Programmatic and Organizational Barriers and Facilitators to Addressing High-Risk Issues in Supportive Housing and Housing First Programs.

Risk management is an important component of service delivery in supportive housing and Housing First programs. However, there is no evidence on the implementation of risk management approaches in these settings. This qualitative study examined what service providers working in supportive housing and Housing First programs in Canada identify as the programmatic and organizational factors that affect the prevention and management of high-risk behaviours and challenges (e.g., overdose, suicide attempts, non-suicidal self-injury, falls and fall-related injuries, fire-setting, hoarding, apartment takeovers, violence, property damage, drug selling) in their programs. In-depth interviews were completed with a purposive sample of 32 service providers. Data were analyzed using an integrative approach that incorporated techniques from qualitative description and thematic analysis. Four thematic factors, which were comprised of various barriers and facilitators, that affected management of high-risk issues in supportive housing and Housing First programs were identified: [1] flexibility in addressing risk issues; [2] early identification of risk issues; [3] built environment and housing location; and [4] resource availability. Overall, the findings underscore how service providers aim to identify high-risk issues promptly, beginning as early as referral, and that their capacity to effectively do this and intervene accordingly is dynamically shaped by various aspects of the program model, environment, and availability of internal and external resources. Yet, the findings also highlight how risk management approaches may conflict with other programmatic goals and values, and the importance of considering these collectively. Systems-level changes to strengthen programs' capacity to prevent risk and implications for future research are discussed.

Managing high-risk behaviours and challenges to prevent housing loss in permanent supportive housing: a rapid review.

Permanent supportive housing is an effective intervention for stably housing most people experiencing homelessness and mental illness who have complex support needs. However, high-risk behaviours and challenges are prevalent among this population and have the potential to seriously harm health and threaten housing tenures. Yet, the research on the relationship between high-risk issues and housing stability in permanent supportive housing has not been previously synthesized. This rapid review aimed to identify the housing-related outcomes of high-risk behaviours and challenges in permanent supportive housing settings, as well as the approaches used by agencies and residents to address them. A range of high-risk behaviours and challenges were examined, including risks to self (overdose, suicide/suicide attempts, non-suicidal self-injury, falls/fall-related injuries), and risks to multiple parties and/or building (fire-setting/arson, hoarding, apartment takeovers, physical/sexual violence, property damage, drug selling, sex trafficking). The search strategy included four components to identify relevant academic and grey literature: (1) searches of MEDLINE, APA PsycINFO, and CINAHL Plus; (2) hand searches of three journals with aims specific to housing and homelessness; (3) website browsing/searching of seven homelessness, supportive housing, and mental health agencies and networks; and (4) Advanced Google searches. A total of 32 articles were eligible and included in the review. Six studies examined the impacts of high-risk behaviours and challenges on housing tenancies, with overdose being identified as a notable cause of death. Twenty-six studies examined approaches and barriers to managing high-risk behaviours and challenges in PSH programs. These were categorized into eight types of approaches: (1) clinical, (2) relational/educational, (3) surveillant, (4) restrictive, (5) strategic, (6) design-based, (7) legal, and (8) self-defence. Consistent across all approaches was a lack of rigorous examination of their effectiveness. Further, some approaches that are legal, restrictive, surveillant, or strategic in nature may be used to promote safety, but may conflict with other program objectives, including housing stability, or resident empowerment and choice. Research priorities were identified to address the key evidence gaps and move toward best practices for preventing and managing high-risk behaviours and challenges in permanent supportive housing.

Cycles of instability: Proximal and distal influences on residential instability among people with histories of homelessness in three Canadian cities.

People with histories of homelessness often have difficulties obtaining and maintaining adequate housing. This qualitative study examined the residential transitions of people with histories of residential instability and homelessness to understand factors contributing to the instability they experience. Interviews were conducted with 64 participants about their housing transitions, in the final year of a 4-year, prospective cohort study in three Canadian cities (Ottawa, Toronto, and Vancouver). Findings showed that participants pointed to both distal and proximal factors as affecting residential transitions, including interpersonal conflict, safety concerns, substance use, poverty, pests, and health. Many reported disconnection from their housing and a lack of improvement from one housing situation to the next, demonstrating how even when housed, instability persisted. Our study highlights the complexity associated with participants' often unplanned and abrupt residential transitions. The complex and distal issues that affect housing transitions require structural changes, in addition to individual-based interventions focused on the proximal problems.

Finding home: Community integration experiences of formerly homeless women with problematic substance use in Housing First.

AIMS: This study explored community integration among women participating in a Housing First program. Physical, social, and psychological dimensions of community integration were examined. METHODS: This study used neighborhood walk-along and photo-elicitation interviews to explore 16 formerly homeless women's experiences of community integration. RESULTS: Participants described limited community integration. Health, poverty, service inaccessibility, and safety concerns shaped how they took part in activities in their neighborhoods. Participants primarily socialized with people in their buildings, though some preferred to keep to themselves. There was minimal sense of neighborhood belonging, with participants not interested in belonging to a community and being judged by others. CONCLUSION: Housing First promoted housing stability but did not contribute to community integration. Participants did not express a strong desire to integrate in their communities. Future research should consider the extent to which community integration remains a priority for marginalized populations, such as formerly homeless women.

Perceptions of Service Use Among Currently and Formerly Homeless Adults with Mental Health Problems.

This qualitative study used in-depth interviews to examine the service experiences of 52 currently and formerly homeless people with mental health problems. Thematic analysis identified five themes associated with positive and negative service experiences: (1) accessibility of services, (2) humanity in approach to care, (3) perceptions and relationships with other service users, (4) physical space and environment, and (5) outcomes of service use. Overall, minimal differences were found between currently and formerly homeless people with mental health problems, suggesting that both groups have the same wants and needs related to service use, including to be treated fairly and without judgment, receive needed support and assistance, and feel good following their service experience. However, both groups also described encountering barriers to accessing programs and navigating service systems; using services where they felt judged, unsafe, or uncared for; and having unmet needs following service use.

Predictors of Mental Health Recovery in Homeless Adults with Mental Illness.

For people with mental illness, experiences of homelessness can complicate mental health recovery processes. This study used longitudinal data from a randomized controlled trial of housing first (HF) to examine predictors of recovery among homeless people with mental illness. Findings showed that health and community predictors were most strongly associated with mental health recovery. Receipt of HF did not have any effect on changes in recovery scores at follow-up. Overall, the findings suggest that interventions aimed at preventing chronic homelessness, strengthening social networks and community involvement, and providing case management services will facilitate mental health recovery.

The effects of housing stability on service use among homeless adults with mental illness in a randomized controlled trial of housing first.

BACKGROUND: Housing First is an effective intervention to stably house and alter service use patterns in a large proportion of homeless people with mental illness. However, it is unknown whether there are differences in the patterns of service use over time among those who do or do not become stably housed and what effect, if any, Housing First has on these differing service use patterns. This study explored changes in the service use of people with mental illness who received Housing First compared to standard care, and how patterns of use differed among people who did and did not become stably housed. METHODS: The study design was a multi-site randomized controlled trial of Housing First, a supported housing intervention. 2039 participants (Housing First: n = 1131; standard care: n = 908) were included in this study. Outcome variables include nine types of self-reported service use over 24 months. Linear mixed models examined what effects the intervention and housing stability had on service use. RESULTS: Participants who achieved housing stability, across the two groups, had decreased use of inpatient psychiatric hospitals and increased use of food banks. Within the Housing First group, unstably housed participants spent more time in prison over the study period. The Housing First and standard care groups both had decreased use of emergency departments and homeless shelters. CONCLUSIONS: The temporal service use changes that occurred as homeless people with mental illness became stably housed are similar for those receiving Housing First or standard care, with the exception of time in prison. Service use patterns, particularly with regard to psychiatric hospitalizations and time in prison, may signify persons who are at-risk of recurrent homelessness. Housing support teams should be alert to the impacts of stay-based services, such as hospitalizations and incarcerations, on housing stability and offer an increased level of support to tenants during critical periods, such as discharges. TRIAL REGISTRATION: ISRCTN. ISRCTN42520374 . Registered 18 August 2009.

Community Psychology and Community Mental Health: A Call for Reengagement.

Community psychology is rooted in community mental health research and practice and has made important contributions to this field. Yet, in the decades since its inception, community psychology has reduced its focus on promoting mental health, well-being, and liberation of individuals with serious mental illnesses. This special issue endeavors to highlight current efforts in community mental health from our field and related disciplines and point to future directions for reengagement in this area. The issue includes 12 articles authored by diverse stakeholder groups. Following a review of the state of community mental health scholarship in the field's two primary journals since 1973, the remaining articles center on four thematic areas: (a) the community experience of individuals with serious mental illness; (b) the utility of a participatory and cross-cultural lens in our engagement with community mental health; (c) Housing First implementation, evaluation, and dissemination; and (d) emerging or under-examined topics. In reflection, we conclude with a series of challenges for community psychologists involved in future, transformative, movements in community mental health.

Poverty and Serious Mental Illness: Toward Action on a Seemingly Intractable Problem.

This paper examines the issue of poverty among people with serious mental illness (SMI), positioning it as a key issue to be confronted by community mental health systems and practitioners. The paper reviews three perspectives on poverty, considering how each sheds light on poverty among people with SMI, and their implications for action: (a) monetary resources, (b) basic needs, and (c) capabilities. The paper argues that community mental health programs and systems are currently unable to address poverty as they are overly focused on individual-level interventions that, on their own, cannot raise people out of poverty. The paper calls for a social justice value, informed by the concept of citizenship, as a necessary complement to the recovery concept that has informed community mental health practice for almost 25 years. Finally, the paper argues that community psychologists, with their concepts, methods, and values, are well positioned to contribute to this important issue. However, it also contends that addressing poverty requires collaboration from community psychologists with researchers and practitioners from other fields and domains of expertise to begin to make progress.

Perceptions of Housing and Shelter among People with Histories of Unstable Housing in three Cities in Canada: A Qualitative Study.

Housing is a key social determinant of health that contributes to the well-documented relationship between socioeconomic status and health. This study explored how individuals with histories of unstable and precarious housing perceive their housing or shelter situations, and the impact of these settings on their health and well-being. Participants were recruited from the Health and Housing in Transition study (HHiT), a longitudinal, multi-city study that tracked the health and housing status of people with unstable housing histories over a 5-year period. For the current study, one-time semi-structured interviews were conducted with a subset of HHiT study participants (n = 64), living in three cities across Canada: Ottawa, Toronto, and Vancouver. The findings from an analysis of the interview transcripts suggested that for many individuals changes in housing status are not associated with significant changes in health due to the poor quality and precarious nature of the housing that was obtained. Whether housed or living in shelters, participants continued to face barriers of poverty, social marginalization, inadequate and unaffordable housing, violence, and lack of access to services to meet their personal needs.

Housing First for Adults with Problematic Substance Use.

OBJECTIVES: This study explores the two-year housing- and non-housing-related outcomes for adults who are homeless with problematic substance use who received scattered-site housing and intensive case management services from a Housing First program in Ottawa, Canada, in comparison with a group of adults who are homeless with problematic substance use who had access to standard care in the community. METHODS: Housing First clients (n = 89) and members of a comparison group (n = 89) completed structured interviews at baseline and were followed for two years. RESULTS: Housing First clients moved into housing more quickly, reported a greater proportion of time housed, were more likely to spend the final six months housed, and had longer housing tenure at 24 months. There was a group by time interaction on problematic alcohol use with more rapid improvement for the comparison group; however, both groups improved over time. The comparison group had a greater decrease on problematic drug use by 24 months. There was no change in physical health and only the comparison group had improvements in mental health by 24 months. The groups had similar improvement on community functioning by 24 months. The comparison group had a greater increase in total quality of life. More specifically, the comparison group had an increase in the family relations-related quality of life, whereas the clients did not. There was a significant interaction for safety-related quality of life, but both groups experienced improvements over time and had comparable levels of satisfaction with safety at each time point. The Housing First clients reported higher levels of satisfaction with living conditions than the comparison group at baseline and 12 months, but not at 24 months. There was significant improvement over time and no main effect of group for finances, leisure, and social relations. CONCLUSIONS: Adults who are homeless with problematic substance use can successfully be housed using a Housing First approach. However, further targeted services might be required to address other areas of functioning, such as health, substance use, and quality of life.

Perceptions of private market landlords who rent to tenants of a Housing First program.

The rental of housing units by landlords to participants in Housing First (HF) programs is critical to the success of these programs. Therefore, it is important to understand the experiences of landlords with having these individuals as tenants. The paper presents findings of qualitative interviews with 23 landlords who rented to tenants from a HF program located in a small city and adjoining rural area in eastern Canada and in which approximately 75 % of tenants had been housed for at least six consecutive months at 2 years in the program. Findings showed that landlords are motivated to rent to HF tenants for financial and pro-social reasons. They reported holding a range of positive, neutral, and negative perceptions of these tenants. They identified problems encountered with some HF tenants that included disruptive visitors, conflict with other tenants, constant presence in their apartments, and poor upkeep of units. On the other hand, landlords perceived HF tenants as being mostly good tenants who are similar to their other tenants. Implications for practice in the context of HF programs are discussed.

"I want purpose in my life": A qualitative exploration of how homeless youth envision their futures.

Preparing for the future is a major developmental task during adolescence and early adulthood. However, youth experiencing homelessness face additional challenges relating to economic instability, housing insecurity, and a lack of social support. Semi-structured interviews were conducted with 38 youth, from Ottawa and Toronto, who were experiencing homelessness and participating in a randomized controlled trial of Housing First for Youth (HF4Y). This qualitative study explores youths' visions for the future, including their goals, aspirations, plans, and barriers to achieving them. Overall, findings demonstrated that youth had positive visions of the future and strove to reach developmentally appropriate goals and responsibilities. Compared to youth receiving HF4Y, the future expectations of those receiving treatment as usual (TAU) were characterized by uncertainty and lacked clear direction. Additionally, they emphasized self-reliance and autonomy, while HF4Y prioritized forming relationships and reconnection. Findings highlight the importance of stable housing intervention, and social, community, and financial support in planning for the future and transitioning out of homelessness. Implications for intervention, directions for future research, and limitations are provided.

Community Mental Health Services for Frequent Emergency Department Users: A Qualitative Study of Outcomes Perceived by Program Clients and Case Managers.

PURPOSE OF STUDY: This study aimed to investigate the perceived outcomes and mechanisms of change of a community mental health service combining system navigation and intensive case management supports for frequent emergency department users presenting with mental illness or addiction. PRIMARY PRACTICE SETTING: The study setting was a community mental health agency receiving automated referrals directly from hospitals in a midsize Canadian city for all individuals attending an emergency department two or more times within 30 days for mental illness or addiction. METHODOLOGY AND SAMPLE: Qualitative interviews with 15 program clients. Focus groups with six program case managers. Data were analyzed using pragmatic qualitative thematic analysis. RESULTS: Participants generally reported perceiving that the program contributed to reduced emergency department use, reduced mental illness symptom severity, and improved quality of life. Perceived outcomes were more mixed for outcomes related to addiction. Reported mechanisms of change emphasized the importance of positive working relationships between program clients and case managers, as well as focused efforts to develop practical skills. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Community mental health services including intensive case management for frequent emergency department users presenting with mental illness or addiction were perceived to effectively address client needs while reducing emergency department resource burden. Similar programs should emphasize the development of consistent and warm working relationships between program clients and case managers, as well as practical skills development to support client health and well-being.

Experiences of LGBTQ Adults Who Have Accessed Emergency Shelters in a Large Urban City in Canada.

This study examines the experiences of adults who identify as LGBTQ (lesbian, gay, bisexual, transgender, queer) and who have accessed emergency shelters in an urban Canadian city. Twenty LGBTQ adults who were currently or formerly homeless participated in one qualitative interview. The interview protocol included questions on the participants' experiences accessing emergency shelters, with a focus on interactions with other emergency shelter residents. Data was analyzed using an iterative coding process. The results demonstrated that participants engage in various identity management strategies and encounter both positive and negative interactions with other emergency shelter residents. The results are discussed in terms of strategies to improve emergency shelter policies to be more inclusive of LGBTQ adults.

Sexual and romantic relationships among people experiencing homelessness: A scoping review.

Homelessness is widely recognized as a pervasive issue. Despite increasing research on factors affecting the health and well-being of people who are homeless, one that remains relatively understudied is the role of romantic and sexual relationships. Given that this population has the same needs for intimacy and closeness as anyone else, it is important to understand how these relationships occur, what barriers exist in developing and maintaining them, and what is their impact. This scoping review aimed to (a) characterize the nature of research that has examined sexual and romantic relationships among people who are homeless and (b) identify and synthesize the findings of studies that examined romantic and sexual relationships among people who are homeless. Of 539 studies that examined sexual or romantic relationships among people who are homeless, 88.87% examined sexual health risk, 11.13% examined sexual victimization, 5.57% examined survival sex, and 2.41% examined consensual sexual or romantic relationships. Of the studies that examined consensual sexual or romantic relationships substantially (n = 13) all used qualitative methods and identified common themes such as love, romance, and emotional support; partner relationships as transactional; barriers to partner relationships; and casual sex and pleasure. Despite the possible benefits of sexual and romantic relationships in the context of homelessness, researchers instead have primarily focused on possible risks associated with sex. We introduce how sexual citizenship can be applied to understand how current practices and policies limit people's civic participation when homeless. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Recovery-oriented service provision and clinical outcomes in assertive community treatment.

OBJECTIVE: While the term "recovery" is routinely referenced in clinical services and health policy, few studies have examined the relationship between recovery-oriented service provision and client outcomes. The present study was designed to examine the relationship between recovery-orientation of service provision for persons with severe mental illnesses and outcomes in Assertive Community Treatment (ACT). METHODS: Client, family, staff, and manager ratings of service recovery-orientation and outcomes across a range of service utilization and community functioning indicators were examined among 67 ACT teams in Ontario, Canada. RESULTS: Significant associations were found between ratings of recovery-oriented service provision and better outcomes in the domains of legal involvement, hospitalization days, education involvement, and employment. Results were not uniformly positive or consistent, however, across stakeholder Recovery Self-Assessment (RSA) ratings or outcomes. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These findings provide some preliminary support for an association between recovery-oriented service delivery for persons with severe mental illnesses and better outcomes. In line with the current practice commentary, this association would suggest the importance of evaluating and cultivating recovery-oriented values and practices in ACT contexts. This is a particularly salient point given that ACT standards minimally address key domains of recovery-oriented service provision. Further study is required, however, to determine if these findings apply to the implementation of ACT in other jurisdictions or generalize to other community support programs.

The use of eHealth interventions among persons experiencing homelessness: A systematic review.

OBJECTIVE: eHealth interventions are being developed to meet the needs of diverse populations. Despite these advancements, little is known about how these interventions are used to improve the health of persons experiencing homelessness. The aim of this systematic review was to examine the feasibility, effectiveness, and experience of eHealth interventions for the homeless population. METHODS: Following PRISMA guidelines, a systematic search of PsycINFO, PubMed, Web of Science, and Google Scholar was conducted along with forward and backward citation searching to identify relevant articles. RESULTS: Eight articles met eligibility criteria. All articles were pilot or feasibility studies that used modalities, including short message service, mobile apps, computers, email, and websites, to deliver the interventions. The accessibility, flexibility, and convenience of the interventions were valued by participants. However, phone retention, limited adaptability, a high level of human involvement, and preference for in-person communication may pose future implementation challenges. CONCLUSIONS: eHealth interventions are promising digital tools that have the potential to improve access to care and service delivery. eHealth interventions are feasible and usable for persons experiencing homelessness. These interventions may have health benefits by augmenting existing services and if implementation challenges are addressed. Further evaluation of the effectiveness of eHealth interventions is needed before widespread implementation. Those with lived experience should also be engaged in developing and evaluating these interventions.

Fidelity and recovery-orientation in assertive community treatment.

There has been increasing commentary about the degree to which Assertive Community Treatment (ACT) teams provide recovery-oriented services, often centered around the question of the use of coercion. The present study was designed to contribute to this discussion through an examination of recovery-oriented service provision and ACT fidelity among 67 teams in the province of Ontario, Canada. The findings indicated a moderate to high degree of recovery orientation in service provision, with no significant relationship between ACT fidelity and consumer and family/key support ratings of recovery orientation. A significant relationship was found, however, between the 'nature of services' domain of the Dartmouth Assertive Community Treatment Scale (DACTS) and ratings of recovery orientation provided by staff and ACT coordinators. These findings extend the existing dialogue regarding the evaluation of ACT intervention process factors and indicate that current measures of fidelity may not be adequately addressing dimensions of recovery-oriented service provision.

Surviving versus living life: Capabilities and service use among adults with mental health problems and histories of homelessness.

The capabilities approach is a framework that can be applied to marginalised populations, including people with mental health problems and histories of homelessness, to measure well-being. Although a range of health and social services exist to address the many challenges associated with mental health problems and homelessness, the extent to which these services impact capabilities is unknown. This qualitative study explored the perspectives of people with mental health problems and histories of homelessness to understand how they perceived their service use as affecting their capabilities. In-depth interviews were conducted over a 1-year period beginning in October 2016 with 52 adults with mental health problems who were currently or formerly homeless and living in Ottawa, Canada. Data were analysed using first and second cycle coding, which involved line-by-line, descriptive coding followed by focused coding to categorise the data within a broadly applied capabilities framework. Findings showed that participants perceived many capability impairments in their lives, including nutritious food scarcities, limited material rights, social role deprivations, social isolation and insufficient income to participate in recreational activities. Services used by participants had mixed, for better and worse, and limited effects on their capabilities (e.g., unable to overcome affordable housing shortages or financial barriers associated with some capability impairments). Furthermore, service use could promote one capability while hindering another, forcing people to choose between competing needs when using services. Overall, the capabilities approach offers a comprehensive, human rights-based framework that is relevant to people with mental health problems and histories of homelessness but the services used by this population primarily help people to survive life but not necessarily live life.