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Table 5 Substance use interventions—participant experiences and perceptions of effectiveness

From: What constitutes effective problematic substance use treatment from the perspective of people who are homeless? A systematic review and meta-ethnography

Features reported by participants as being effective or notExamples of first-order participant data
Abstinence-based programmes: interventions that required participants to be abstinent from alcohol/drugs, including residential programmes. Twelve Step programmes such as Alcoholics Anonymous or Narcotics Anonymous have a spiritual orientation and advocate complete abstinence although participants take part in various activities including attending meetings and getting a ‘sponsor’. These were discussed in five papers [24, 61, 65, 71, 79].
(+) Adapting principles to meet needs
(+) Desire to help others
(+) Peer support
(−) Power imbalances
(−) Increased urges/ cravings
(−) Sense of failure
(−) Challenges associated with finding a ‘sponsor’ at AA
‘I wanna be able to help somebody. I wanna be able to start something. If I wanna go to the grocery store, and out of my pocket, buy lunchmeat, cheese, and a couple of cases of soda, go out on a Saturday, where people at, and just hand out food—I wanna be able to do that’ (Participant in Rayburn and Wright [61])
‘I’ve gone to AA, and it does help because you are around like-minded people’ (Participant in Collins et al. [65])
‘I went to [Narcotics Anonymous] and this guy was talking about how his pockets were turned inside out looking for crack…I had a using dream of crack after listening to his thing. So…I just really did not want to go back’ (Participant in Clifasefi et al. [71])
‘Oh, this ‘AA all the way,’ and ‘the only way to stay sober is AA’ … There are other ways to stay sober … And, you know, you just feel like when you go to AA, you feel like you are a failure’ (Participant in Collins et al. [24])
‘Getting a sponsor. I got one, but I struggle with it. I had a real deep struggle with it, because at first I said, “I’m not getting no sponsor man.” For me to get a sponsor, is just like saying, I do not trust in my higher power. And then a sponsor is just a human being, just like me. You know, I’m not gonna have nobody telling me … you not ready for no relationship …I just wasn’t ready for that’ (Participant in Rayburn and Wright [79]).
Housing-based harm reduction: Managed Alcohol Programmes provide regular doses of alcohol with supported housing and wider care provision [63, 70, 73] and help users manage/reduce unpleasant and potentially fatal alcohol withdrawals. In Housing First settings participants are provided with accommodation where alcohol use is tolerated [65, 71, 77]. Housing First refers to programmes which provide “low-barrier, non-abstinence-based, immediate, supportive and permanent housing to chronically homeless people who often have co-occurring substance use and/or psychiatric disorders” [65]. Transitional housing programmes provide support in helping people move out of homelessness and those with a harm reduction approach may be more beneficial than those expecting abstinence at entry [78].
(+) Having a home
(+) Managing withdrawal symptoms
(+) Safety
(+) Peer support
(+) Non-judgemental staff
(−) Availability of alcohol when wishing to be sober
(−) Challenges associated with settling into a new, unknown environment (e.g. MAP/housing programme), such as getting to know peers and staff
‘You know sometimes you do not drink that much but it’s enough to get you well—to stop the shakes’ (Participant in Collins et al. [65])
‘It has helped me a lot you know; where I used to drink heavy and now I slowed down a lot. Right?’ (Curtis, in Evans et al. [70])
‘I’m starting to feel very comfortable now. Putting my pictures up. .. makes me feel at home…I can relax a little better because I know the people’ (Mark in Kidd et al. [63])
‘Like I went out last week and I ended up using... I came back and I talked about it and I have not used all week, which is great. But they are there for me whether I do, whether I do or I do not’ (Participant in Pauly et al. [78])
‘Yeah, we think of each other as a family. When there’s a new person that comes in we welcome them with arms open. And we see they need to be [guided] for the first couple of weeks and we take them and we teach ‘em. And we, ah, show them around and if they need something I’ll show them where to get it, where to ask for it’ (Participant in Pauly et al. [73])
‘… it’s hard to stop [drinking]. I mean it’s hard to stop here, you know what I mean? Because … [if] I do not have [alcohol], somebody else does. People invite you to come along and all that other kind of things … and it’s hard” (Participant in Collins et al. [65])
“I do not know anybody who do not have fear, you know? What happens if I lose this place, you know? Am I gonna go back home to [name]? I do not wanna go to treatment. I did nothing bad’ (Participant in Collins et al. [77])
Harm reduction interventions delivered online: Breaking Free Online is a tailored intervention for men and women experiencing homelessness and problematic substance use. It provided users with a 12-week computer-assisted psychological treatment alongside ‘real world’ staff mentor support [68, 69]. It offered various strategies aimed at helping people identify, understand and actively address the psychosocial and lifestyle factors underpinning their substance use, without requiring abstinence.
(+) Flexibility, easily accessible, non-judgemental, user friendly
(+) Prompts to have conversations with staff
(+) Development of new skills (including computing) and routine
(+) Increased awareness of substance use
(+) Development of coping strategies
(−) Lack of privacy, poor equipment, lack of availability of staff
‘The convenience of it for starters. I mean, it can be done in the hostel, it can be done in my bedroom…it can be done anywhere, if you have got a laptop. You can do it in the middle of the park somewhere on a nice summers day, rather than going all the way to [drug agency], catching the bus and travelling all the way up there’ (Trent, in Neale and Stevenson [69])
‘I am doing my daily routine quite well, making sure I get up in the morning and do not just stay up watching shit TV until like four o‘clock in the morning. So I think I’m better now, better equipped to get up and do something during the day, like a normal human being’ (Sarah, in Neale and Stevenson [68])
‘It [BFO] gives me the ability to talk about my emotions, about me, to [name of mentor]…I am just becoming more open, and, as I said, which it helps me to open up to him’ (Leona, in Neale and Stevenson [68])
‘There is always somebody on them [computers]…I have not really had the head space to get on and concentrate, you know. I would like to, but there is always somebody shouting or screaming or bawling, you know, and I want to get on it, you know, but I just cannot get the space to’ (Thomas, in Neale and Stevenson [68])
  1. (+) = Components of these interventions that participants found to be effective (i.e. beneficial or liked)
  2. (−) = Components of these interventions that participants found to be ineffective (i.e. disadvantageous or disliked)