title: In their own words: Content analysis of pathways to recovery among individuals with the lived experience of homelessness and alcohol use disorders.
abstract: BACKGROUND
  Alcohol use disorders (AUDs) are more prevalent among homeless individuals than in the general population, and homeless individuals are disproportionately affected by alcohol-related morbidity and mortality. Unfortunately, abstinence-based approaches are neither desirable to nor highly effective for most members of this population. Recent research has indicated that homeless people aspire to clinically significant recovery goals beyond alcohol abstinence, including alcohol harm reduction and quality-of-life improvement. However, no research has documented this population's preferred pathways toward self-defined recovery. Considering principles of patient-centred care, a richer understanding of this population's desired pathways to recovery may help providers better engage and support them.
  
  
  METHODS
  Participants (N=50) had lived experience of homelessness and AUDs and participated in semi-structured interviews regarding histories of homelessness, alcohol use, and abstinence-based treatment as well as suggestions for improving alcohol treatment. Conventional content analysis was used to ascertain participants' perceptions of abstinence-based treatment and mutual-help modalities, while it additionally revealed alternative pathways to recovery.
  
  
  RESULTS
  Most participants reported involvement in abstinence-based modalities for reasons other than the goal of achieving long-term abstinence from alcohol (e.g., having shelter in winter months, "taking a break" from alcohol use, being among "like-minded people"). In contrast, most participants preferred alternative pathways to recovery, including fulfilling basic needs (e.g., obtaining housing), using harm reduction approaches (e.g., switching from higher to lower alcohol content beverages), engaging in meaningful activities (e.g., art, outings, spiritual/cultural activities), and making positive social connections.
  
  
  CONCLUSIONS
  Most people with the lived experience of homelessness and AUDs we interviewed were uninterested in abstinence-based modalities as a means of attaining long-term alcohol abstinence. These individuals do, however, have creative ideas about alternative pathways to recovery that treatment providers may support to reduce alcohol-related harm and enhance quality of life.
authors.affiliation: Department of Psychiatry and Behavioral Sciences, University of Washington - Harborview Medical Center, 325 Ninth Ave, Box 359911, Seattle, WA 98104, USA. Electronic address: collinss@uw.edu.
authors.forename: Susan E
authors.initials: SE
authors.lastname: Collins
authors.affiliation: Department of Psychiatry and Behavioral Sciences, University of Washington - Harborview Medical Center, 325 Ninth Ave, Box 359911, Seattle, WA 98104, USA. Electronic address: cbj5@uw.edu.
authors.forename: Connor B
authors.initials: CB
authors.lastname: Jones
authors.affiliation: Department of Psychiatry and Behavioral Sciences, University of Washington - Harborview Medical Center, 325 Ninth Ave, Box 359911, Seattle, WA 98104, USA. Electronic address: gaileh2@uw.edu.
authors.forename: Gail
authors.initials: G
authors.lastname: Hoffmann
authors.affiliation: Department of Health Services, University of Washington School of Public Health, 1100 Olive Way, Suite 1200, Seattle, WA 98101, USA. Electronic address: lonnin@uw.edu.
authors.forename: Lonnie A
authors.initials: LA
authors.lastname: Nelson
authors.affiliation: Department of Psychiatry and Behavioral Sciences, University of Washington - Harborview Medical Center, 325 Ninth Ave, Box 359911, Seattle, WA 98104, USA. Electronic address: hawess@uw.edu.
authors.forename: Starlyn M
authors.initials: SM
authors.lastname: Hawes
authors.affiliation: Department of Psychiatry and Behavioral Sciences, University of Washington - Harborview Medical Center, 325 Ninth Ave, Box 359911, Seattle, WA 98104, USA. Electronic address: graziv@uw.edu.
authors.forename: Véronique S
authors.initials: VS
authors.lastname: Grazioli
authors.affiliation: Department of Psychiatry and Behavioral Sciences, University of Washington - Harborview Medical Center, 325 Ninth Ave, Box 359911, Seattle, WA 98104, USA. Electronic address: jlmack11uw@gmail.com.
authors.forename: Jessica L
authors.initials: JL
authors.lastname: Mackelprang
authors.affiliation: Department of Psychiatry and Behavioral Sciences, University of Washington - Harborview Medical Center, 325 Ninth Ave, Box 359911, Seattle, WA 98104, USA. Electronic address: jkholttum@gmail.com.
authors.forename: Jessica
authors.initials: J
authors.lastname: Holttum
authors.affiliation: Department of Psychiatry and Behavioral Sciences, University of Washington - Harborview Medical Center, 325 Ninth Ave, Box 359911, Seattle, WA 98104, USA. Electronic address: gmkaese@uw.edu.
authors.forename: Greta
authors.initials: G
authors.lastname: Kaese
authors.affiliation: Department of Psychiatry and Behavioral Sciences, University of Washington - Harborview Medical Center, 325 Ninth Ave, Box 359911, Seattle, WA 98104, USA. Electronic address: jamesml@uw.edu.
authors.forename: James
authors.initials: J
authors.lastname: Lenert
authors.affiliation: Department of Psychiatry and Behavioral Sciences, University of Washington - Harborview Medical Center, 325 Ninth Ave, Box 359911, Seattle, WA 98104, USA. Electronic address: herndp@uw.edu.
authors.forename: Patrick
authors.initials: P
authors.lastname: Herndon
authors.affiliation: Department of Psychiatry and Behavioral Sciences, University of Washington - Harborview Medical Center, 325 Ninth Ave, Box 359911, Seattle, WA 98104, USA. Electronic address: seemac@uw.edu.
authors.forename: Seema L
authors.initials: SL
authors.lastname: Clifasefi
mesh_terms: D064829:Alcohol Abstinence / Q000523:psychology*; D000428:Alcohol Drinking / Q000453:epidemiology / Q000517:prevention & control* / Q000523:psychology; D019973:Alcohol-Related Disorders / Q000453:epidemiology / Q000523:psychology / Q000534:rehabilitation*; D005260:Female; D040261:Harm Reduction; D006703:Ill-Housed Persons; D006801:Humans; D008297:Male; D008875:Middle Aged; D018802:Patient-Centered Care; D011788:Quality of Life; D013695:Temperance
keywords: Alcohol use; Content analysis; Drinking; Homelessness; Pathways to recovery; Qualitative analysis