“The Apartment is for You,It’s Not for Anyone Else”: Managing Social Recovery and Risk on the Frontlines of Single-Adult Supportive Housing

This multi-method qualitative study examines frontline provider perspectives on consumer social relationships and barriers to social recovery in supportive housing programs for adults with serious mental illness. Thematic analyses show that guest and occupancy policies that enforce the “single” nature of single-adult supportive housing challenge consumer rights to self-determination in the realm of social recovery. Findings also highlight the ways in which providers act to reinforce and subvert these policies while mitigating risk in this service setting. Recommendations for enhancing the recovery orientation of supportive housing and implications for the design of the homeless service system are discussed.     

Impact of chronically street homeless tenants in congregate supportive housing

New initiatives to house chronically street homeless (CSH) adults have led to increasing proportions of this population living in congregate supportive housing, but little is known about the impact of this shift on supportive housing programs. The present multisite, mixed-methods study examined service utilization and lease compliance among 52 chronically street homeless and 46 long-term shelter stayer (LTSS) adults during their first 12?months in congregate supportive housing. Quantitative analysis of administrative data revealed that CSH tenants used significantly more service resources than LTSS tenants, including more advocacy, escorting, and psychiatric treatment and more assistance with financial, housing, and mental and physical health issues. The 2 groups did not differ significantly on measures of lease compliance. Qualitative focus groups with CSH tenants, service provider staff, and property management staff all indicated that existing supportive housing services are suitable for this population, although some adjustments, additional resources, or both, may be indicated.     

An Exploratory Analysis of Unhealthy and Abusive Relationships for Adults with Serious Mental Illnesses Living in Supportive Housing

Individuals living with serious mental illness are at high risk of chronic homelessness, victimization, and intimate partner violence. In recent years, supportive housing programs have emerged as one way to prevent homelessness and victimization for this population, while also expanding social interactions and social networks. In concert with a focal supportive housing program, this research conducted two focus groups with 18 individuals who have a serious mental illness diagnosis. The authors sought to answer the research question, “What are perceptions of healthy and unhealthy relationships among formerly homeless people with serious mental illness?” To this end, the eight-item questionnaire was created around dimensions of power and control, as well as relationship equality. Findings from an inductive thematic analysis reveal three broad families of themes (relationship ideals, lived experiences, and risk/resources in supportive housing), around which smaller themes and subthemes are organized. Implications for policy, practice, and future research are also discussed.     

From Principles to Practice: A Study of Implementation of Supported Housing for Psychiatric Consumers

In the post-deinstitutionalization era, supported housing has emerged as a housing and service approach considered most conducive to the goal of consumer empowerment and community integration. Although prior research found beneficial effects of supported housing, little empirical work has been done on identifying the gaps between the principles and practice of supported housing. Using multiple data sources on 27 supported independent living (SIL) programs for psychiatric consumers in a large metropolitan community, this paper examines the extent to which these programs are implemented in accordance with supported housing. Findings suggest consistency with as well as deviation from the supported housing approach in regard to consumer choice, typical and normalized housing, resource accessibility, consumer control and provision of individualized and flexible support. This study suggests methods for assessing housing programs for psychiatric consumers along these domains. Implications for the development of housing programs that promote consumer empowerment and community integration are discussed.     

Management of chronic schizophrenic outpatients

Mental health practitioners can effectively manage outpatient care of chronic schizophrenic patients by regulating antipsychotic and ancillary maintenance medications; providing supportive "psychotherapy"; advising on programs to fulfill basic needs such as housing, vocational rehabilitation, and a social network; engaging the patient's family along with the patient in a partnership to maximize functioning; and encouraging appropriate social interactions. When done skillfully, this outpatient practice can be among the most rewarding in psychiatry.     

Community integration of persons with psychiatric disabilities in supportive independent housing: a conceptual model and methodological considerations

Despite the consensus regarding community integration as a major goal of mental health policy and the emergence of supportive independent housing as a critical component of community mental health services, mental health services research has not examined the extent to which housing and service characteristics are associated with community integration of persons with psychiatric disabilities in supportive independent housing. The main goal of this paper is to propose a conceptual model of factors influencing community integration that takes into account the differential configuration of housing setting and support structure in supportive independent housing. The conceptual model encompasses a multidimensional conceptualization of community integration and considers an array of housing and service characteristics that are potentially relevant determinants of community integration. On the basis of the proposed model, this paper outlines the methodological considerations for future research with regard to measurement, research designs, and statistical models.     

Impact of permanent supportive housing on the use of acute care health services by homeless adults

OBJECTIVE: This analysis examined the impact of permanent supportive housing on the use of acute care public health services by homeless people with mental illness, substance use disorder, and other disabilities. METHODS: The sample consisted of 236 single adults who entered supportive housing at two San Francisco sites, Canon Kip Community House and the Lyric Hotel, between October 10, 1994, and June 30, 1998. Eighty percent had a diagnosis of dual psychiatric and substance use disorders. Administrative data from the city's public health system were used to construct a retrospective, longitudinal history of service use. Analyses compared service use during the two years before entry into supportive housing with service use during the two years after entry. RESULTS: Eighty-one percent of residents remained in permanent supportive housing for at least one year. Housing placement significantly reduced the percentage of residents with an emergency department visit (53 to 37 percent), the average number of visits per person (1.94 to .86), and the total number of emergency department visits (56 percent decrease, from 457 to 202) for the sample as a whole. For hospitalizations, permanent supportive housing placement significantly reduced the likelihood of being hospitalized (19 to 11 percent) and the mean number of admissions per person (.34 to .19 admissions per resident). CONCLUSIONS: Providing permanent supportive housing to homeless people with psychiatric and substance use disorders reduced their use of costly hospital emergency department and inpatient services, which are publicly provided.     

Housing for people with mental illness: update of a report to the President's New Freedom Commission

A significant barrier to participation in community life for people with serious mental illness is the lack of decent, safe, affordable, and integrated housing of their choice linked with supportive services. The nation's affordable housing and mental health systems have historically failed to address consumers' housing needs and choices. The lack of housing has resulted in disproportionately high rates of homelessness and chronic homelessness. The author summarizes these issues, which were examined by the Subcommittee on Housing and Homelessness of the President's New Freedom Commission, and discusses the subcommittee's recommendations to end chronic homelessness among people with mental illness, expand access to affordable housing resources for consumers, and promote evidence-based practices. There has been uneven progress nationwide in ameliorating the widespread and multidimensional housing and homelessness problems that were exposed in the subcommittee's paper. The permanent supportive housing model, including "housing first" approaches, has proven effective in preventing and ending homelessness among consumers, but efforts to expand the supply are hampered by significant reductions in federal funds for housing. State and local mental health systems are also struggling to re-configure service system resources to better address housing and homelessness issues. Apparent reductions in chronic homelessness will be short-lived unless affordable housing policies and mental health services are reoriented to both prevent and end homelessness for people with mental illness.     

A survey of psychiatric residency directors on current priorities and preparation for public-sector care

OBJECTIVE: This study assessed how resident psychiatrists are being prepared to deliver effective public-sector care. METHODS: Ten leaders in psychiatric education and practice were interviewed about which tasks they consider to be essential for effective public-sector care. The leaders identified 16 tasks. Directors of all general psychiatry residency programs in the United States were then surveyed to determine how they rate the importance of these tasks for delivery of care and how their training program prepares residents to perform each task. RESULTS: A total of 114 of 150 residency directors (76 percent) responded to the survey. Factor analysis divided 14 of the tasks into three categories characterized by the extent to which their performance requires integration of services: within the mental health system (for example, lead a multidisciplinary team), across social service systems (for example, interact with staff of supportive housing programs), and across institutions with different missions (for example, distinguish behavioral problems from underlying psychiatric disorders among prisoners). Preparation for tasks that involved integration of services across institutions was rated as least important, was least likely to be required, and was covered by less intensive teaching modalities. Tasks entailing integration within the mental health system were rated as most important, preparation was most likely to be required, and they were covered most intensively. Midway between these two categories, but significantly different from each, were tasks relying on integration across social service systems. CONCLUSIONS: Tasks that involved integrating services across institutions with different missions were consistently downplayed in training. Yet the importance of such tasks is underscored by the assessments of the psychiatric leaders who were interviewed, the high valuation placed on this type of integration by a substantial subset of training directors, and the extent of mental illness among populations who are institutionalized in nonpsychiatric settings.     

A narrative approach to the evaluation of supportive housing: stories of homeless people who have experienced serious mental illness

We present the findings of a narrative approach to the evaluation of supportive housing for formerly homeless people who have experienced serious mental illness. According to the accounts of 11 men and 9 women, their youth and adult years were filled with personal problems, troubled relationships, and a lack of adequate social resources. Since entering supportive housing, participants noted more stability in their lives and the beginning of journeys to recover positive personal identities, restore or develop new supportive relationships, and reclaim resources vital to leading lives with dignity and meaning. The findings add to the literature on housing interventions for this population in suggesting many positive gains beyond reductions in homelessness and hospitalization.     

Do faith-based residential care services affect the religious faith and clinical outcomes of homeless veterans?

Data on 1,271 clients in three residential care services funded by the Department of Veterans Affairs was used to examine: (1) how religious-oriented programs differ in their social environment from secular programs, (2) how religious-oriented programs affect the religiosity of clients, and (3) how client religiosity is associated with outcomes. Programs were categorized as: secular, secular now but religious in the past, and currently religiously oriented. Results showed (1) participants in programs that were currently religious reported the greatest program clarity, but secular services reported the most supportive environments; (2) participants in programs that were currently religious did not report increases in religious faith or religious participation over time; nevertheless (3) greater religious participation was associated with greater improvement in housing, mental health, substance abuse, and quality of life. These findings suggest religious-oriented programs have little influence on clients' religious faith, but more religiously oriented clients have somewhat superior outcomes.     

Integrating the Integrated: Merging Integrated Dual Diagnosis Treatment (IDDT) with Housing First

This study reports on a housing program that merged two evidence-based practices frequently applied in tandem: Integrated Dual Diagnosis Treatment and Housing First. Quantitative measures show that consumers in the program were receptive to supportive housing and core services. These quantitative measures, when considered alongside qualitative interviews, suggest that in order for more consumers to move through the IDDT stages of educational and vocational advancement, the staff will need to emphasize the permanence of supportive housing. Thus, the study also demonstrates the importance of integrating results of qualitative evaluations with quantitative data to strengthen a program’s evidence base.     

Gender differences among clients of a case management program for the homeless.

Differences between 24 female and 35 male clients were assessed at entry into an intensive case management program serving homeless shelter residents and again nine months later. Both men and women were socially isolated, with small social networks and severe deficits in social functioning. Histories of homelessness were similar for both genders, and there were no gender differences in psychopathology at baseline or follow-up. At entry into the program women had higher levels of social skills, larger and more supportive networks, and better housing conditions than men, but these differences disappeared after the subjects spent nine months in the program. Inadequate living conditions may have contributed to the more negative initial picture for men. Although there were more similarities than differences between the men and women in this sample, more research on gender differences is needed to design and evaluate programs for homeless mentally ill persons.     

Using volunteer therapists to reduce hospital readmissions.

Two aftercare programs using volunteers as therapists for former inpatients have been effective in reducing hospital readmissions. The volunteer therapists ensure that patients take medications, evaluate them for decompensation, help them find housing and jobs, and give them supportive counseling. In the first program the recidivism rate after one year for 36 chronic schizophrenic women was 11 per cent for the group treated by volunteers and 34 per cent for the control group receiving traditional aftercare. In the second program the recidivism rate after one year for 11 men and women with various types of schizophrenia was 9 per cent for the treatment group and 37 per cent for the control group.     

Housing Model for Persons with Serious Mental Illness Moderates the Relation Between Loneliness and Quality of Life

This study compared levels of loneliness, quality of life (QOL) and social support among people with serious mental illness (SMI) living in two different types of housing: group homes and supportive community housing. Forty persons with SMI living in supportive community housing and 57 living in a group home completed measures of QOL, symptoms, perceived social support and loneliness. Analysis of variance tests were conducted to examine whether there were differences in degree of loneliness, QOL and social support between the groups living in the two residential types. No significant differences between the two housing models were found. Correlational analysis, however, indicated a strong relationship between loneliness and QOL. Subsequent regression analysis revealed that residence in group homes moderates the relationship between social loneliness and QOL, such that social loneliness impacted QOL only among group home residence. Implications of the findings for understanding the impact of housing on QOL are discussed.     

The ICCD benchmarks for clubhouses: a practical approach to quality improvement in psychiatric rehabilitation

OBJECTIVE: The study evaluated whether the average performance of clubhouses certified by the International Center for Clubhouse Development (ICCD) should be considered valid benchmarks for clubhouse programs. METHODS: A representative sample of clubhouses more than three years old that were based on the Fountain House model participated in a 1998 mail survey. To verify that ICCD certification is a valid indicator of program quality for use in setting benchmark performance rates, 71 certified and 48 noncertified programs were compared on a variety of organizational variables. RESULTS: Even though certified and noncertified clubhouses were similar in organizational structure and resources, findings from a logistic regression analysis confirmed that certified clubhouses provided a wider array of rehabilitation services and achieved higher rates of employment. CONCLUSIONS: The findings suggest that ICCD certification is a valid indicator of program quality. The ICCD has therefore proposed that the average performance of certified U.S. clubhouses in specific domains be adopted as benchmarks for organizational performance. When tailored for programs in particular regions and with specific levels of funding, the ICCD benchmarks for clubhouse performance set fair and reasonable expectations for clubhouse programs and for the design of performance contracts between departments of mental health and ICCD clubhouses.     

Negotiating the boundaries between clinical and non-clinical work within a supported housing program

Many contemporary mental health care programs rely on cross-agency models of service delivery. In these models, staff from different organizations provide care for the same clients, and this requires negotiation around role boundaries. In Australia, cross-agency programs have been developed to promote collaboration between government and not-for-profit community groups to meet the needs of those with serious mental health problems. Policy makers need to be aware of how staff in these roles conceptualize the boundaries and interconnection of their work with others to ensure that program goals are achieved. This study examined the division of labor that emerged between support workers (employed by the not-for-profit sector) and government health workers within a cross agency supported housing program for people with serious mental illness at risk of homelessness and self-neglect. Interviews were conducted with 40 government health workers and 37 staff from non-government agencies that shared clients in a supported housing program. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis. While the division between clinical and non-clinical work was accepted and co-produced, tensions arose in defining the boundaries between them. These tensions resulted from poor communication on the part of both groups, perceived lack of clinical intervention by case managers, high caseloads of case managers, role ambiguity, and support workers feeling their input and feedback were not valued by government health workers. Divisions of labor in cross-agency programs need to be critically evaluated to assess whether they serve program goals. Tensions are inevitable when dividing the tasks involved in care of a single client between different organizations. Co-location of multidisciplinary teams that include health professionals, support workers and peer workers may lead to more effective recovery oriented care. The findings have implications for the future development of recovery oriented mental health services.     

Sorting it out: Eliciting consumer priorities for recovery in supportive housing

This study aims to understand participant priorities in their personal recovery journey and their perspectives of recovery domains. A card-sort data-gathering technique was employed to elicit priorities in recovery from consumers in supportive housing programs serving adults who were formerly homeless with severe mental illnesses in New York City. Participants (N = 38) were asked to sort 12 cards printed with recovery domains in order of importance and describe the meaning attached to each domain. Mental health (95%), physical health (89%), and housing (92%) were the domains most frequently included and prioritized in the top three rankings. Family (76%) and partner (74%) were also frequently included and endorsed as most important second only to mental health. Housing was prioritized yet rated most important less often (58%). Work, school, hobbies, program, friends, and neighborhood were less frequently endorsed. “Card-sort talk” revealed critical understanding of participants’ priorities and their reasons for endorsing other domains less frequently. Most important to participants was regaining functional independence through improved mental and physical health and access to housing. With underlying principles of efficiency and empowerment, card sort is a promising engagement technique for providers to elicit consumer priorities in their own recovery.     

The interruption of bulimic behaviors. A review of three treatment programs

This article reviews three programs for treating bulimic behaviors. Although the structures of these programs differ considerably, all are geared to an outpatient approach and stress patient education, behavioral self-monitoring, and healthy eating behaviors. The programs described demonstrate a heavy reliance on behavioral treatments including cognitive restructuring, emphasis on individual patient responsibility for progress in treatment, and an expectation for success by supportive therapists and by patients.