Deborah Finfgeld-Connett, Tina L. Bloom, and E. Diane Johnson

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PERCEIVED COMPETENCY AND RESOLUTION OF HOMELESSNESS AMONG WOMEN WITH SUBSTANCE ABUSE PROBLEMS¹

                We are approaching a new age of synthesis. Knowledge cannot be merely a degree or a skill … it demands a broader vision, capabilities in critical thinking and logical deduction without which we cannot have constructive progress.

—Li Ka-shing

Despite evidence of relative prosperity in some places, homelessness remains a problem in many locales. Homelessness in Canada is estimated to range from 150,000 to 300,000 (Intraspec.ca, 2010), and in Australia the numbers are thought to hover around 105,000 (Australian Bureau of Statistics, 2008). Over the course of a year, it is estimated that 1,593,150 individuals in the United States experience homelessness. Of that number, approximately 605,397 (38%) are women residing in shelters (Substance Abuse and Mental Health Services Administration [SAMHSA], 2011). Reasons for homelessness among women include a lack of jobs and public assistance funds and a coinciding increase in poverty and home foreclosures. Other exacerbating problems among women include domestic violence, mental illness, substance abuse, and a commensurate lack of affordable treatment programs (Human Resources and Skills Development Canada [HRSDC], 2010; National Coalition for the Homeless [NCH], 2009).

Moving homeless women into stable housing can be challenging when substances of abuse such as alcohol, cocaine, and heroin are involved. Among a sample of homeless women from three Canadian cities, 82% (n = 193) were found to have at least one type of substance abuse disorder (Torchalla, Strehlau, Li, & Krausz, 2011). In the United States, it is estimated that women comprise one-fifth of the homeless who are admitted to substance abuse treatment facilities. About half of these individuals report between one and four prior treatment episodes, and 20% report five or more treatment experiences (SAMHSA, 2004). Given these recidivism rates, efforts to systematically examine and fine-tune assistance programs for homeless women with substance abuse problems are needed (O’Campo et al., 2009).

We conducted the current meta-synthesis following a prior investigation in which the process of becoming homeless, being homeless, and resolving homelessness among persistently homeless women was investigated (Finfgeld-Connett, 2010a). Based on findings from that study, it appears that becoming and being homeless are likely to involve maladaptive experiences of interpersonal abuse, neglect, and/or abandonment, all of which may be fueled by the psychic instability and/or immoral proclivities of close associates. Other contextually permeating factors include circumstantial poverty and transience, and social service system barriers. These barriers appear to extend beyond mere problems of availability and accessibility. Of particular note are more intangible impediments pertaining to trust and overall integrity of the system.

Based on findings from this same meta-synthesis (Finfgeld-Connett, 2010a), it was also concluded that resolving homelessness among a heterogeneous group of persistently homeless women involves cyclic stages. These women tend to seek assistance when crises occur, but they remain vulnerable to homelessness. It is not unusual for persistently homeless women to repeatedly engage–disengage–engage with the social service system prior to making sustained efforts to become stably housed. The cyclic nature of this process prolongs the resolution of homelessness and is attributable, at least in part, to substance abuse problems (Burlingham, Andrasik, Larimer, Marlatt, & Spigner, 2010; Finfgeld-Connett, 2010a). The specific purpose of this investigation was to articulate new insights relating to the cyclic process of resolving homelessness among adult women with substance abuse problems.

METHODOLOGY

Qualitative Meta-Synthesis

Qualitative meta-synthesis, as outlined by Finfgeld-Connett (e.g., 2009a, 2009b, 2010a), was used to conduct this investigation. This method was inspired by the work of Noblit and Hare (1988), Miles and Huberman (1994), and the grounded theory approaches of Corbin and Strauss (2008) and Strauss and Corbin (1990). Qualitative meta-synthesis does not involve data aggregation or any other quantitative method. It is not a secondary analysis of raw qualitative data, nor is it a type of meta-analysis. Meta-synthesis is a methodology in which qualitative findings from existing research reports are systematically acquired and qualitatively analyzed and synthesized (Finfgeld-Connett, 2010b). Qualitative meta-syntheses result in novel interpretations of qualitative findings that cannot be identified in original research reports (Thorne, Jensen, Kearney, Noblit, & Sandelowski, 2004).

Within the context of meta-synthesis work, validity is not dependent on the logic of replication (Thorne et al., 2004); rather, it is based on trustworthiness (Lincoln & Guba, 1985). One way that trustworthiness is established is through transparent data extraction and analysis processes. To this end, these iterative processes are described next.

Sample

There is some overlap (n = 23) between the reports that comprise the database for this study (N = 60) and a prior investigation (N = 45; Finfgeld-Connett, 2010a); however, with the help of an expert reference librarian (third author), the pool of potential research reports was greatly expanded for this study. In addition, unlike the prior investigation, research reports were excluded if substance abuse issues were not addressed.

Electronic databases that were searched included Cumulative Index to Nursing and Allied Health Literature (CINAHL), ETOH Archival Database, GenderWatch, Google Books, Ovid MedLine, ProQuest Dissertations, PsycINFO, Scopus, and Social Work Abstracts. Customized search strategies, were used to maximize the potential of each unique database and to exclude reports such as those that pertained solely to children, adolescents, and men, or those that were not conducted using qualitative methods. These tailored search strategies resulted in over 5,500 English language citations, with unavoidable duplication across databases.

A cursory review of each citation title and abstract was conducted to further eliminate publications that were clearly not reports of qualitative research relating to homeless women. This resulted in the identification of 90 promising reports that were subsequently secured for further evaluation. Thirty of these were eliminated for one or more reasons. For example, findings relating to substance abuse could not be identified, or findings relating to women could not be separated from those pertaining to men, or findings relating strictly to homeless women could not be isolated from those associated with low-income women. In total, 60 reports of qualitative research, dating from 1990 to mid-2010, comprised the sample for this investigation. This number consisted of 30 published peer-reviewed articles, 7 books, and 23 theses/dissertations.

Data Extraction, Analysis, and Synthesis

To avoid potential theoretical bias, grounded theory process concepts (e.g., antecedents, attributes, outcomes, and interrelationships among constructs; Corbin & Strauss, 2008; Strauss & Corbin, 1990) were the only theoretical foundations that were used for data analysis. Coding structures from a prior investigation (Finfgeld-Connett, 2010a) were not used to guide data analysis since the foci of this study and that one differed.

A data collection form that was adapted from Finfgeld-Connett (2010a) was used to gather information pertaining to each study such as aim/purpose, theoretical framework, methods, and sample. This information was used throughout the data analysis process to provide context. When available, information relating to substance abuse treatment strategies was also gathered; however, the utility of these data was limited because they were inconsistently reported across studies.

Each research report was carefully read, and the findings were high-lighted. In keeping with meta-synthesis methods, findings were limited to researcher interpretations rather than raw data such as quotations (Finfgeld, 2003; Finfgeld-Connett, 2010a). To avoid bias, all interpreted findings, regardless of how they compared with the researchers’ preconceived ideas, were extracted from the original research reports and placed into data analysis matrices for coding and categorizing. Concrete and in vivo codes were initially used to ensure a firm grounding in the data. To further ensure well-grounded results, metaphorical coding was carried out in small iterative and reflexive steps. Subsequently, memos were iteratively and reflexively composed and revised to clearly articulate singular codes, explicate abstract categories, and delineate links among concepts (Finfgeld-Connett, 2010a). Memos were gradually translated into provisional lines of argument and continually evaluated against the original data to assess for truthfulness and fittingness with associated findings. This reflexive and iterative process continued until conceptual clarity was achieved and the core concept of perceived competency was fully articulated (Corbin & Strauss, 2008; Finfgeld-Connett, 2010a; Noblit & Hare, 1988).

Trustworthiness

In addition to the data collection and analysis methods that have already been outlined, the following steps were taken to enhance trustworthiness. First, instead of vetting research reports in their entirety for quality, each finding was evaluated based on its credibility and fittingness within the emergent findings (Pawson, 2006). Based on this strategy, only those findings that lacked support within the context of the current investigation were omitted. This is in contrast to potentially rejecting all findings from an entire research report based on the way that a study is presented or written. The approach used to conduct this investigation is consistent with the fact that no known valid method currently exists for judging the overall quality of qualitative research based on written reports (Centre for Reviews and Dissemination, 2009). In the end, only those findings that lacked support within the context of the current investigation were excluded from further consideration. This is in contrast to rejecting all findings from an entire research report based on the way a study is presented or written. For example, because research reports as old as 20 years were included in the database, each finding was carefully vetted for currency. In large part, data relating to the topic under investigation transcended time. Those that did not were excluded from further analysis. These included time-sensitive findings pertaining to treatment funding and public policy initiatives.

It is notable that because findings from multiple qualitative investigations comprise a meta-synthesis database, several forms of triangulation are inherent to the methodology. These types of triangulation include a variety of research frameworks (i.e., phenomenology, ethnography, grounded theory, etc.), sampling methods, data analysis methods, and researchers (Finfgeld, 2003; Finfgeld-Connett, 2010b).

In the case of this meta-synthesis, the second author independently reviewed codes and memos at critical junctures in the data analysis process and provided feedback to the first author. Her feedback was used to reflexively review coding, categorizing, and memoing, and to make adjustments that were congruent with the data.

FINDINGS

Overview

The reports included in this investigation represent studies that were carried out in the United States (n = 51), Canada (n = 3), and Australia (n = 1). One was a multisite study (Canada and Scotland), and in four instances, the data collection locations were undisclosed. In light of contextual information, these four studies appear to have been carried out in the United States and Canada.

The findings that comprised the sample for this meta-synthesis represent data from 1,871 homeless women. This includes data from 674 Black women, 346 White women, 252 Hispanic women, 100 women who were classified as other, and 499 individuals whose race/ethnicity remain unknown. The study database also included findings generated from 251 staff and 74 members of the public. These numbers do not account for countless others who were included in the research process through observation and participant observation.

Findings from the meta-synthesis portion of this investigation are presented next. This meta-synthesis is not comprehensive; instead, it is intended to orient the reader and to provide an overview of the findings. Based on the results of this meta-synthesis, distorted perceptions of competency, which are shaped by dysfunctional relationships and mental health problems, appear to make it challenging for women with substance abuse problems to resolve homelessness. Women with low and high levels of perceived competency grapple with challenges related to structure and control, trust, and hopelessness. Therapeutic strategies for approaching women with distorted perceptions of competency include careful assessment, caring, personalized structure and control, development of interpersonal trust, and instillation of hope. Targeted efforts to manage substance abuse and other exacerbating mental health problems are also consistent with optimal care.

Perceived Competency

Perceived competency is a concept that is inferred based on the findings of this meta-synthesis. It is the personally interpreted ability to make decisions, take action, and execute positive change in one’s life. Perceived competency exists on a continuum and is based on individual insights and interpretations. Given the enduring personal and interpersonal challenges that many homeless women face (Marcus, 2001; Padgett, Hawkins, Abrams, & Davis, 2006), they tend to present with varying levels of perceived competency. Some homeless women project a high level of perceived competency whereas others project very little. Still others lie somewhere in the middle. Supporting references are used to explicate these ideas in the following paragraphs.

Low Perceived Competency

Women with low levels of perceived competency are likely to present as chronically homeless owing to a sense of personal paralysis (Lineberger, 2009). They are apt to psychologically distance themselves from the reality of their situations (Acquaviva, 2000) and to disassociate from their mental and physical health care needs (Enriquez, 2005; Liebow, 1993). These women tend to see themselves as unable to effect positive change, and they attribute their gridlocked status to forces beyond their control such as the economy or the bureaucratic system (Williams, 2003). Using this mindset, fatalism tends to become a consoling way to explain a powerful and unjust world, and blame and loathing may be projected elsewhere (Acquaviva, 2000; Brink, 2001; Carroll & Trull, 2002; Lineberger, 2009; Williams, 2003). Although adaptive in some ways, this nihilistic worldview is apt to inhibit change by obfuscating links between personal behavior and negative consequences. It may also lead to acquiescence and behavioral inertia on the part of the individual (Acquaviva, 2000; Gelberg, Browner, Lejano, & Arangua, 2004).

High Perceived Competency

Women with high levels of perceived competency also tend to present as intransigently homeless; however, their affect may be notably different than those individuals with low levels of perceived competency. Freedom and the liberty to abide by one’s own value system and rules are likely to take priority over getting help in a structured setting that functions based on conventional mores and regulations (Fogel, 1997; Patterson, 2003). These women may see the treatment environment as alien, and expectations of social service providers may exceed their willingness or ability to adapt. Instead of feeling more stable and secure in a structured environment (Fogel, 1997), they tend to feel out of control, and their behavior may be disruptive (Fogel, 1997; Grella, 1994).

Homeless women with high levels of perceived competency appear to overestimate their ability to independently execute change and improve their lives outside of therapeutic environments. Based on this vantage point, they may repress or deny injustices and assume personae of strength, toughness, and autonomy (Huey & Quirouette, 2010). These women have been known to go so far as to believe that they are exceptionally lucky, skillful, strong, or manipulative. At this polarity of the continuum, homeless women may perceive that societal rules do not apply to them, which can lead to aggressive, antisocial, or criminal activities (Carroll & Trull, 2002; Gentry, 2003; Luhrmann, 2008). Consequently, they may habitually gravitate toward illegal and unsustainable activities such as drug sales and sex work (Geter, 1993; Greene, Ball, Belcher, & McAlpine, 2003; Marcus, 2001; Wheeler, 2006).

Perceived Competency at Mid-Continuum

It is inferred that homeless women in the middle of the perceived competency continuum appear to have a relatively good grasp of their personal assets and limitations, and they tend to possess skills that are needed to effectively make decisions and resolve problems. These women are better equipped than those on the margins of the continuum to assertively approach social service providers, gain knowledge, build healthy supportive relationships, establish conventional daily routines, and pursue job and housing leads (Banyard, 1995; Gillette, 2001; Haydon, 2005; Sysko, 2002). They tend to be more adept at instituting creative coping strategies, and they are not as likely to rely on social services for extended periods of time (Grella, 1994). These women are not the focus of this investigation.

Factors That Shape Perceived Competency

Dysfunctional Relationships

High and low perceptions of competency tend to emerge in the context of dysfunctional relationships. Homeless women are likely to have been raised in unstable homes where there was a history of multigenerational dysfunction and loss (Trickett & Chung, 2007). It is not unusual for their parents to have been divorced, deceased, and/or substance abusers. As youth, many homeless women endured some form of neglect and physical and emotional abuse, and they may have been raised by relatives or placed in foster care at an early age (Acquaviva, 2000; Carroll & Trull, 1999, 2002; Haydon, 2005; Marcus, 2001).

As adults, homeless women frequently report that they have experienced familial abuse and/or alienation (Carroll & Trull, 2002; Lineberger, 2009; Trickett & Chung, 2007; Wheeler, 2006). Although they may seek refuge with sympathetic acquaintances and family members, these relationships are tenuous, tensions escalate over time, and eventually the women feel compelled to leave (Belcher, Greene, McAlpine, & Ball, 2001; Brink, 2001; Montgomery, McCauley, & Bailey, 2009; Williams, 2003). As a result of these types of experiences, many homeless women do not have the opportunity to develop healthy interpersonal relationships (Belcher et al., 2001), and their social support systems are, at best, fragile (Brink, 2001; Gillette, 2001; Williams, 2003).

Among individuals with low levels of perceived competency, it is inferred that innate needs to stay interpersonally connected may sometimes override needs to ensure one’s own well-being and safety (D’Amico, Barnes, Gilbert, Ryan, & Wenzel, 2009; Urbanoski, 2001). In an attempt to create mutually fulfilling relationships, these women are apt to endure a number of different types of interpersonal abuse for the short term in hopes of satisfying their need for fulfilling relationships in the long run (Haydon, 2005; Liebow, 1993; Lineberger, 2009).

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