Content Analysis of Advantages and Disadvantages of Drinking Among Individuals with the Lived Experience of Homelessness and Alcohol Use Disorders

Abstract

Background:

AUDs are more prevalent among people who are homeless than in the general population. Thus, homeless individuals experience disproportionately high levels of alcohol-related problems and associated publicly funded criminal justice and health-care system utilization. Available treatment services, however, are not effective at engaging and treating this population. To better tailor treatment services to their needs, it is imperative we understand this population’s perceptions of their alcohol use.

Objectives:

The aim of this study was to provide description and relative rankings of the advantages and disadvantages of alcohol use from this population’s perspectives.

Methods:

Participants were 44 individuals with lived experiences of AUDs and homelessness who received services at community-based agencies in Seattle, Washington. Open-ended prompts were used in interviews conducted in 2013–2014 to assess the perceived role of alcohol in participants’ lives, including participants’ perceptions of the advantages and disadvantages of their current drinking, and a conventional content analysis was conducted.

Results:

The most frequently mentioned advantages of drinking included positively and negatively reinforcing psychological reasons, perceived control over drinking, and social benefits. Physical effects, concerns about dependence on alcohol, and health problems were the most commonly mentioned disadvantages.

Conclusions/importance:

By documenting the perceived advantages and disadvantages of drinking among people with the lived experience of homelessness and AUDs, this study supplies information providers may use to better tailor treatment services to this multimorbid, high service-utilizing population’s needs and interests.

1. Introduction

Alcohol dependence is 10 times more prevalent among homeless adults than in the general US population (Fazel, Khosla, Doll, & Geddes, 2008; Grant et al., 2004). Thus, homeless adults are disproportionately affected by acute and chronic alcohol-related morbidity and mortality and are frequent users of high-cost emergency medical services (Hwang, Wilkins, Tjepkema, O’Campo, & Dunn, 2009). Despite their high levels of alcohol-related problems, most homeless adults with alcohol use disorders (AUDs) never go to, are turned away from, or drop out of traditional abstinence-based treatments (Orwin, Garrison-Mogren, Jacobs, & Sonnefeld, 1999; Rosenheck et al., 1998; Wenzel et al., 2001). In fact, the few existing abstinence-based AUD treatments designed for homeless adults have achieved only modest improvements in alcohol outcomes (Hwang, Tolomiczenko, Kouyoumdjian, & Garner, 2006; Zerger, 2002).

Lack of information concerning perceptions of alcohol use among homeless people with AUDs may be contributing to lagging treatment outcomes in this population. In fact, only one study to date has assessed perceived disadvantages of alcohol use among homeless people (Velasquez, Crouch, von Sternberg, & Grosdanis, 2000). That study found that the primary disadvantages were family, work and legal problems, respectively. It did, however, only assess disadvantages and not perceived advantages of alcohol use. Research has indicated that assessment of both perceived advantages and disadvantages of alcohol use provides a more comprehensive view of individuals’ decisional balance {Hall, 2014 #4049;Janis, 1977 #445;Collins, 2009 #2425;Migneault, 1999 #526;Velicer, 1985 #1569;Miller, 1999 #534}, which may support development of more comprehensive, tailored treatment approaches. Moreover, Velaquez et al. (2000) utilized exclusively researcher-generated items to assess perceived disadvantages of alcohol use. Researcher-generated items, however, may not adequately capture individuals’ perceptions of drinking when they do not share the same demographic characteristics, perspectives, or goals as the researchers who generated the items (Beyth-Marom, Austin, Fischhoff, Palmgren, & Jacobs-Quadrel, 1992; Fischoff & Quadrel, 1991).

Considering the literature to date, no studies have either a) explored both the perceived advantages and disadvantages of alcohol use among people with the lived experience of homelessness and AUDs or b) used open-ended interviews to assess participants’ responses. A more comprehensive understanding of this population’s perspectives on their drinking is an important step in designing treatments that are better tailored to the needs of this high-cost and multimorbid population.

To fill this gap in the literature, the present study features a conventional content analysis of participants’ responses during a semi-structured, qualitative interview. The aim of this study was to provide qualitative descriptions and relative rankings of the perceived advantages and disadvantages of alcohol use from the perspectives of people with the lived experience of homelessness and AUDs.

2. Material and Methods

2.1. Participants

Participants were people with the lived experience of homelessness and AUDs who were recruited from local agencies serving homeless individuals in Seattle, Washington. Participants (N = 44) had an average age of 53.16 (SD = 7.75) years and were predominantly male (18% female; n = 8). Of the overall sample, 43% self-identified as White/European American, 23% as American Indian/Alaska Native/First Nations, 21% as Multiracial, 11% as Black/African American, and 2% as Other. Additionally, 10% of the sample self-identified as Hispanic/Latino(a).

2.2. Measures

A set of single-item sociodemographic questions assessed participants’ age, gender, race, and ethnicity. These items were used in this study to provide the sample description.

Open-ended prompts were used in interviews to assess the perceived role of alcohol in participants’ lives, including the “good things/things you like” and the “not-so-good things/things you don’t like as much” about drinking. These prompts were part of a larger, semi-structured interview that comprised open-ended questions about participants’ experiences of homelessness; their alcohol use and problems; and their suggestions for improvement of treatment, housing and programs/services.

2.3. Procedures

Potential participants were identified by staff at agencies providing community-based services to homeless individuals. Research staff then approached these individuals at the agency sites to inquire whether they would be interested in participating in a research study. Interested individuals were informed as to the purpose and procedures of the interviews as well as their rights and role as participants. After obtaining, written, informed consent, research staff conducted the 45–60 minute, one-on-one interviews using open-ended prompts to encourage discussion about the perceived advantages and disadvantages of current alcohol use among other topics (i.e., homelessness and housing, perceptions of substance abuse treatment, suggestions for enhancement of treatment, supportive services, and housing). Interviews were conducted by two psychologists (SEC, SLC). Participants received a $20 payment at the end of their interview. All procedures were approved by the institutional review board at the University of Washington.

2.4. Data Management and Analysis Plan

Interviews were audio recorded and transcribed for qualitative data analyses. Transcripts were stripped of identifying information prior to data coding. The goal of this project was to provide a conventional content analysis of perceived advantages and disadvantages of drinking. Conventional content analysis is a qualitative research method used to interpret the content of text data through a systematic classification process involving coding and identifying themes (Hsieh & Shannon, 2005; Krippendorff, 2004). In conventional content analysis, the researcher does not start with preconceived, theory-based notions about what kinds of codes or categories of codes will be found. Instead, the researcher allows the data to drive the codes and categories (Hsieh & Shannon, 2005).

Atlas.ti version 7 (Friese, 2012) was used to manage and code qualitative data. Data were independently coded by the study authors using a constant comparative process (Charmaz, 2006; Miles & Huberman, 1994). Initial coding was conducted using a line-by-line technique, whereby coders narrated the actions occurring in the interviews (Charmaz, 2006). Following independently conducted initial coding, we created a codebook in consensus meetings, pooling incident-by-incident codes and removing or collapsing idiosyncratic or redundant codes. In the next coding phase, we used the codebook to independently double-code 10% of the sessions until adequate intercoder consistency (80%) was established (Miles & Huberman, 1994; Shek, Tang, & Han, 2005). Adequate intercoder consistency was achieved (88%), and thereafter, sessions were coded individually and independently.

3. Results

Considered as an overall sample, advantages of current drinking represented 39% (n = 211/537) of all responses, whereas disadvantages of current drinking represented 61% (n = 326/537) of all responses. Tables1 and 2 show the frequencies of responses within each of the overall categories.

Table 1.

Advantages of Drinking Listed in Rank Order of Percentage of Unique and Total Responses

Rank	Category	Examples	% Participants experiencing it	% Totalresponses
1	Psychological reasons		72.7	19.9
	Coping mechanism	“Makes me not get so angry”	56.8	16.1
	Desired emotional state	“It makes me mellow”	15.9	3.8
2	Control over drinking	“I don’t overdo it”	59.1	31.3
3	Social reasons	“I seem to like people better”	36.4	10.9
4	Physical effects		34.1	12.3
	Acute intoxication	“I get a little happy buzz on”	22.7	6.6
	Hangover reliever	“Well, if I go without, I’ll get sick”	11.4	4.3
	Tolerance	“I don’t wake up with hangovers either”	4.5	1.4
5	Fun	“It makes some things more enjoyable”	22.7	5.7
6	Legal/ acceptable	“You can [legally] drink here”	13.6	4.3
7	Other	“I stayed drunk just so I had a place to sleep”	13.6	4.3
8	Cognitive effects	“I like the way it makes me think”	13.6	2.8
9	Identity/ image when drinking	“Maybe my company will be good”	6.8	2.8
10	Taste	“I’ve always loved the taste of beer”	6.8	1.4
11	Alone time	“That’s it, just to get away and stuff”	4.5	1.9
12	Something to do	“I just drink because it’s what I do”	4.5	0.9
13	Health effects		4.5	1.0
	Current	“When my sugar level was low in myblood, the alcohol has a tendency to raise it for me”	2.3	0.5
	Long-term	“Drinking can help your heart”	2.3	0.5
14	Drinking atmosphere	“Going to shows, and we’d always drink. You know, that was our thing”	2.3	0.5
	Total			100

Table 2.

Disadvantages of Drinking Listed in Rank Order of Percentage of Unique and Total Responses

Rank	Category	Examples	% Participants experiencing it	% Total responses
1	Acute physical effects		84.0	17.1
	Withdrawal/hangovers	“Hangovers”	59.1	13.8
	Accute intoxication	“You pass out”	15.9	2.8
	Tolerance	“I never got drunk. It’s high resistance”	4.5	0.6
	Nonspecific effects	“I don’t like the feeling anymore”	4.5	0.6
2	Dependence	“I’m basically obsessed with it”	63.6	8.9
3	Chronic health problems		52.3	11.7
	Current illness	“The liver’s gone”	31.8	7.1
	Future illness	“Alcoholism leads to death”	20.5	4.6
4	Legal problems	“Every legal problem I’ve ever had has been due to alcohol”	36.3	9.5
5	Behavioral consequences	“Made me say stupid things”	31.8	6.7
6	Interferes with goals	“Made me lose my job”	29.5	5.2
7	Lack of control over drinking	“You feel like you can’t drink enough”	27.3	4.3
8	Image	“It’s embarrassing”	22.7	5.5
9	Harm		20.5	5.8
	Getting hurt/ accidents	“I fell down two flights of stairs”	13.6	4.0
	Other/ unspecified	“I might have a couple of bumps”	2.3	0.6
	Risky sex	“Leads to people not using condoms”	2.3	0.6
	Vulnerable to others aggression	“People will wait until you’re really drunk and then take that time to get you”	2.3	0.6
10	Cognitive effects	“Made me black out”	18.2	3.7
11	Social	“Lost family through my breakdown”	13.6	4.3
12	Expense	“It costs money and once you drink one you drink another one”	13.6	2.8
13	Prejudice, moral judgement	“They just think I’m a big drunk”	11.4	3.7
14	Other cons of drinking	“I can’t drink and take medication”	11.4	2.5
15	Eating	“The more I drink the less I eat”	9.1	2.5
16	Risky drinking	“I was drinking mouthwash and rubbing alcohol and extracts”	9.1	2.5
17	Psychological effects		6.6	0.9
	Negative affect	“Depression”	2.3	0.3
	Secondary state/self-concept	“I lost some family members and it kinda didn’t help”	4.3	0.6
18	Housing	“I got evicted from that for alcohol”	4.3	0.9
19	Concerns about inflicting harm	“I’m afraid I’ll kill somebody”	4.3	0.91
20	Interferes with activities of daily living	“You don’t shower regularly”	2.3	0.6
	Total			100

3.1. Advantages of Current Drinking

3.1.1. Psychological effects.

As shown in Table 1, the advantage to drinking cited by the most participants was its positive psychological effects. In most instances, this category referred to the use of alcohol as a negatively reinforcing coping mechanism. More specifically, many participants reported using alcohol to dull psychological pain due to psychiatric disorders and related symptoms, including posttraumatic stress disorder (PTSD) (e.g., “I do have real bad PTSD sometimes, and I keep it in check with the alcohol”), anxiety (e.g., “I learned from the first beer how well it cured anxiety”), and depression (e.g., “You need another drink to kind of wake you up and say, ‘Hey, you are somebody. Stop feeling so down.’”). Other participants reported using alcohol to boost their confidence in stressful social situations. One participant shared, “It helps me deal with people sometimes, especially in nervous situations.” Others said they used alcohol as a stress reliever, citing alcohol as “[helping] me to relax” and “calm my fucking nerves.” For example, one participant noted that when in an “irritating mood, I just go off by myself, drink me a couple [malt liquor beverages with high alcohol content]…It helps me take my mind off shit.” A smaller number of participants reported that alcohol provides positive reinforcement in that it helps them achieve a desired emotional state. Specifically, some participants reported that drinking makes them “happy,” “mellow,” or “perks [them] up.”

3.1.2. Perceived control over drinking.

Also among the top five advantages of drinking was participants’ perceived ability to control their drinking. Ability to control drinking was expressed either through reduced frequency of drinking (e.g., “If I want to drink, I can take a drink. If I choose not to drink, I don’t have to.”) or quantity consumed (e.g., “I can only drink eight beers a day now…I can’t remember the last time I was drunk to be honest with you”), including selecting beverages with lower alcohol content (e.g., “I’m back to trying not to drink hard alcohol”). Many individuals referred to a perceived sense of control as drinking to “maintain.” This meant that participants drank more evenly throughout the day to stave off alcohol withdrawal. One participant stated, “I just drink a few beers here and there…maybe a shot or two of vodka or whiskey, man. I am just maintaining myself.” Many participants likewise indicated that controlling their drinking became easier after they obtained permanent, supportive housing. When discussing his recently obtained housing, one participant said, “That’s one thing this place has taught me: how to slow down…start maintaining my own substance control program for my individual self.”

3.1.3. Social advantages.

Participants also cited the social advantages of drinking. Some participants spoke of having a sense of “community” around street culture and drinking. Most commonly, participants said that drinking provided “companionship” and “camaraderie.” One participant noted, “That’s what we do around here. We get our drink, and then we go share.” Another participant said what he likes about alcohol is that he “can drink with [his] friends and chill.” Thus, alcohol is a shared experience among members of this community and is a means of connecting and relaxing together.

3.1.4. Physical effects of intoxication.

Participants also reported drinking to experience the physical effects of intoxication. For some participants, intoxication was perceived as a pleasant physical sensation: One participant liked getting “a little happy buzz on.” For other participants, intoxication was seen as a necessity. One participant indicated that it helped him to “pass out and sleep.” A smaller proportion of participants appreciated their tolerance because it was perceived as preventing hangovers. They reported using alcohol to soothe their withdrawal symptoms or to “keep [them] well.” One participant described withdrawal has having “butterflies in [his] stomach” and then reflected, “Oh yeah, man. All I need is a drink.”

3.1.5. Enjoyment and fun.

Rounding out the top five cited advantages was participants’ perception of drinking as something to be enjoyed or as a way to have a good time. Within this category, participants reported that drinking helped them let loose and have fun. For example, one participant said he used alcohol for “just getting out and going crazy and being nuts.” Participants also said they drank to “make things more enjoyable.” As one participant stated, “Even watching a TV show gets better.” Another said simply, “I just love drinking.”

3.2. Disadvantages of Current Drinking

3.2.1. Physical effects.

Of the top five disadvantages of current drinking, acute physical effects were most frequently cited (see Table 2 for a rank-ordered list of all disadvantages). Most participants reported needing to drink regularly throughout the day to avoid withdrawal, which was generally perceived as distressing. One participant noted, “When I was drinking all that vodka, I’d wake up…shaking like a leaf. And God forbid I drink a glass of water. It was just like [vomiting noise].” If a person does not receive adequate treatment, physical withdrawal can become more severe, leading to alcohol withdrawal delirium or delirium tremens, which is an acute state that entails disorientation, fever, autonomic hyperactivity, severe tremors, seizures and hallucinations (American Psychiatric Association, 2013). One participant said that, after quitting, he “went to DTs. Oh, my God, that was awful.” Smaller proportions of participants also reported as disadvantages the physical effects of acute intoxication (e.g., “I don’t like drinking way too much because I black out.”) and tolerance (e.g., “I used to drink three fifths of vodka a day…That’s me. I just have a very high tolerance.”).

3.2.2. Concerns about alcohol dependence.

The second most frequently endorsed category of drinking disadvantages was concern about having alcohol dependence. One participant reported that alcohol has a “pretty good hold on me. I won’t lie about it. There’s not one morning I don’t wake up that I—I have to have a drink. It’s got a hold on me.” Some participants also pointed out the consequences of alcohol dependence: “It fucks up your life. I seen my dad die of alcoholism.” A common theme was participants labeling themselves as “alcoholics” and also voicing dissatisfaction with their alcohol dependence. One participant stated that “being a low-bottom drunk was not a part of my little girl dreams.” Many participants felt they were destined to become alcohol dependent—even though they “didn’t ask to be an alcoholic.” For example, one participant recounted that he “never drank, really, honestly, to have a good time because I was a chronic alcoholic from the time I took my first drink.”

3.2.3. Long-term health consequences.

The health consequences of drinking, which comprised the third most common disadvantage, referred to concerns about chronic conditions (e.g., liver cirrhosis). A few participants talked about early, teratogenic effects of alcohol on their system: “I was born with a birth defect. I was a premature baby like my brother. My mama died at 36 years…She drank when she had me. She drank when she had my brother.” Participants also acknowledged alcohol’s ongoing effects on their health, which often took the form of gastric and liver disease (“Had, uh, indigestion and bleeding—internally bleeding”), pancreatitis (“My shit’s fucked up with my pancreas…sometimes I shit on myself.”), and cognitive impairment (“I stopped drinking that fortified cheap wine…The cheap shit will fuck up your brain.”) Some participants also acknowledged the combined effects of alcohol and preexisting conditions, such as hepatitis C. One participant reported, “I got Hep C. I shouldn’t even be drinking. My Hep C alone is killing my liver…” Some participants were also concerned that alcohol-related health consequences would worsen in the future and would result in death. One participant said, “Might as well take a gun and blow my head off. You know what I am saying? You are just killing yourself slowly.”

3.2.4. Legal concerns.

Legal concerns comprised the fourth most frequently cited disadvantage. Many participants acknowledged that alcohol was often linked to their encounters with the criminal justice and legal systems. One participant noted that “every legal problem [he’d] ever had has been due to alcohol.” Because participants were homeless, drinking in public was a necessity; however, it is a misdemeanor violation in Washington State, where this study was conducted. One participant recounted, “They’ll throw you in jail for drinking on the streets. One time I had 49 open-container tickets.” Further, many participants acknowledged that the disinhibiting effects of alcohol precipitated criminal activity: “You get stupid, wind up in fucking jail.” Another participant said that drinking continued to pose legal problems for him while he was on probation: “Every time I go in there…first thing [my probation officer] do is she have me blow into a breathalyzer. She goes, ‘Oh you’ve been drinking, huh?’ I said, ‘Yeah.’ She said, ‘Well, you know where you’re going.’ King County Jail, here I come.”

3.2.5. Behavioral disinhibition.

The fifth most commonly encountered disadvantage of drinking involved concerns about engaging in alcohol-related behaviors participants later regretted. Participants said intoxication lowered their inhibitions causing them to “make silly, fucking mistakes.” Such behaviors can make individuals more vulnerable to injury and victimization: “The staff know I’m drunk. I don’t get into fistfights, but I go around naked.” Other concerns included the resulting interpersonal problems. As one participant explained, “You hurt people you care about. You do things you ain’t exactly coherent about at the time. Then, when you sober up, you go, ‘Wow! Did I do that?’” This loss of behavioral control was often considered somewhat alluring at first: “All the sudden, you’ve like got these huge drinking powers. So [you] end up doing off the wall stuff.” However, participants also associated it with a risk for serious consequences. One participant noted, “I’m scared to death to drive a car. I’m afraid I’d kill somebody.” Another participant said, “I was intoxicated…I was in a blackout, and I guess I tried to choke some woman downstairs.”

4. Discussion

No studies to date have described both the perceived advantages and disadvantages of drinking in the words of people with the lived experience of homelessness and AUDs. To address this gap in the literature, this study provided qualitative descriptions and relative rankings of the perceived advantages and disadvantages of alcohol use from the perspectives of members of this population.

4.1. Perceived Advantages of Drinking

The perceived advantage of drinking described most frequently by participants comprised psychological reasons, which reflected predominantly negatively reinforcing aspects of drinking (Cooper, Frone, Russell, & Mudar, 1995). Most commonly, participants indicated that alcohol served as a coping mechanism that facilitated challenging social situations and relieved stress and anxiety. The important role of drinking to cope with stress, particularly in social situations, is well-established in the stress-response dampening literature (Marlatt, 1987; Sayette, 1993; Sher, 1987). The fact that coping with stress and social situations represented the most frequently encountered category echoes the conclusions of a critical review on the topic, which concluded that positive expectancies about tension reduction are associated with increased problem drinking in socially anxious adults (Morris, Stewart, & Ham, 2005). Findings from the present study suggest that homeless people with AUDs are aware of this connection.

The ability to control one’s drinking was another frequently mentioned advantage of alcohol use. On the one hand, some responses in this category suggested reactance or reassurance (e.g. “I don’t get drunk.” “I don’t overdo it.”) and may thereby have reflected a potential social desirability bias or an attempt to reassure the investigator that their alcohol use was not a significant problem. On the other hand, some participants indicated they had recently made changes in their drinking; thus, this category may also reflect participants’ ability to regain a sense of control over drinking, particularly in conjunction with service access (e.g., housing attainment) and the resulting increased stability. This finding aligns with a recent narrative review, which concluded that loss of control may not be the stable and key defining feature of AUDs it is currently assumed to be (Rehm et al., 2013). Future research is needed to better understand individuals’ assertion that they do have a sense of control over their drinking, which stands in contrast to assumptions that people with moderate to severe AUDs experience a loss of control over their drinking.

Physical aspects of alcohol use was among the top five most frequently cited advantages of drinking. Although some participants cited the role of alcohol as a means of negative reinforcement (e.g., relieving physical withdrawal, tolerance staving off hangovers), this category primarily included the positively reinforcing effects of intoxication (e.g., “getting a buzz on”). This finding underscores this population’s perception of the ongoing physically reinforcing effects of alcohol despite its negative physical effects.

Social enjoyment and fun were the third and fifth most commonly cited advantages and reflected positively reinforcing aspects of drinking (Cooper et al., 1995). The prevalence of positively reinforcing aspects of drinking suggests they are highly salient and important. These findings correspond to the literature on drinking motives and expectancies, which has indicated that social and general enjoyment/enhancement aspects of drinking are high on the list of desired effects among less severely affected populations (Kuntsche, Knibbe, Gmel, & Engels, 2005; LaBrie, Hummer, & Pedersen, 2007; Orford, Krishnan, Balaam, Everitt, & Van der Graaf, 2004). Unfortunately, positive social and general enjoyment are not typically assessed among more severely affected populations in which it is assumed negatively reinforcing aspects dominate the experience of AUDs (Velasquez et al., 2000). Our study suggests the less pathological and more positively reinforcing effects of alcohol should be more consistently assessed to achieve an accurate representation of individuals’ perceptions of their alcohol use and to tailor interventions to address perceptions more holistically.

4.2. Perceived Disadvantages of Drinking

Only one study to date has documented perceived disadvantages of drinking among people with the lived experience of homelessness and AUDs. That study, which involved 100 service-seeking individuals, indicated that the top drinking disadvantages were family (53%), work (43%), and legal (41%) problems (Velasquez et al., 2000). Similarly, the present study indicated legal problems--reportedly due to drinking in public or other infractions incurred when drinking had lowered inhibitions--were the fourth most common disadvantages. Although they were mentioned, family and work problems were not mentioned among the top five disadvantages in our sample. This discrepancy may be due to our use of open-ended prompts to ascertain perceived disadvantages of drinking instead of researcher-generated, Likert-type items such as those used in Velasquez et al (2000). It may also reflect differences in the severity of drinking-related consequences in our sample: Many individuals reported being on social security disability and having little contact with their families after their time on the streets. Thus, these problems may have been less salient than they had been earlier in their trajectories.

Acute physical symptoms comprised the most frequently cited disadvantages of drinking, and of these, symptoms resulting from alcohol withdrawal were the most common. This finding corresponds to a prior study, which indicated alcohol withdrawal and the need to prevent and relieve its symptoms were a primary concern among chronically homeless people with AUDs (Collins, Clifasefi, Dana, et al., 2012). Taken together, these two studies’ findings indicate that acquiring, using and recovering from the effects of alcohol is a time-consuming, risky and stressful pursuit for this population.

The second most commonly perceived disadvantage was a perception of the inevitability of and concern about dependence on alcohol. Many participants mentioned their families of origin were affected by AUDs and felt they did not have a choice in their own development of AUDs. This phenomenon suggests there may be learned helplessness among homeless people with AUDs and signals a potential role for strengths-based approaches that support hope for alternative pathways forward for individuals from this population (Collins, Clifasefi, Andrasik, et al., 2012).

The third most commonly perceived disadvantage was a concern about chronic health conditions. This finding corresponds to the existing literature, which has indicated that the high levels of alcohol use among people with AUDs are associated with increased morbidity, mortality, and costs due to acute (e.g., falls, interpersonal violence, vehicular accidents, risky sex) and chronic (e.g., cardiovascular disease, liver cirrhosis, gastric disorders, nutritional deficiencies leading to cognitive impairment) causes (van Amsterdam & van den Brink, 2013; WHO, 2011).

Rounding out the top five perceived disadvantages were behavioral consequences, which referred to participants engaging in behaviors they later regretted while they were intoxicated. Although this perceived disadvantage has not been reported in the literature on homelessness, it has been established as a commonly cited disadvantage among college drinkers (Collins et al., 2014). This disadvantage thus appears to be a robust concern across two very different populations.

4.3. Study Limitations

The study limitations deserve mention. First, self-report can be subject to inaccuracies due to cognitive impairment, memory biases, social desirability and prompt wording (Belli, 1998; Bickart, Phillips, & Blair, 2006; Garry, Sharman, Feldman, Marlatt, & Loftus, 2002; Langenbucher & Merrill, 2001; Yoshino & Kato, 1995). It can, however, be reliable when the target behavior is not stigmatized and there are few negative consequences tied to disclosure of information (Babor, Stephens, & Marlatt, 1987; Carey, 2002; Clifasefi, Collins, Tanzer, Burlingham, & Larimer, 2011; Gelberg & Siecke, 1997; Maisto, Sobell, & Sobell, 1982). The present study procedures adhered to the above conditions; thus, we have confidence we have minimized the risk of self-report biases in this study.

Second, the study sample comprised a more severely affected and racially/ethnically unique subset of the larger homeless population (i.e., overrepresentation of American Indian/Alaska Natives and European Americans). Additionally, participants were recruited from community-based settings where they received harm-reduction oriented supportive services. Considering the specificity and uniqueness of the sample and setting, these findings may not generalize to other populations and supportive service environments. That said, understanding the needs of nontreatment-seeking, multimorbid, high-cost individuals is necessary to begin to address their needs and the associated burden on the health-care system.

4.4. Conclusions

Findings from this content analysis indicated that the top perceived advantages of drinking among homeless people with AUDs were its positively and negatively reinforcing psychological effects, perceived control over alcohol use, and associated social benefits. The acute physical effects of alcohol, concerns about alcohol dependence, and chronic health conditions comprised participants’ top disadvantages of drinking. These findings echoed different aspects of studies across various areas of alcohol research (e.g., drinking motives, expectancies, reasons for and against alcohol use). That said, this study is the first to report on these topics in participants’ own words.

These findings suggest ways in which alcohol treatment may be better tailored to this population’s interests and needs. First, alcohol treatment for this population may be more engaging if it takes into account participants’ perceived benefits of drinking as well as perceived negative consequences. Further, treatments could be more holistic in nature to help participants cope with the multiple stressors they face due to socioeconomic, shelter, psychiatric, medical and substance use problems. Finally, alcohol withdrawal was an oft mentioned concern as well as a primary reason for participants’ continued high levels of alcohol consumption. Future interventions could help participants learn to more safely modulate drinking to avoid alcohol withdrawal as they gain greater control over their drinking and reduce the frequency and quantity of their alcohol use.

Glossary:

•Homelessness:

As defined in the McKinney-Vento Homeless Assistance Act, homelessness is lacking a fixed, regular and adequate nighttime residence; having a primary nighttime dwelling that is not a regular sleeping accommodation; living in a supervised shelter or transitional housing; exiting an institution that served as temporary residence when the individual had previously resided in a shelter or place not meant for human habitation; or facing imminent loss of housing when no subsequent residence is identified and insufficient resources/support networks exist.

•Alcohol use disorders (AUDs):

AUDs are conditions characterized by craving/urges, a pattern of compulsive alcohol use, the harmful consequences of repeated alcohol use, and sometimes, physiological dependence on alcohol (i.e., tolerance, withdrawal).

•Conventional content analysis:

A qualitative research method used to interpret the content of text data through a systematic classification process involving coding and identifying themes. In conventional content analysis, the researcher does not start with preconceived, theory-based notions about what kinds of codes or categories of codes will be found. Instead, the researcher allows the data to drive the codes and categories.