Creating a Shared Narrative: Using Ethnographic Methods to Understand Service Engagement

Background: Despite mental health reform efforts, rates of disengagement remain high with 20-70 percent of people dropping out of services (Kreyenbuhl, Nossel & Dixon, 2009). The program Housing First, however, has succeeded in engaging those who are hardest-to-reach, people who have experienced long-term homelessness and have co-occurring disorders. The program provides immediate access to independent apartments and intensive services with assertive community treatment. Now designated an evidence based practice, Housing First has consistently demonstrated engagement rates of more than 80 percent (Mares & Rosenheck, 2010). This ethnographic study explored service engagement within Housing First, focusing on the social interactions between case managers and clients and how they relate to program structure.

Methods: Conducting participant observation and interviews, researchers followed 10 clients and 14 case managers from two treatment teams in a Housing First program, over the course of a year. Researchers observed service contacts in the program office, the community and clients' homes. Field notes were recorded on the social interaction between case managers and clients. In-depth semi-structured interviews were also conducted with each study participant. Data analysis was guided by symbolic interactionism theory (Blumer, 1969). Open coding identified categories indicating engagement behaviors and activities and higher level coding derived intersubjective themes related to meaning making within social interactions.

Results: Engagement resulted both from the structure of the program, which determined the context for engagement, and the social processes, which was reflected in the quality of the interaction between case manager and clients. A shared narrative was created between case managers and clients, beginning with the housing offer, acceptance and move into the apartment. Case managers were able to realize this turning point for clients and experience the transformation with them, which created a particular bond. The shared narrative was also shaped by the intensity of assertive community treatment. The model allowed for a myriad of engagement sites and activities which led to case managers permeating all aspects of clients' lives and playing roles similar to those of friends and family. The quality of the interaction emerged from how case managers paid attention, listened, communicated, and regarded the clients while doing shared activities. These social processes, in turn, determined how clients understood the role of case managers in their lives and their connectedness to the program.

Conclusions and Implications: Based on its effectiveness, Housing First is now being replicated around the U.S and in other countries. The task is to identify essential program elements and translate them to new settings. This study illustrated that while the structural aspects of Housing First provided the context and opportunities for engagement, the quality of the interaction between the case managers and clients played a key part in making clients feel connected to the program. It is this aspect that has often been absent from manuals and fidelity measures that guide replication. The challenge, therefore, is to reflect these elements in the evidence base and integrate them into program implementation.