title: Voices of homeless alcoholics who frequent Bellevue Hospital: a qualitative study.
abstract: OBJECTIVE
  We describe the evolution, environment, and psychosocial context of alcoholism from the perspective of chronically homeless, alcohol-dependent, frequent emergency department (ED) attendees. We use their words to explore how homelessness, health care, and other influences have contributed to the cause, progression, and management of their alcoholism.
  
  
  METHODS
  We conducted detailed, semistructured, qualitative interviews, using a phenomenological approach with 20 chronically homeless, alcohol-dependent participants who had greater than 4 annual ED visits for 2 consecutive years at Bellevue Hospital in New York City. We used an administrative database and purposive sampling to obtain typical and atypical cases with diverse backgrounds. Interviews were audio recorded and transcribed verbatim. We triangulated interviews, field notes, and medical records. We used ATLAS.ti to code and determine themes, which we reviewed for agreement. We bracketed for researcher bias and maintained an audit trail.
  
  
  RESULTS
  Interviews lasted an average of 50 minutes and yielded 800 pages of transcript. Fifty codes emerged, which were clustered into 4 broad themes: alcoholism, homelessness, health care, and the future. The participants' perspectives support a multifactorial process for the evolution of their alcoholism and its bidirectional reinforcing relationship with homelessness. Their self-efficacy and motivation for treatment is eroded by their progressive sense of hopelessness, which provides context for behaviors that reinforce stigma.
  
  
  CONCLUSIONS
  Our study exposes concepts for further exploration in regard to the difficulty in engaging individuals who are incapable of envisioning a future. We hypothesize that a multidisciplinary harm reduction approach that integrates health and social services is achievable and would address their needs more effectively.
authors: Department of Emergency Medicine, New York University School of Medicine, New York, NY. Electronic address: ryan.mccormack@nyumc.org.
authors: Ryan P
authors: RP
authors: McCormack
authors: Department of Emergency Medicine, New York University School of Medicine, New York, NY; New York University Gallatin School of Individualized Study, New York, NY.
authors: Lily F
authors: LF
authors: Hoffman
authors: Department of Emergency Medicine, New York University School of Medicine, New York, NY; Arthur L. Carter Journalism Institute, New York University College of Arts and Sciences, New York, NY.
authors: Michael
authors: M
authors: Norman
authors: Department of Emergency Medicine, New York University School of Medicine, New York, NY.
authors: Lewis R
authors: LR
authors: Goldfrank
authors: Department of Emergency Medicine, New York University School of Medicine, New York, NY; Department of Humanities and Social Sciences and Interdepartmental Research Studies, New York University Steinhardt School of Culture, Education, and Human Development, New York, NY.
authors: Elizabeth M
authors: EM
authors: Norman
mesh_terms: D000328:Adult; D019973:Alcohol-Related Disorders / Q000209:etiology / Q000534:rehabilitation; D057229:Alcoholics; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006703:Ill-Housed Persons; D006786:Hospitals, Urban; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D016743:Mental Competency; D008875:Middle Aged; D009519:New York City; D036301:Qualitative Research; D011795:Surveys and Questionnaires