Outcomes of Supported Housing for Homeless Veterans with Psychiatric and Substance Abuse Problems

This study examines the effect of previous participation in time limited residential treatment and other factors on treatment outcomes among homeless veterans with serious mental illness placed into permanent supported housing. The sample consisted of 655 veterans placed into supported housing at 18 sites through the VA's Healthcare for Homeless Veterans (HCHV) Supported Housing Program during the period 1993-2000. Data on client and program characteristics, and treatment outcomes, were documented by HCHV case managers staffing these programs. Data on use of VA services, including time limited residential treatment received 6 months prior to entry into supported housing, were extracted from VA administrative files. The relationship of prior residential treatment, as well as other measures of client characteristics, service use, and program characteristics, to outcomes were assessed using both bivariate and multivariate Cox proportional hazards regression and logistic regression. After adjusting for client characteristics, service use, and program characteristics, no differences in outcomes were found between clients who had received prior residential treatment and those placed directly into permanent supported housing. Prior residential treatment appears to have little effect on treatment outcomes among formerly homeless veterans placed into permanent supported housing programs providing indirect support for the direct placement supported housing model.     

Racial Differences Among Supported Housing Clients in Outcomes and Therapeutic Relationships

This study examined racial differences between African American and White supported housing clients in clinical outcomes and in their relationships with their landlords, medical and mental health care providers, and religious faith. Housing, mental health, and substance abuse outcomes of 204 White clients and 269 Black clients participating in a national homeless initiative were examined, along with their ratings of their relationships with landlords, health care providers, and religious participation. There were no significant racial differences found on outcomes or on client ratings of the helpfulness of relationships with landlords and health care providers. However, Black participants reported significantly stronger religious faith and religious participation than White participants. Together, these results suggest the religious faith of Black clients should be appreciated as a potential asset in supported housing services and that efforts to maintain racial equality should be continued in the delivery of health services.     

Indications of Reduced Prefrontal Cortical Function in Chronically Homeless Adults

This study investigated why some homeless individuals seem unable to transition towards self-reliance, following traditional supportive services. It was hypothesized that this may be due to some cognitive dysfunction. Chronically homeless adults were compared to controls on three tests of prefrontal competency: the Iowa Gambling Task, Word Fluency (FAS), and the Burglar’s Story; they performed significantly worse than controls on all three tests. These results indicate a relationship between chronic homelessness and possible pre-frontal deficits. This may explain why some long-term homeless fail to learn from the consequences of unproductive behavior and to develop more constructive behaviors needed to attain stability.     

Client-level Measures of Services Integration Among Chronically Homeless Adults

Introduction  While several major studies have examined services integration at the system or interagency level, there has been far less effort to measure the integration of services at the client-level and its correlates. Methods  This study presents three client-level measures of services integration, two objective measures, representing the proportion of needed services received and the number of outpatient services received by each client, and one subjective measure, a five-item scale measuring perceived coordination of care among clients’ service providers. Data from the evaluation of the collaborative initiative to help end chronic homelessness (CICH) are used to examine bivariate and multivariate relationships of these three client-level measures to two system-level measures of services integration, one addressing interagency services coordination/planning and the other interagency trust/respect as well as to baseline client characteristics among 734 chronically homeless adults in 11 cities. Results  Client-level measures of service integration were not strongly associated to each other or to the system-level measures, except for weak associations (r = 0.10) between one objective client measure and the system-level measure of service coordination and planning, and another between client-level use of outpatient mental health services and system-level trust and respect. Multivariate analysis showed that clients who received a greater array of needed services received more service overall and were more likely to have a diagnosis of PTSD and more medical problems, but less serious alcohol problems. Clients who reported more outpatient mental health and substance abuse visits were significantly more likely to be married, to be veterans, to have more serious drug problems, and to be dually diagnosed. Clients with more serious drug problems reported poorer coordination among their service providers on the subjective measure of client-level service integration. Conclusion  Three client-level measures of services integration were, at best, weakly associated with measures of system-level integration. Positive associations between client-level measures of integration and health status, outpatient service use and negative relationships with indicators of substance abuse suggest they may usefully represent the experiences of chronically homeless clients, even though they are not strongly related to system-level measures.     

Association of Therapeutic Alliance with Outcomes Over Two Years in Youth and Family Service

This study examines therapeutic alliance (TA) over 2 years and the association with clinical outcomes for children and youth in a home and school-based behavioral health service characterized by innovative TA practices. Caregiver report of TA and functioning were collected monthly and discussed to inform service planning. Trajectory analysis was conducted to discern distinct patterns of TA ratings over time with linear mixed models to examine factors associated with the resulting TA patterns. We identified 1714 Medicaid-eligible youth and families. The majority of families (84%) reported high and steady ratings of TA, 5% reported lower but improving TA ratings, and 11% reported declining TA ratings over time. Average TA rating was associated with family and child functioning, yet all TA groups experienced improved functioning over time. Measurement of TA over time may help clinicians target and improve care for children and families.     

Therapeutic Alliance Formation for Adolescents and Young Adults with Autism: Relation to Treatment Outcomes and Client Characteristics

Journal of Autism and Developmental Disorders - Therapeutic alliance may influence treatment outcomes for individuals with autism spectrum disorder (ASD). The present study examined the trajectory...     

A Comparison of Treatment Outcomes Among Chronically Homelessness Adults Receiving Comprehensive Housing and Health Care Services Versus Usual Local Care

Service use and 2-year treatment outcomes were compared between chronically homelessness clients receiving comprehensive housing and healthcare services through the federal Collaborative Initiative on Chronic Homelessness (CICH) program (n = 281) a sample of similarly chronically homeless individuals receiving usual care (n = 104) in the same 5 communities. CICH clients were housed an average of 23 of 90 days (52%) more than comparison group subjects averaging over all assessments over a 2-year follow-up period. CICH clients were significantly more likely to report having a usual mental health/substance abuse treater (55% vs. 23%) or a primary case manager (26% vs. 9%) and to receive community case management visits (64% vs. 14%). They reported receiving more outpatient visits for medical (2.3 vs. 1.7), mental health (2.8 vs. 1.0), substance abuse treatment (6.4 vs. 3.6), and all healthcare services (11.6 vs. 6.1) than comparison subjects. Total quarterly healthcare costs were significantly higher for CICH clients than comparison subjects (4,544 vs.4,544 vs. 3,326) due to increased use of outpatient mental health and substance abuse services. Although CICH clients were also more likely to receive public assistance income (80% vs. 75%), and to have a mental health/substance provider at all, they expressed slightly less satisfaction with their primary mental health/substance abuse provider (satisfaction score of 5.0 vs. 5.4). No significant differences were found between the groups on measures of substance use, community adjustment, or health status. These findings suggest that access to a well funded, comprehensive array of permanent housing, intensive case management, and healthcare services is associated with improved housing outcomes, but not substance use, health status or community adjustment outcomes, among chronically homeless adults.     

Outcomes from a Therapeutic Community for Homeless Addicted Mothers and Their Children

A women's therapeutic community (TC) designed to prevent homelessness was evaluated using a quasi-experimental process. Propensity analysis selected comparable experimental (E) and comparison (C) participants. Significant improvements were found for the E group at the domain level, both in "psychological" dysfunction on symptoms (e.g., depression), and in "health," including ratings of health and adherence to medication regimens. No significant difference was found at the domain level for "parenting" or "housing stabilization," but specific outcomes did differ. For example, a greater number of children resided with the E group mothers who also assumed financial responsibility for more of their children.     

Incarceration Histories of Homeless Veterans and Progression Through a National Supported Housing Program

There is increasing concern that adults with a past history of incarceration are at particular disadvantage in exiting homelessness. Supported housing with case management has emerged as the leading service model for assisting homeless adults; however there has been limited examination of the success of adults with past history of incarceration in obtaining housing within this paradigm. Data were examined on 14,557 veterans who entered a national supported housing program for homeless veterans, the Housing and Urban Development-Veterans Affairs Supportive Housing program (HUD-VASH) during 2008 and 2009, to identify characteristics associated with a history of incarceration and to evaluate whether those with a history of incarceration are less likely to obtain housing and/or more likely to experience delays in the housing attainment process. Veterans who reported no past incarceration were compared with veterans with short incarceration histories (≤1 year) and those with long incarceration histories (>1 year). A majority of participants reported history of incarceration; 43 % reported short incarceration histories and 22 % reported long incarceration histories. After adjusting for baseline characteristics and site, history of incarceration did not appear to impede therapeutic alliance, progression through the housing process or obtaining housing. Within a national supported housing program, veterans with a history of incarceration were just as successful at obtaining housing in similar time frames when compared to veterans without any past incarceration. Supported housing programs, like HUD-VASH, appear to be able to overcome impediments faced by formerly incarcerated homeless veterans and therefore should be considered a a good model for housing assistance programs.     

Impact of Community-Based Programs on Incarceration Outcomes Among Gay and Bisexual Stimulant-Using Homeless Adults

This study was part of a randomized controlled trial designed to improve hepatitis knowledge and health promoting behaviors and subsequently decrease stimulant use and incarceration with 422 (G/B) homeless men between 18 and 46 years of age. Findings revealed that no significant program differences on incarceration in the 4 months following the intervention. However, younger participants (p = .010), and those with prior incarceration (p = .001) were at greater risk for incarceration at 4 months. An additional factor associated with incarceration at 4 months included living on the street for at least 1 week (p = .049).     

The Impact of Criminal Justice Involvement and Housing Outcomes Among Homeless Persons with Co-occurring Disorders

The relationship between criminal justice involvement and housing among homeless persons with co-occurring disorders was examined. Program participants assisted in moving to stable housing were interviewed at baseline, six months, and discharge. Those who remained homeless at follow-up and discharge had significantly more time in jail in the past month than those who were housed. However, criminal justice involvement was not significantly related to housing status at the six month follow-up or discharge. Findings suggest that housing people with complex behavioral health issues reduces the likelihood of further criminal justice involvement.     

Predictive Association of Low- and High-Fidelity Supported Employment Programs with Multiple Outcomes in a Real-World Setting: A Prospective Longitudinal Multi-site Study

Purpose

The individual placement and support (IPS) model of supported employment is a leading evidence-based practice in community mental health services. In Japan, individualized supported employment that is highly informed by the philosophy of the IPS model has been implemented. While there is a body of evidence demonstrating the association between program fidelity and the proportion of participants gaining competitive employment, the association between fidelity and a wider set of vocational and individual outcomes has received limited investigation. This study aimed to assess whether high-fidelity individualized supported employment programs were superior to low-fidelity programs in terms of vocational outcomes, preferred job acquisition, and patient-reported outcome measures (PROMs).

Methods

A prospective longitudinal study with 24-month follow-up analyzed 16 individualized supported employment programs. The Japanese version of the individualized Supported Employment Fidelity scale (JiSEF) was used to assess the structural quality of supported employment programs (scores: low-fidelity program,?≤?90; high-fidelity program,?≥?91). Job acquisition, work tenure, work earnings, job preference matching (e.g., occupation type, salary, and illness disclosure), and PROMs such as the INSPIRE and WHO-Five Well-being index were compared between groups.

Results

There were 75 and 127 participants in the low-fidelity group (k?=?6) and high-fidelity group (k?=?10), respectively. The high-fidelity group demonstrated better vocational outcomes than the low-fidelity group, i.e., higher competitive job acquisition (71.7% versus 38.7%, respectively, adjusted odds ratio (aOR)?=?3.6, p?=?0.002), longer work tenure (adjusted mean difference?=?140.8, p?<?0.001), and better match for illness disclosure preference (92.6% versus 68.0%, respectively, aOR?=?5.9, p?=?0.003). However, we found no differences between groups in other preference matches or PROM outcomes.

Conclusion

High-fidelity individualized supported employment programs resulted in good vocational outcomes in a real-world setting. However, enhancing service quality to increase desired job acquisition and improve PROMs will be important in the future.

Clinical Trial Registration

UMIN000025648

     

Disability Benefits and Clinical Outcomes among Homeless Veterans with Psychiatric and Substance Abuse Problems

This study examined the relationship between disability payment status and clinical outcomes among 305 homeless veterans entering VA treatment. Disability status and clinical outcomes were characterized using self-report data at program entry, and quarterly for 2 years thereafter. Seeking or already receiving disability benefits at program entry was not associated with any of the 8 clinical outcomes examined. Those seeking or receiving disability benefits during the 2 years that followed showed more serious mental health problems and lower levels of mental health functioning, but no greater risk of substance use or not being employed nor worse housing outcomes than those who remained uninterested in applying for disability benefits. This study does not, therefore, support the notion that disability orientation results in poorer clinical outcomes, at least not among homeless veterans. Alvin S. Mares and Robert A. Rosenheck are affiliated with the Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, CT, and the Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.     

The Helping Alliance in Case Management for Homeless Persons with Severe Mental Illness

This study examined the role of the helpingalliance in case management with homeless persons whohave a severe mental illness. A strong alliance aftertwo months of treatment was marginally associated with three outcomes: higher consumersatisfaction, less severe global symptom severity, andgreater hostility. The only outcome associated with thealliance after fourteen months of treatment was consumer satisfaction. Several variables predicted astrong helping alliance at month two, including: beingAfrican American, low hostility, more perceived needs,and more program contacts. The only variable that predicted a strong alliance at month fourteenwas a strong alliance at month two.     

Research on Therapeutic Impasses and Ruptures in the Therapeutic Alliance

In this article, we provide an overview of our research program on therapeutic impasses and alliance ruptures. Beginning in the mid-1980s at the University of Toronto, and continuing in New York at Beth Israel Medical Center since the early 1990s, we have focused our efforts on trying to illuminate the processes associated with resolving ruptures in the alliance and working through therapeutic impasses. Influenced both by the relational turn in psychoanalysis and findings emerging from our own research on the process of change, we have developed and evaluated an approach to short-term treatment that appears promising. We are also developing and evaluating the effectiveness of training methods for enhancing therapists’ capacities to work constructively with negative therapeutic process, regardless of the particular “brand” of treatment they are practicing. Finally, we summarize some preliminary findings regarding the impact of therapists’ capacity for mentalization on both treatment process and outcome.     

Association and Clinical Outcomes of Marijuana in Patients with Intracerebral Hemorrhage

Objective

An epidemiological relationship between intracerebral hemorrhage (ICH) and marijuana use is not known. Data about the impact of marijuana on ICH patient's outcomes remain scarce.

Longitudinal Outcomes for Victims of Child Abuse

Studies on natural long-term course of borderline personality disorder (BPD) as well as on treatment outcome suggest that social integration remains seriously unsatisfactory in the majority of the subjects concerned. Identification of typical borderline problems in social interaction should facilitate both, treatment development and elucidation of the related neuropsychological mechanisms and underpinnings. This review focusses on the experimental investigation of three core domains of social interaction: social affiliation, cooperation and hostility. Data converge, that patients meeting criteria for BPD show a tendency to misinterpret neutral situations, feel socially rejected during normative inclusion conditions and reveal difficulties in repairing cooperation after experiencing disappointment. While from a clinical perspective, most attention has been focused on relationships of BPD patients with their significant others, the literature suggests that encounters with unknown individuals also indicate impairments in interaction behavior, and that such impairments can be linked to altered cerebral processing. Considering these findings psychosocial treatments should extend the programs and develop trainings in normative behavior.