There's Nowhere to Go from Here: Barriers to Recovery and the Paradox of “Permanent” Supportive Housing

Background and Purpose: Homeless adults with both psychiatric and substance use disorders are a highly vulnerable population that is expensive to care for due to repeated rounds of emergency room, hospital, shelter, and jail stays. Federal initiatives have focused on dissemination of supportive housing, a community-based model of care that combines supportive services and subsidized housing in an effort to disrupt this costly circuit, promote recovery, and end homelessness for this population. While this model has demonstrated high rates of housing retention effectively ending consumers’ homelessness, supportive housing as an intervention has had mixed results in regards to recovery outcomes (e.g. community integration, substance use reduction). This multi-method qualitative study examines the views and practices of frontline supportive housing providers related to consumers’ recovery in order to better understand barriers to recovery-oriented practice in these settings.

Methods: This National Institute of Mental Health-funded longitudinal qualitative study utilized 84 in-depth interviews with frontline providers and 106 hours of “ride-along” and site visit observations in order to develop a grounded theory of provider practice related to recovery in housing for individuals with co-occurring psychiatric and substance abuse disorders. Frontline providers (n=34) were purposively sampled from three supportive housing programs within two social service agencies, representing both transitional and permanent housing.

Results: Analyses of these data revealed differences in the views and practices of providers working within transitional versus permanent supportive housing programs in their conceptualization of and orientation to recovery. While transitional housing programs premised on sobriety and adherence to treatment were found to support more paternalistic practice (practice antithetical to a recovery approach), staff in these programs were also more likely to be oriented toward growth and skill-building for independent living than were providers of permanent supportive housing. Permanent housing providers noted a lack of easily accessible affordable housing options beyond service-linked housing and without this next step on the housing continuum, they focused on providing passive supports, maintaining consumers in care rather than assisting consumers with concrete skill-building towards a recovered life outside of services. The permanency of housing additionally necessitated a “pragmatic flexibility” on the part of providers in order to maintain consumers in care long-term. Alternatively, transitional housing providers were found to enact “punitive pressure” as a means of moving consumers along to the next level of care within a certain timeframe. Providers cited both system-level and individual-level challenges to moving consumers on from service-intensive housing programs into mainstream housing outside of the mental health system.

Conclusions and Implications: These paradoxical barriers to recovery-oriented practice in supportive housing draw attention to the need for flexible pathways out of psychiatric housing services that would orient consumers and providers towards recovery beyond services. Findings from this study have implications for the design and implementation of the supportive housing continuum of care and the larger homeless service system.