A Comparison of Front-Line Provider Attitudes to Housing in Residential Continuum and Housing First Programs

Background: The need to provide housing for persons with psychiatric disabilities has emerged as both necessary and challenging since deinstitutionalization. In response, the mental health system has developed several program models that incorporate both housing and treatment services. Housing First and Residential Continuum programs serve homeless adults with co-occurring psychiatric and substance use disorders (CODs). The former provides immediate access to supported, scattered-site housing and tailors community-based services based on individual need while the latter links housing and services in a step-wise fashion that begins with outreach, provides transitional housing, and ends with permanent housing. This paper considers how these two distinct program models inform front-line provider practice. Specific study questions include: What values do providers express in relation to consumer's access and/or receipt of housing in each type of program? Do providers think their programs are effective in addressing consumers' needs? How does the differential access to housing between program models affect providers' relationships with consumers?

Methods: This qualitative study investigates the views of 44 case managers evenly divided between Housing First and Residential Continuum providers who were part of the New York Services Study, a four-year NIMH-qualitative study of 75 new enrollees of programs serving homeless adults with CODs. Case managers were recruited through their client's participation in the study and were twice interviewed in-depth; once upon their client's enrollment and again when their client either left the program or six-months later, whichever came first. Case manager interviews, consisting of general questions about their job as well as client-specific questions, were transcribed verbatim and entered into Atlas/ti software for inductive analysis. Coding and thematic analyses (Boyatzis, 1998) were used to compare similarities and differences between the two sets of providers.

Results: Case managers working in the separate program models expressed markedly different views about housing that were largely consistent with their program's overall philosophy. Contrasting themes that emerged between Housing First and Residential Continuum providers (respectively) included viewing housing as: (1) a right versus a privilege; (2) a tool of engagement versus leverage; and (3) a source of liberation versus frustration. Discussion of the use of discretionary power was also more prominent among Residential Continuum versus Housing First providers.

Implications: These two groups of providers serve the same population yet presented markedly different ideas and experiences. While Residential Continuum programs offer transitional housing and short-term relationship-building, Housing First programs provide permanent housing and challenge providers to develop lasting relationships. Residential Continuum providers served as powerful gatekeepers not always willing or able to satisfy consumer preferences regarding access to independent housing, and this complicated the consumer-provider relationship. Provider perspectives were largely consistent with their program model's overall philosophy indicating the importance of organizational context in promoting recovery-oriented practices and policies.