r o l t h e i r money I don't know Other ( P l e a s e s p e c i f y )  b) In your boarding home?  Nothing, as l o n g as they d i d n ' t over do i t Ask them t o s t o p R e f e r them t o a m e n t a l h e a l t h c o u n s e l l o r R e f e r them t o a s u b s t a n c e abuse c o u n s e l l o r R e f e r them t o a s e l f - h e l p group l i k e A l c o h o l i c s Anonymous Ask them t o move out of the b o a r d i n g home C o n t r o l t h e i r money I don't know Other ( P l e a s e s p e c i f y )  1 . Have you ever t r i e d t o g e t h e l p f o r a r e s i d e n t with.an d r u g problem? No Yes -> a)With whom?  a l c o h o l or  •> b)What was t h e outcome?  2.  How o f t e n do you a c c e p t a p p l i c a n t s w i t h h i s t o r i e s o f s u b s t a n c e abuse i n t o your boarding home? (Check t h e c a t e g o r y t h a t f i t s b e s t ) Never Rarely Some times Often A h i s t o r y of s u b s t a n c e abuse does not i n f l u e n c e our decision  209 13. I have heard i t s a i d t h a t f o r p e o p l e w i t h p s y c h i a t r i c problems, s u b s t a n c e u s e i s the same as s u b s t a n c e a b u s e , because "even s m a l l amounts of these s u b s t a n c e s cause a worsening of p s y c h i a t r i c symptoms." What, based on your e x p e r i e n c e , i s your r e a c t i o n t o t h a t statement?  14. Think f o r a minute about the p a s t two weeks. D u r i n g t h a t time, how many r e s i d e n t s have taken i l l i c i t " s t r e e t " drugs or used a l c o h o l the f o l l o w i n g number of t i m e s ? ( P l e a s e i n d i c a t e t h e number of r e s i d e n t s who f i t i n t h e f o l l o w i n g c a t e g o r i e s : ) USED ALCOHOL,  USED "STREET" DRUGS  0 times 1 t h r u 5 times 6 t h r u 10 times 11 t h r u 15 times 16 or more times I don't know 15. Have any of the r e s i d e n t s had problems r e l a t e d t o h e a l t h , b e h a v i o r , f a m i l y , work, o r the law due to drug or a l c o h o l use d u r i n g the past two weeks? ( I f t h e y have, p l e a s e i n d i c a t e how many people, and g i v e a b r i e f d e s c r i p t i o n of the p r o b l e m s : )  a) Alcohol Related NO Yes  1  > (How many p e o p l e ? > (Description:  b) Drug Related No Yes  1  Problems: )  Problems:  > (How many people?_ > (Description: ~  16. A r e a l c o h o l i c b e v e r a g e s a l l o w e d a t b o a r d i n g home C h r i s t m a s p a r t i e s and/or o t h e r s p e c i a l f u n c t i o n s ? (Check the b e s t answer) Yes No Somet imes  )  210 17.  What, i f any, s e r v i c e s do you t h i n k s h o u l d be o f f e r e d to h e l p reduce the d r u g or a l c o h o l r e l a t e d p r o b l e m s of mental h e a l t h b o a r d i n g home r e s i d e n t s ?  18.  Are t h e r e any substance abuse programs o p e r a t i n g i n your b o a r d i n g home? ( I f there a r e , p l e a s e s p e c i f y what they a r e ) No I Don't Know Yes -> (What?  ) 19.  Would you p l e a s e answer the f o l l o w i n g q u e s t i o n s about y o u r s e l f , t o h e l p me u n d e r s t a n d more about the p e o p l e who work i n mental h e a l t h b o a r d i n g homes? (Of course, your a n s w e r s w i l l be kept conf i d e n t i a l ) . a)  What  b) What 30  i s your sex?  Male  Female  i s your age? (Please mark the or  less  31-49  appropriate  50-64  65  category)  or more  c) Do you have a c o l l e g e diploma or u n i v e r s i t y d e g r e e , or s e v e r a l y e a r s of work e x p e r i e n c e r e l e v a n t to your p r e s e n t job? No Yes >(If you do, p l e a s e s p e c i f y what:) college university work d)  Have you r e c e i v e d any t r a i n i n g No Yes -> ( i f you have, p l e a s e  i n the  area  of  substance  s p e c i f y what t h i s  abuse?  was:  ) e) Have you r e c e i v e d any t r a i n i n g s u b s t a n c e abuse? No Yes -> ( i f you have, p l e a s e  i n the  area  of d u a l  diagnosis  s p e c i f y what t h i s was:  )  211 20. V a r i o u s programs have been s u g g e s t e d as r e s p o n s e s t o d u a l d i a g n o s i s s u b s t a n c e abuse. Which of the f o l l o w i n g s e r v i c e s do you t h i n k would be u s e f u l ? a) b) c) d) e) f) g) h) i) j)  S e l f - h e l p group l i k e A l c o h o l i c s Anonymous Drug e d u c a t i o n program Life skills training Individual Counselling Group C o u n s e l l i n g Family C o u n s e l l i n g Job t r a i n i n g program A s s i s t a n c e o b t a i n i n g independent h o u s i n g R e c r e a t i o n programs t h a t a r e a l c o h o l and drug Other ( P l e a s e s p e c i f y )  21. Which of the above w i t h i n the b o a r d i n g a) f)  programs do you t h i n k s h o u l d be o f f e r e d home? (check the a p p r o p r i a t e c a t e g o r i e s ) b) c) d) e) g) h) i) j)  22. Would you l i k e t o be o f f e r e d a workshop on d u a l s u b s t a n c e abuse? ( S e l e c t o n l y one answer) Yes No Maybe  free  (Please  feel  diagnosis  f r e e to comment h e r e : )  23. I f a workshop or s t a f f t r a i n i n g s e s s i o n on d u a l d i a g n o s i s s u b s t a n c e abuse were a v a i l a b l e , what would you l i k e i t t o i n c l u d e ?  24. P l e a s e use t h i s l i k e t o make.  space t o i n c l u d e any a d d i t i o n a l comments you would  THANK YOU VERY MUCH FOR PARTICIPATING  IN THIS STUDY.  213 2. P l e a s e i n d i c a t e i f any of the r e s i d e n t s use any of t h e f o l l o w i n g d r u g s : ( I f they do, p l e a s e i n d i c a t e how many people f i t i n t o e a c h of the s p e c i f i e d c a t e g o r i e s : ) once or once o r once o r every twice a t w i c e a t w i c e a day week month year No Yes a)Alcohol ->( No Yes b)Mar i juana ->( Yes No c)Opiates ->( No Yes d)PCP/Angel Dust ->( Yes e)LSD/Ac i d No ->( No Yes f)Amphetamines ->( No Yes g)Barbiturates ->( No Yes h)Inhalants/Glue ->( i)Other Yes No ->( > ( I f you i n d i c a t e d use of drugs p l e a s e i n d i c a t e what they a r e :  i n the " o t h e r "  category,  ) 3. Does the b o a r d i n g home have a p o l i c y use by r e s i d e n t s ? No I Don't Know Yes -> (What i s i t ?  concerning a l c o h o l or drug  ,  ) 4. What would you do i f you d i s c o v e r e d one of the r e s i d e n t s was d r i n k i n g a l c o h o l : (Mark as many as a p p l y )  a) Outside of your boarding home? N o t h i n g , as l o n g as they d i d n ' t over do i t Ask them to s t o p R e f e r them t o a mental h e a l t h c o u n s e l l o r R e f e r them t o a s u b s t a n c e abuse c o u n s e l l o r R e f e r them t o a s e l f - h e l p group l i k e A l c o h o l i c s Anonymous Ask them t o move out o f t h e b o a r d i n g home C o n t r o l t h e i r money I don't know Other (Please s p e c i f y )  b) In your boarding home?  N o t h i n g , as l o n g as t h e y d i d n ' t over do i t Ask them t o s t o p R e f e r them t o a mental h e a l t h c o u n s e l l o r R e f e r them t o a s u b s t a n c e abuse c o u n s e l l o r R e f e r them t o a s e l f - h e l p group l i k e A l c o h o l i c s Anonymous Ask them t o move out o f t h e b o a r d i n g home C o n t r o l t h e i r money I don't know Other (Please s p e c i f y )  214  5. Are a l c o h o l i c b e v e r a g e s a l l o w e d at b o a r d i n g home C h r i s t m a s p a r t i e s and/or o t h e r s p e c i a l f u n c t i o n s ? (Check t h e b e s t answer) Yes No Somet imes 6. Have you ever t r i e d t o g e t h e l p f o r a r e s i d e n t drug problem? _No Yes -> a ) W i t h whom?  w i t h an a l c o h o l or  > b)What was the outcome?  7. I have heard i t s a i d t h a t f o r people w i t h p s y c h i a t r i c problems, s u b s t a n c e u s e i s the same as substance abuse, b e c a u s e "even s m a l l amounts of t h e s e s u b s t a n c e s cause a worsening o f p s y c h i a t r i c symptoms." What, based on your e x p e r i e n c e , i s y o u r r e a c t i o n t o t h a t statement?  8. Think f o r a minute about the p a s t two weeks. D u r i n g t h a t time, how many r e s i d e n t s have t a k e n i l l i c i t " s t r e e t " d r u g s o r used a l c o h o l the f o l l o w i n g number of t i m e s ? ( P l e a s e i n d i c a t e the number of r e s i d e n t s who f i t i n the f o l l o w i n g c a t e g o r i e s ) . 0 1 thru 5 6 t h r u 10 11 t h r u 15 16 or more I don't 9.  USED ALCOHOL,  USED "STREET" DRUGS  times times times times times know  Have any of the r e s i d e n t s had problems r e l a t e d t o h e a l t h , b e h a v i o r , f a m i l y , work, o r the law due t o drug o r a l c o h o l use d u r i n g the p a s t two weeks? ( I f they have, p l e a s e i n d i c a t e how many p e o p l e , and g i v e a b r i e f d e s c r i p t i o n of t h e p r o b l e m s : )  a) A l c o h o l R e l a t e d  Problems:  No  Yes 1  > (How many p e o p l e ? > (Description:  b) Drug R e l a t e d  Problems:  No  Yes 1  > (How many people?_ > (Description:  ) )  215 10. What, i f any, s e r v i c e s do you t h i n k s h o u l d be o f f e r e d to h e l p reduce the d r u g or a l c o h o l r e l a t e d problems of mental h e a l t h b o a r d i n g home r e s i d e n t s ?  11.  Are t h e r e any substance abuse programs o p e r a t i n g i n your b o a r d i n g home? ( I f t h e r e a r e , p l e a s e s p e c i f y what they a r e ) No I Don't Know Yes -> (What?  ) 12.  Would you p l e a s e answer the f o l l o w i n g q u e s t i o n s about y o u r s e l f , t o h e l p me u n d e r s t a n d more about the p e o p l e who work i n mental h e a l t h b o a r d i n g homes? (Of c o u r s e , your answers w i l l be kept conf i d e n t i a l ) . a) What  i s your sex?  b) What i s your age? 30  or  less  Male  Female  ( P l e a s e mark the 31-49  50-64  appropriate  category)  65 or more  c ) Do you have a c o l l e g e d i p l o m a or u n i v e r s i t y d e g r e e , or s e v e r a l y e a r s of work e x p e r i e n c e r e l e v a n t to your p r e s e n t job? No Yes >(If you do, p l e a s e s p e c i f y what:) college university work d) Have you r e c e i v e d any t r a i n i n g No Yes -> ( i f you have, p l e a s e  i n the a r e a  of s u b s t a n c e  abuse?  s p e c i f y what t h i s was:  ) e) Have you r e c e i v e d any t r a i n i n g s u b s t a n c e abuse? No Yes -> ( i f you have, p l e a s e  i n the a r e a  of d u a l  diagnosis  s p e c i f y what t h i s was:  )  216  3. V a r i o u s programs have been s u g g e s t e d as responses t o d u a l d i a g n o s i s s u b s t a n c e abuse. Which of the f o l l o w i n g s e r v i c e s do you t h i n k would be u s e f u l ? a) b) c) d) e) f) g) h) i) j)  S e l f - h e l p group l i k e A l c o h o l i c s Anonymous Drug e d u c a t i o n program Life skills training Individual Counselling Group C o u n s e l l i n g Family C o u n s e l l i n g Job t r a i n i n g program A s s i s t a n c e o b t a i n i n g independent housing R e c r e a t i o n programs t h a t a r e a l c o h o l and drug Other ( P l e a s e s p e c i f y :  free  _ 4.  Which within  )  of the above the b o a r d i n g a) f)  programs do you t h i n k s h o u l d be o f f e r e d home? (check the a p p r o p r i a t e c a t e g o r i e s ) b) c) d) e) q) h) i) j)  5. Would you l i k e to be o f f e r e d a workshop on d u a l s u b s t a n c e abuse? ( S e l e c t o n l y one answer) Yes No Maybe 6.  (Please  feel  diagnosis  f r e e to comment h e r e : )  I f a workshop or s t a f f t r a i n i n g s e s s i o n on d u a l d i a g n o s i s s u b s t a n c e abuse were a v a i l a b l e , what would you l i k e i t t o i n c l u d e ?  7. P l e a s e use t h i s l i k e t o make.  space t o i n c l u d e any a d d i t i o n a l comments you would  THANK YOU VERY MUCH FOR PARTICIPATING  IN THIS STUDY.  218  How l o n g have you l i v e d appropriate category) Weeks Months Years I Don't Know  in this  b o a r d i n g home? ( P l e a s e check t h e  Do y o u t h i n k t h a t even s m a l l amounts of a l c o h o l or " s t r e e t " d r u g s c a u s e problems f o r p e o p l e with p s y c h i a t r i c problems, because i t makes t h e i r p s y c h i a t r i c problems g e t worse? Yes No Sometimes I Don't Know  (Please f e e l  f r e e t o comment h e r e :  )  Do y o u take any m e d i c a t i o n s ? ( p l e a s e check t h e a p p r o p r i a t e category) No I Don't Know Yes > ( I f you know what m e d i c a t i o n s you t a k e , please i n d i c a t e what they a r e :  ) Do y o u take any of the f o l l o w i n g d r u g s ? i n d i c a t e how o f t e n )  a)Alcohol b)Marijuana c)Opiates d ) P C P / A n g e l Dust e)LSD/Ac i d f)Amphetamines g)Barbiturates h)Inhalants/Glue i)Other >  No No No No No No No No No  Yes Yes Yes Yes Yes Yes Yes Yes Yes  ( I f you do, p l e a s e  every day ->( ->( ->( ->( ->C ->( ->( ->( ->(  once or twice a week  once or twice a month  ( I f you take drugs i n t h e " o t h e r ' c a t e g o r y , i n d i c a t e what they a r e :  once o r twice a year  please  ) Do y o u know of anybody i n your b o a r d i n g home who has had p r o b l e m s w i t h t h e i r h e a l t h , b e h a v i o r , f a m i l y , work, o r t h e law due t o d r u g o r a l c o h o l use d u r i n g t h e p a s t two weeks? No Yes  -> (How many p e o p l e ?  )  219  7. Have y o u had any problems r e l a t e d t o h e a l t h , b e h a v i o r , f a m i l y , work, or the law due t o drug o r a l c o h o l use d u r i n g the p a s t two weeks? ( I f you have, w i l l you p l e a s e g i v e me one or two examples?) No Yes -> (What kind of p r o b l e m s ? ) 8. Have you e v e r r e c e i v e d t r e a t m e n t No Yes -> (Where? 9.  f o r d r i n k i n g or drug use?  Have you ever t r i e d to g e t h e l p f o r an a l c o h o l or drug problem? No Yes > ( I f you have t r i e d t o get h e l p , p l e a s e i n d i c a t e who i t was from:) A Friend A F a m i l y Member A B o a r d i n g Home S t a f f Member A Counsellor A Doctor I Don't Remember Other -> (What was t h e i r r e l a t i o n s h i p t o you?  . 10.  )  )  Have you ever been t o l d t h a t y o u have an a l c o h o l or drug p r o b l e m ? No Yes > ( I f you have been t o l d you have a p r o b l e m , p l e a s e i n d i c a t e who s a i d s o : ) A Friend A F a m i l y Member A B o a r d i n g Home S t a f f Member A Counsellor A Doctor A Police O f f i c e r Other -> (What was t h e i r r e l a t i o n s h i p t o you?  ) 11. What do you t h i n k the b o a r d i n g home s t a f f would do i f they f o u n d out t h a t you were d r i n k i n g a l c o h o l : (Mark as many c a t e g o r i e s as a p p l y : ) N o t h i n g , as l o n g as I d i d n ' t over do i t Ask me to s t o p Ask me to see a c o u n s e l l o r R e f e r me t o A l c o h o l i c s Anonymous Ask me to l e a v e t h e b o a r d i n g home C o n t r o l my money I don't know O t h e r (Please s p e c i f y )  220  12. Would you p l e a s e answer the f o l l o w i n g q u e s t i o n s about y o u r s e l f , to h e l p me u n d e r s t a n d more about the people who l i v e i n m e n t a l h e a l t h b o a r d i n g homes? (Of c o u r s e , your answers w i l l be kept confidential). a) Do you have a j o b a t t h i s time? No b) Are y o u :  Male  c) What i s your age? 30 or l e s s  ,  or  Yes  Female  ( P l e a s e mark the a p p r o p r i a t e c a t e g o r y ) 31-49  50-64  65 or more  d) How many y e a r s of s c h o o l have you completed? None Some E l e m e n t a r y S c h o o l G r a d u a t e d from Elementary School Some S e c o n d a r y S c h o o l G r a d u a t e d from Secondary School Some C o l l e g e , Trade S c h o o l , or U n i v e r s i t y G r a d u a t e d from C o l l e g e , Trade S c h o o l , or U n i v e r s i t y 13. Do you t h i n k t h a t any o f t h e programs l i s t e d below would be u s e f u l t o h e l p p e o p l e who have both p s y c h i a t r i c and d r u g o r a l c o h o l p r o b l e m s ? ( P l e a s e put a check mark i n f r o n t o f any programs t h a t y o u t h i n k would be u s e f u l : ) a) b) c) d) e) f) g) h) i) j)  S e l f - h e l p g r o u p ( l i k e A l c o h o l i c s Anonymous) Drug e d u c a t i o n Life s k i l l s training Individual Counselling Group C o u n s e l l i n g Family Counselling Job t r a i n i n g A s s i s t a n c e o b t a i n i n g independent h o u s i n g R e c r e a t i o n programs that a r e a l c o h o l and d r u g O t h e r -> ( P l e a s e s p e c i f y :  free  ) 14. Do you a t t e n d any of t h e programs l i s t e d s p e c i f y what) No Yes -> (What?  above?  ( I f y o u do, p l e a s e  ) 15. Would you a t t e n d any o f t h e programs mentioned above o f f e r e d t o you? ( I f y o u would, p l e a s e s p e c i f y what:) No Maybe > (What? Yes >  i f t h e y were  )  221  16.  What, i f any, s e r v i c e s do you t h i n k s h o u l d be o f f e r e d t o h e l p r e d u c e t h e drug o r a l c o h o l r e l a t e d p r o b l e m s of mental h e a l t h b o a r d i n g home r e s i d e n t s ?  17.  P l e a s e use t h i s space t o i n c l u d e any a d d i t i o n a l comments you would l i k e t o make.  THANK YOU VERY MUCH FOR PARTICIPATING IN THIS STUDY.  

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