Adams believes her recovery began about 10 years ago when she was attending a group therapy session at ShelterCare's Royal Avenue crisis program. She caught the eye of a ShelterCare program manager who was looking for someone to work as a peer advocate at a new emergency and transitional housing facility called Shankle Safe Haven. Adams was a natural because of her teaching background and an ability to share and listen honed after years of attending Alcoholics Anonymous and group therapy meetings. When she left the crisis program, she found an apartment and began her job at Safe Haven, where she still works. She still lives in the same apartment, too.

“In a way, it saved my life,” Adams says of Safe Haven. In helping the shelter clients, she has learned to help herself.  “I've got some experiences to share, and they respect me because I live on my own. But I feel like I'm one of them. I'm still crazy, no doubt, but so are they.”

Adams and others who understand the connection between dual disorders believe the integrated approach is only part of a holistic treatment required to heal people whose illnesses often make them vulnerable to trauma. Ban, of ShelterCare, points to organizations like the Oregon Engagement Model, which postulates that mental illness is often dramatically worsened because of trauma.

 “Many people with mental illness never get into the system because they manage to function well enough not to be hospitalized,” she says. “If they stay trauma-free, with the aide of medication and therapy, their level of illness is manageable.” The theory is that life traumas -- violence or family abuse, for example -- will induce severe behavioral problems that may lead to lengthy hospitalization, which, depending on the disorder, may worsen the problem. Posttraumatic stress disorder (PTSD) is an example of trauma that has pushed people into mental health institutions when they may not need to be there, Ban says. If avoidance of trauma is important to staying functional, then it makes sense to provide basic needs to a client, with housing the first priority.  

In February, ShelterCare started an experimental “hybrid” called The Inside Program (TIP), targeting people who are homeless, severely mentally ill and addicted. A few similar programs have begun in the U.S., including two in Portland. One of the program's key elements is the national “housing first” model, which provides each client with basic needs – safe housing, clothing, food, transportation, etc. – before addressing the person's disorder problems. Another important element of TIP is the “harm reduction” model of dealing with substance abuse. It sidesteps the moralistic prevention programs that focus on abstinence and zero-tolerance. Instead, it takes the view that drugs and alcohol will always be there to bedevil people. The approach attempts to educate individuals on excessive behavior with the goal of having them become responsible for their choices.

The task is formidable. It is also complex and expensive, but it is nowhere near as costly, officials at all levels are beginning to realize, as the expense incurred by the chronically homeless with dual disorders as they move in and out of jails and hospitals year after year. The goal of David Withem, TIP's director and case manager, is to move each client from the street into independent living situations within six months, with the eventual goal of placing them in long-term housing. He believes a year is a more realistic time frame, especially because their futures often depend on qualifying for Social Security Insurance (SSI) or disability funding – always a difficult chore.

At 47, Withem has seen, and experienced, much suffering. He wasn't homeless growing up, but he ran the streets with that subculture, eventually becoming a heavy drug user in his twenties. In his thirties, he was in a car accident in which his wife died, and he was burned over 95 percent of his body. He changed direction after the tragedy, eventually getting a master's degree in counseling from a seminary school. His focus has become homelessness and dual disorders. “Hopefully other people don’t have to go through such a tragedy in order to make life changes,” he says. 

He operates out of a 6-by-12-foot office in a dingy Springfield motel now housing a few families that have been rescued from the streets by ShelterCare. Skin grafts cover Withem's body, giving it a pinkish, glazed sheen. His dark, deep-set eyes have a haunting affect as they stare out of his pale face. Withem and Ban consider the housing first approach, now adapted in more than 200 cities in the country, as a tool to overcome homelessness, as the critical element in achieving TIP's goal. “Most agencies involved with dual disorders think they are doing a holistic approach, which certainly is true to a degree,” Withem says. “They are doing a fantastic job when it comes to dealing with a person's mental illness and addictions.” But he sees a need for a bridge spanning the streets and independent living because agencies often are not set up to take care of a client's critical needs – including helping them get medical benefits. Withem serves as a safety net for his clients, helping them with their urges, stresses, anger. He knows that eventually they'll have to go it alone, but until then they need help with the basics. Without such assistance, low self-esteem, stress or a traumatic experience can easily trigger poor choices that cause them to revert to their old tendencies.