The "high cost of low living": Substance use recovery among older formerly homeless adults.

BACKGROUND: The population of older homeless substance-using adults is growing considerably, and we sought to understand how such individuals gain control of problematic substance use amidst other life problems.Methods: Data were collected in an NIMH-funded study in which four in-depth interviews were conducted over 18 months with formerly homeless adults living in permanent supportive housing. The study subsample was comprised of 15 predominantly African American individuals over age 45 who were in recovery for at least six months. Cross-case analyses used a template approach followed by inductive sub-theme analyses.Results: Three themes drawn from the literature yielded seven sub-themes as follows. Theme #1: Acute life stressors: (a) "substance use as primary"; (b) "acute life events and substance use"; (c) "incarceration as turning point." Theme #2: Attributions of recovery: (a) "quitting as personal decision"; (b) "I just got to stay on top of it"; Theme #3: Social relationships: (a) "I have associates, not friends"; (b) "taking a cautious approach."Conclusion: Participants viewed substance use as the primary problem in their lives despite other adversity. Recovery was viewed as a personal decision, but maintaining recovery involved positive social relationships. Policies and practices related to recovery should address the complexities of lives-as-lived.

Understanding Health Talk in Behavioral Health Encounters: A Qualitative Analysis.

Although physical and behavioral health conditions commonly cooccur, best practices making behavioral health treatment responsive to clients' health needs are limited. Particularly little is known about how physical health is addressed by clinicians within routine therapeutic treatment. This study describes the frequency and type of health talk occurring within integrated behavioral health sessions, and explores how this talk functions within ongoing therapeutic work. Participants in this study included 51 dyads of clinical social workers (n = 13) and clients (n = 51) receiving therapy within an integrated community health and behavioral health center. Therapy sessions were recorded and transcribed verbatim. Content analysis determined the frequency and content of health talk in sessions. Thematic analysis was used to understand the function of health talk within these visits. Health talk occurred in 92% (n = 47) of sessions. Clients initiated the majority of discussions. Talk about sleep (40%, n = 19), diet/exercise (35%, n = 16), and chronic health conditions (28%, n = 13) were most common. Health talk either complimented or conflicted with therapeutic work, depending on the topic discussed and when it occurred during session. Health talk changed the scope of therapeutic work by integrating care coordination into routine practice. Health talk was pervasive and was frequently initiated by clients, signaling its relevance to clients' recovery. Providers leveraged heath talk to complement their therapeutic work, but these strategies were not universally applied. Care coordination activities were a part of routine therapy. Practice and policy changes that support a more interdisciplinary approach to clinical work are needed.

From the streets to a hotel: a qualitative study of the experiences of homeless persons in the pandemic era.

In the wake of COVID-19, programs for housing homeless individuals in hotels have emerged in the U.S., though research has yielded little information about the impact of these programs on participants expressed in their own words. In this qualitative study conducted in a major northeastern city, 13 previously street homeless individuals recount their experiences of hotel housing during the pandemic. Participants were recruited from an advocacy-initiated collaborative that operated with a housing first approach, providing private rooms without requirements or intrusive oversight typically found in shelter environments. Benefits of hotel housing reported include improvements in physical health, sleep, personal hygiene, privacy, safety, nutrition, and overall well-being. Inductive coding by consensus and thematic development yielded three themes. Participants described hotel living as (1) a platform for stability; (2) protection from COVID and other hazards; and (3) freeing mental space for future planning. As research shows hotel programs' success, an unprecedented opportunity has arisen from the pandemic to end homelessness for many. Given current federal budget increases, it is recommended that hotels become part of a larger effort to reduce shelter populations and increase access to independent housing.

Transitioning to independent living: Experiences of homeless young adults in rapid rehousing.

Rapid rehousing (RRH) is an intervention that is being adopted nationally to assist adolescents and emerging adults who are homeless. RRH provides short-term rental assistance for independent scattered-site housing, in addition to an array of support services for approximately 12-24 months. The aim of this study is to explore the experiences of young adults (18-23 years old) who had previously been homeless and who were enrolled in RRH programs set in two urban Northeastern cities, and their subsequent preparedness for independent living. Our sample mostly consisted of non-Hispanic Black females, many of whom identified as LGBTQ. Semi-structured interviews (n = 15) were conducted after participants had been in the program for nine months - three months prior to their initial program completion date. Thematic analysis revealed three themes: the importance of tangible support, communication among all parties: staff lead the way, and "I gotta start learning to do it on my own". These domains provided essential assistance for young people to attain their goals and through this process they learned skills to live independently and transition into adulthood. These findings suggest that rapid rehousing programs and service providers should focus on these domains to facilitate successful transition to independent living for this population.

Mental Health and Service Impacts During COVID-19 for Individuals with Serious Mental Illnesses Recently Released from Prison and Jail.

Individuals recently released from jail or prison with serious mental illnesses may be vulnerable to the coronavirus pandemic. This study aims to understand how they experienced the pandemic during initial stay-at-home orders in New York City. Structured surveys and in-depth semi-structured interviews examined the impact of the pandemic on participants. Survey responses are presented as percentages. Thematic analysis was used to code and analyze in-depth interviews. All participants (N = 5) knew about the coronavirus pandemic, and most took steps to minimize risk. Participants experienced changes to their services, including suspensions of some supportive services. They also reported an increase in psychiatric symptoms but utilized a variety of coping mechanisms in response. Community reintegration was essentially on hold as supportive services were suspended. Comprehensive reentry services may need to be adapted during the pandemic to address the multiple needs of individuals and to facilitate community reintegration.

Coping amidst an assemblage of disadvantage: A qualitative metasynthesis of first-person accounts of managing severe mental illness while homeless.

WHAT IS KNOWN ON THE SUBJECT?: Understanding what strategies individuals use to cope with serious mental illness is vital for enhancing their quality of life, mental well-being and recovery, and effective use of services; An episode of homelessness can be a profoundly disruptive event that often leads to chronic stress, social isolation, a negative belief about oneself and restricted access to care, among other adverse experiences; WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: In contrast to existing reviews of qualitative research focusing on escaping homelessness, managing problem substance use and growing resilience, the current review offers an in-depth, interpretive account of coping with serious mental illness during an episode of homelessness; This paper integrates evidence showing the diverse and intricate processes via which homelessness can impede an individual's ability to successfully cope with life stressors and with chronic mental illness; Despite experiencing severe social disadvantage, many individuals demonstrate positive adaptation and coping, and even personal growth; WHAT ARE THE IMPLICATIONS FOR PRACTICE?: It is important to be aware of the many ways in which coping with serious mental illness can be influenced by adverse environmental factors such as poverty, homelessness, traumatic life experiences and institutional discrimination; Nursing practice should recognize that coping efforts by individuals facing multiple forms of social disadvantage may be shaped by acute adverse life events and institutional interactions, as well as by the stresses and strains of living on the streets; Nursing practice should focus not only on reducing clients' mental illness symptoms and facilitating positive coping behaviours, but also on helping create the conditions that aid clients in leveraging inner resources for personal growth and constructive meaning-making. Abstract Introduction An evidence gap persists concerning the impact of extreme socio-structural disadvantage, such as homelessness, on the nature and effectiveness of coping with severe mental illness (SMI). While existing reviews of qualitative research into homelessness have focused on processes such as escaping homelessness and managing concurrent problem substance use, as well as on the experiences of specific vulnerable groups such as women and youth, no analogical review has been dedicated to understanding the management of SMI during an episode of homelessness. Aim/Question A qualitative metasynthesis of first-person accounts was conducted to understand how individuals cope with SMI when experiencing homelessness. Method The systematic search strategy yielded 481 potentially eligible sources. Following the team-based full-text screening and the two-tiered quality appraisal, 14 studies involving 377 participants with lived experience were synthesized following Noblit and Hare's metaethnographic method. Results Seven third-order concepts were derived capturing the complex nature and processual character of coping, as well as the web of contextual influences upon coping strategies. The resultant line-of-argument synthesis reveals the dialectical relationship between the two higher-order constructs-"the continuum of coping" and "the assemblage of disadvantage." Discussion Despite the profoundly adverse impacts of biographical and socio-structural conditions, many individuals mobilized internal and external resources to enable various coping processes. Coping in the context of multiple disadvantage is not a monolith but rather a multidimensional, contingent and fluid phenomenon. Implications for practice Nursing practice should espouse a humanizing, structurally competent, and strength- and meaning-oriented approach in order to meet the complex and multifaceted needs of such multiply disadvantaged persons.

Correction to: Transitioning to Person-Centered Care: a Qualitative Study of Provider Perspectives.

The original article misspelled the name of Lauren Jessell. The original article has been corrected.

Eliciting Life Priorities of Older Adults Living in Permanent Supportive Housing.

BACKGROUND AND OBJECTIVES: Adults who have experienced chronic homelessness are considered to be "old" by age 50 due to accelerated aging. While permanent supportive housing (PSH) has been found effective for these individuals, there is limited focus on the needs of adults "aging in place" in PSH. This study examined (1) how older adults in PSH identify and rank their life priorities, (2) how they describe these priorities in their own words, and (3) how life course adversity deepens an understanding of these priorities. RESEARCH DESIGN AND METHODS: A convergent parallel mixed methods design was used in which qualitative case study analyses informed by a life course perspective provided a deeper understanding of how 14 older residents of PSH viewed their life priorities using quantitative card-sort rankings of 12 life domains. RESULTS: Housing, family, mental health, physical health, and partner were the most frequently endorsed life priorities. Four themes emerged from the cross-case analyses: "aging in, aging out," "carefully restoring relationships," "life goes on," and "housing is fundamental." Convergent findings indicated that life adversity-social losses and interrupted lives-influenced both the high- and low-ranked card-sort priorities. DISCUSSION AND IMPLICATIONS: This study demonstrated that participants were aware of their advancing years yet they sought to overcome adversity and losses through maintaining mental health and sobriety, improving physical health, and cautiously rebuilding relationships. As the numbers of older homeless rise, the inclusion of age-related services will be an important component of PSH services for residents as they age.

"If you're gonna help me, help me": Barriers to housing among unsheltered homeless adults.

Despite a legally-mandated right to shelter and extensive outreach efforts, an estimated 3,675 homeless individuals were living on the streets of New York City in 2018. Through interviews with 43 unsheltered homeless individuals in the borough of Manhattan (age range 21-74 years), this qualitative study examined barriers they face in accessing housing and other services as well as experiences surviving on the street. Through thematic analysis of the interview data, the most common barriers found were obtaining required identification documents, lack of accessibility of shelters amid complex healthcare needs, waiting as part of the process, and exclusion of pets from shelters and housing options. Themes capturing survival on the street included sleeping safe, avoiding shelters, and meeting daily needs. Virtually all barriers street homeless New Yorkers face stem from bureaucratic policies that, however well-intentioned, do not address their diverse needs. Thus, long delays and poor communication, combined with crowded, unsafe shelters, lead to frustration and alienation. While homelessness is ultimately the result of a severe and chronic shortage of affordable housing, creating accessible, safe, pet-friendly shelter and safe haven options and instituting a smoother, more transparent process for moving from the streets could substantially reduce street homelessness.