Mental Health Recovery and Homelessness: A Mixed Method Study of Supportive Housing

Introduction: Research has consistently shown that mental health recovery is possible for many individuals with serious mental illness. Yet recovery is challenged when these individuals also experience homelessness and substance abuse. The recent shift in national policy favoring ‘housing first’ (HF) is based upon rigorous evidence showing that homeless individuals with complex needs have more favorable outcomes living in HF scatter-site supportive housing when compared to traditional care or ‘treatment-contingent housing’ (TCH). However, little is known about how these types of programs affect the quality and trajectory of mental health recovery. This mixed method study examined changes in recovery over time, HF vs. TCH group differences in recovery trajectories, and consumer perspectives on their lives after being housed.

Methods: The study sample included 38 homeless participants newly enrolled in a HF or TCH program in New York City between October 2011 and February 2013. All had DSM Axis I diagnoses of serious mental illness and histories of substance abuse. Four waves of in-depth interviews were conducted at 6-month intervals over 18 months. Qualitative interview data were independently rated and quantified for 8 domains of recovery: employment, mental health, physical health, family, friends/significant others, hobbies/meaningful activities, substance use and housing stability.  Consensus was used to generate an individual’s recovery score for each wave of data collection and trend lines were plotted for each trajectory. Data analyses of the scores included descriptive statistics, t-tests, and growth curve analysis.  Trend lines were used to purposively select four case studies representing positive and negative recovery trajectories for each program type. Qualitative case study analyses were conducted for each individual using all waves of interview data.

Results: Findings from the t tests and growth curve analyses indicated no statistically significant group differences at each wave of data collection and no differences in the trajectories over time (p<.05).  Qualitative findings provided insight into barriers to recovery such as cumulative trauma (including childhood sexual and physical abuse), unemployment and poor health. Positive changes were found in re-forming family relationships and maintaining sobriety. Stable housing was strongly positive even though group differences in recovery trajectories were not significant.

Implications:  Non-significant group and time differences indicate that recovery is a slow process and access to housing, whether permanent or transitional, is not sufficient to overcome decades of adversity as well as structural barriers such as a lack of jobs and medical care. Some mainstream indicators of recovery may be setting the bar too high, not due solely to individual deficits but to the persistence of structural barriers. Nevertheless, services can be improved by fostering positive change in some recovery domains and building upon the ‘platform’ that permanent housing provides.