Research That Matters (January 17 - 20, 2008)

Objective: Despite calls for recovery-oriented services from consumer advocates and the President's New Freedom Commission, little research has been conducted on recovery among homeless mentally ill adults. Innovative ‘housing first' (HF) programs present a challenge to the traditional ‘treatment first' (TF) approach in addressing the need for independent housing as a precondition for recovery in other life domains. This mixed method NIMH-funded study offers comparative findings on progress toward recovery among 37 psychiatric consumers enrolled in HF and TF programs in New York City.

Methods: The longitudinal study design provided baseline and six-month interview data for 9 HF study participants (SPs) and 28 TF SPs. Eligibility criteria for inclusion were: 1) a DSM Axis I diagnosis of severe mental illness; 2) current or recent homelessness; and 3) co-occurring substance abuse. Scores on a 7-item Recovery Checklist were computed and in-depth interview transcripts were analyzed in which SPs talked about social networks, jobs/income, service use, substance use, and general life concerns. Qualitative data were coded using ATLAS/ti software and grounded theory analyses focused on ‘sensitizing concepts' from the recovery literature. Bivariate statistics were computed comparing the two groups and change scores over time. Qualitative and quantitative findings were triangulated to examine areas of convergence or discrepancies.

Findings: At 6 months, the 9 HF SPs remained housed and enrolled; of the 28 in TF programs, 12 stayed enrolled, 12 went AWOL, and 4 graduated to other programs. Only the AWOL group scored significantly lower on the Recovery Checklist (p=.007) at 6 months; change score analyses showed no significant group differences over time. Qualitative findings revealed: 1) the toll of cumulative adversity and multiple losses; 2) a ‘step approach' to recovery (housing, then job, then partner) that gave HF SPs a distinct advantage; 3) a preference for ‘normalizing talk' about the future in which TF goals of psychiatric stability and sobriety were accorded priority but not over basic needs.

Conclusion/Implications: Measured indices of progress toward recovery were not strongly evident in the 6-month time span; this relatively brief window of observation plus the smaller sample sizes may have undermined the significance of the quantitative findings. However, qualitative analyses revealed that SPs voiced a strong vision of recovery focused on the pursuit of normalizing activities that recalls Maslow's needs hierarchy and Giddens' theory of ‘ontological security'. Implications of these findings for social work practice and policies include: 1) recovery is a difficult, long-term process for those having experienced cumulative adversity; 2) consumers' opinions point to the need for a secure platform, i.e., housing, as necessary though not sufficient for achieving greater independence; 3) ‘housing first' models of service delivery are an optimal fit for consumer preferences.