Bridging Disciplinary Boundaries (January 11 - 14, 2007)

Objective: Housing leverage refers to the practice of using access to and/or retention of housing as a tool to procure treatment adherence of people with psychiatric disabilities. Although leverage is considered instrumental for reducing hospitalization and increasing community participation, critics have contended that leverage is antithetical to the notions of rights and normalization, and that leverage might lead to consumers' avoidance of service use through strained consumer-worker relationships. Despite its practice and policy significance, few studies have documented characteristics of housing leverage and the extent that leverage is associated with consumer outcomes.

Methods: This study involved a random sample of 237 psychiatric consumers in 26 permanent supported housing (SH) programs in a metropolitan area. Interviews with SH program staff provided information on housing site, staffing pattern, policy choice, consumer involvement, and program's response to problematic behavior. Consumer interviews provided data on socio-demographics and clinical characteristics. Claims data on Medicaid and non-Medicaid publicly-funded behavioral health services provided information on non-SH mental health services use. Administrative data on SH stays tracked the residential outcomes of study participants for 2 years after consumer interviews, including length of stay in SH, retention/discharge status, and discharge destinations of consumers who left SH. Two types of exits were discerned: positive exits of moving to more independent settings without staff support and negative exits including more supervised settings such as congregate/group home, homelessness, and incarceration. Univariate and bivariate analyses were used to examine SH programs' use of housing leverage. The relationship between housing leverage and residential outcomes was assessed using competing-risk proportional hazards regression.

Results: Two distinct mechanisms capture the means through which the 26 programs applied housing leverage. The mechanism through program structure includes ownership of housing units by mental health programs (instead of housing agencies or regular landlords) and having support staff at the housing sites. The mechanism of rules and regulations includes required program participation, curfew and escrow rules, testing residents for alcohol and/or drug use, adopting a “no-tolerance” policy for behavior such as medication and treatment non-compliance, and limiting consumer involvement in decision-making. After adjusting for socio-demographic characteristics, clinical characteristics and service use, results of the competing-risk regression indicated that increase in the number of housing rules raises the risk of negative exits from SH by 9% (p=.0001). Encouraging consumer involvement in decision-making, on the other hand, decreases the risks of both positive and negative exits by, respectively, 8% (p=.001) and 5% (p=.01).

Implications: This study documents the prevalent use of leverage in supported housing and its potentially negative effects on residential outcomes. It highlights the importance of social work practitioners to enhance their awareness of the negative consequences of employing leverage (e.g., homelessness and incarceration). Using social work values by encouraging consumer's involvement in decision-making may result in more positive outcomes. To understand the context of housing leverage, social work researchers need to examine the legal issues, policy frameworks, and organizational environment that permit leverage despite its contrariety to the principles of rights and self-determination.