Interview with Kenneth Minkoff, MD
Athealth.com: Let's discuss our clinical vignette.
A 43-year-old man with a long history of schizophrenia, homelessness, alcohol dependence, and current legal involvement has recently been enrolled in a community based mental health clinic for services as a condition of a court order. While his housing is stable at this time and other basic needs are
being met, his is relatively decompensated and is at risk for losing his group home living arrangement due to his alcoholism.
How would you proceed to care for this patient?
Dr. Minkoff: As the first step, this patient needs a treatment relationship with a team of clinicians that are capable of addressing both disorders simultaneously in an integrated and continuous way. The treatment
team should maintain involvement with him whether or not he continues to drink and whether or not he becomes homeless. Therefore, the first order of business is to make sure that such a relationship has been established.
We know that he has a medication regime to stabilize his mental illness; and the team
should make sure that he is on the best medication regime for stabilizing his mental illness that can be offered and that he will take.
Parenthetically, one of the emerging bits of data is that better medicine for schizophrenia, including using atypicals and in particular clozapine, can not only improve the outcome from the schizophrenia, but may also, either directly or indirectly, promote better outcome from the substance use disorder.
The second issue has to do with helping him maintain stable housing. The vignette states that he has stable housing, but that he is at risk for losing it because of his substance use. One of the things that we need to remember is that putting people who cannot provide for their own housing in sober settings--
where housing is conditional upon sobriety--may be a set-up for precipitating homelessness. This is particularly true where the housing is not within the the person's choice or sobriety is not within the person's capacity.
Athealth.com: In a case like this, what types of housing options are available and how would you address the housing issue?
Dr. Minkoff: In developing systems of care, we try to provide housing options for people who are at different levels of willingness and capacity to address their substance use. This implies that there is a range
of supported housing options (wet, damp, and dry) for people with psychiatric disabilities.
Dry is for those people who really want to live in a sober setting, who want that kind of support, and who have those kinds of skills. Damp is for those people who want to live
in a setting where substance use is limited. They are willing to live in this setting, but they are not willing to make an absolute commitment to being abstinent. Wet housing is for those people who do not want to make any commitment at all, but who, if they are not assisted to obtain housing, will actually be homeless.
The individual in the vignette may be in the latter group. He is currently in a group home that appears to have some conditions about his not using substances. He is apparently not clear that he is willing to go along with those conditions. Therefore, if he makes the choice not to follow the rules of the group home, we
need a plan for obtaining housing for him other than the streets or a shelter. That often involves some kind of individual housing option that has wrap-around supports of appropriate intensity to help him to maintain his housing, even though he may continue to drink.
One of the more notable and innovative models for this is Pathways to Housing in New York City, which is a fairly intensive model for the most difficult street-homeless people.
The individual in the vignette does not seem to be that difficult. With appropriate assistance he probably could live more independently. The challenge would be to make sure he doesn't lose his housing, that he is able to manage his money (e.g.: possibly with a payeeship), that he continues his medication, and so on.
Athealth.com: What is the important message to a clinician with regard to this patient's substance use?
Dr. Minkoff: With regard to his substance use, the most important message is that he needs primary substance use disorder treatment, but it has to be stage or phase specific. This concept is based on the work of Dr. Robert Drake's
group which recognizes that there are stages of treatment in working with people with serious mental illness. Stage specific treatment is similar to the work that comes from James Prochaska and Carlo DiClementi on the transtheoretical stage of change model.
These models recognize that people are in various stages of change and need stage specific intervention.
So, we identify whether or not this person is in, using the Drake language, the engagement phase or the persuasion phase-where he is at least willing to consider discussing a change in his use of alcohol. This would be similar to the Prochaska and
DiClemente terminology of stage of precontemplation and stage of contemplation. We work with him in the context of our treatment relationship to do a stage specific intervention based on principles of motivational interviewing or motivational enhancement. These interventions can be done individually.
Page last modified or reviewed on March 8, 2009
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