"If I Stay By Myself, I feel Safer": Dilemmas of Social Connectedness among Persons with Psychiatric Disabilities in Housing First

Despite advances in mental health and housing interventions, social isolation among persons with severe mental illness (SMI), particularly among those who have experienced homelessness, continues to be high (Perese & Wolf, 2005; Hawkins & Abrams, 2007). Given that social attachment can be considered a fundamental need and that social connectedness is key to health, well-being, and recovery, it is imperative to understand why high levels of social isolation persist among persons with SMI. Whereas prior research has typically focused on how individual pathology undermines the ability of individuals to develop social connections, and how stigma leads to social exclusion, this study investigates the possibility that social isolation may also be addressed as a by-product of agency; that is, that it may result in part from a calculated decision-making process in response to the social conditions in which formerly homeless individuals with SMI live their lives. Using grounded theory methodology, the study analyzes in-depth qualitative interviews at baseline and eight-year follow-up with participants who have SMI and are receiving housing and support services through a Housing First program. Interviews elicited individuals' experiences with their social networks and social interactions, while also capturing the perceived context in which these patterns of relating are embedded. The study sought to address the following research questions: 1: How do formerly homeless individuals with SMI describe their social connectedness and how does overall social connectedness change over time? 2: What are the factors that hinder social connectedness as reported by persons with severe mental illness? 3: What are the factors that facilitate social connectedness as reported by persons with severe mental illness? In line with previous research (Hawkins & Abrams, 2007; Padgett et al., 2008; Tsai et al., 2012; Yanos et al. 2012), participants' social connectedness was generally low. Further, individuals appeared to make limited progress in the domain of social connectedness over the course of eight years. This was generally attributable to their underlying ambivalence regarding social connectedness. On the one hand, individuals valued the privacy and solitude of being at home and were content with spending their time alone; on the other, individuals also expressed concerns regarding loneliness and when discussing what was missing in their lives, the subject was overwhelmingly in the domain of social connectedness. Individuals' actions regarding social connectedness were generally characterized by social distancing - a purposeful limiting of social interaction - yet their desires still reflected a longing for close others. Engaging in social distancing appeared to have developed in reaction to individuals' history of exposure to relationships that involved negative interactions, stress, and threats to personal freedom, resources, and recovery. Social distancing thus emerged as a strategy for minimizing exposure to risky situations and often occurred for practical reasons of self-preservation. Individuals described much of their social environments as characterized by poverty, prejudice, discrimination, and illicit activity, which set the stage for problematic relationships and sustained social distancing. Many themes reflected upstream factors that influence people's opportunities to develop social relationships and likelihood of experiencing negative consequences, including residential segregation, racial discrimination, stigma, disability policies that yield inadequate incomes, poverty in general, and concentrated poverty in particular. Despite depicting a fairly consistent picture of strained relationships, disadvantaged social conditions, and social distancing, the data also suggested several factors that prevented complete isolation for persons with SMI. These included connecting with aspects of their past, taking care of others, pursuing artistic activities, accessing distal neighborhood supports and resources, and having employment or volunteering. Further, maintaining or rebuilding relationships with past network members posed one of the few viable alternatives to social isolation. Overall, this study suggests that social isolation among formerly homeless persons with SMI often reflected a lack of perceived opportunities for safe, stress-free, and supportive social affiliations, an issue that may be more a consequence of cumulative and concentrated disadvantage than a direct effect of mental illness (Draine, Salzer, Culhane, & Hadley, 2002). Given the benefits to quality of life that persons with mental illness derive from having their own homes through Housing First programs (Padgett, 2007; Yanos et al., 2004), addressing the broad factors that contribute to social isolation could increase connectedness and further enhance the effectiveness of this program model

Introducing Housing First in a Rural Service System: A Multistakeholder Perspective

Housing First (HF) represents a fundamental shift in thinking about how to address chronic homelessness that has taken place during the past two decades. Whether and how the logic of HF fits in rural systems of care has not been previously explored in the research literature. Using a case study approach and thematic analysis of accounts from 20 key stakeholders, this study investigated whether and how the introduction of HF into a small, rural state in the Northeastearn United States affected the dominant institutional logic. The overall account by multiple stakeholders remained largely consistent: The introduction of an outside HF program brought new resources and expertise, which resulted in a previously underserved population being effectively engaged in services. The extent to which the introduction of an outside provider with a specific, well-defined HF philosophy fit within the existing social services system was complicated by existing providers’ limited knowledge about or input during the grant submission that provided funding for the HF program. Numerous social forces and concerns regarding limited resources also influenced stakeholder perceptions. The impact of HF on existing institutional logics was not always clearly identified by stakeholders, yet HF’s emphasis on providing service options and allowing for client choice, as well as the demonstrated effectiveness of the approach, emerged as influential. Features of local environments (including systems of care but also funding, political, and cultural contexts) and their potential for triggering transformative change may influence the relative merits of implementing HF services by an outside provider with known expertise or supporting an existing provider to develop the infrastructure and foster a service philosophy based on an HF logic

Introducing Housing First in a Rural Service System: A Multistakeholder Perspective

Housing First (HF) represents a fundamental shift in thinking about how to address chronic homelessness that has taken place during the past two decades. Whether and how the logic of HF fits in rural systems of care has not been previously explored in the research literature. Using a case study approach and thematic analysis of accounts from 20 key stakeholders, this study investigated whether and how the introduction of HF into a small, rural state in the Northeastearn United States affected the dominant institutional logic. The overall account by multiple stakeholders remained largely consistent: The introduction of an outside HF program brought new resources and expertise, which resulted in a previously underserved population being effectively engaged in services. The extent to which the introduction of an outside provider with a specific, well-defined HF philosophy fit within the existing social services system was complicated by existing providers’ limited knowledge about or input during the grant submission that provided funding for the HF program. Numerous social forces and concerns regarding limited resources also influenced stakeholder perceptions. The impact of HF on existing institutional logics was not always clearly identified by stakeholders, yet HF’s emphasis on providing service options and allowing for client choice, as well as the demonstrated effectiveness of the approach, emerged as influential. Features of local environments (including systems of care but also funding, political, and cultural contexts) and their potential for triggering transformative change may influence the relative merits of implementing HF services by an outside provider with known expertise or supporting an existing provider to develop the infrastructure and foster a service philosophy based on an HF logic

Measuring homelessness and residential stability: The residential time-line follow-back inventory

Reliable and valid longitudinal residential histories are needed to assess interventions to reduce homelessness and increase community tenure. This study examined the test-retest reliability, sensitivity to change, and concurrent validity of the Residential Time-Line Follow-Back (TLFB) Inventory, a method used to record residential histories in the Collaborative Program to Prevent Homelessness (n = 1,381). The Residential TLFB Inventory yielded temporally stable aggregate measures of duration in residential categories, and it revealed significant differences in change over time when contrasting study groups. A comparison of agency and participant data at one site

The Association Between Food Insecurity and Physical Activity in Adults with Serious Mental Illness Living in Supportive Housing

Rates of food insecurity are high among adults with serious mental illness (SMI); this population also engages in less physical activity than the general population. However, the relationship between food insecurity and physical activity in this group has not been explored. We examined food insecurity prevalence and its association with physical activity in 314 adults with SMI living in supportive housing in New York City and Philadelphia and enrolled in an institutional review board-approved randomized controlled trial of a Peer Group Lifestyle Balance (PGLB) program. We analyzed 2014 baseline survey data, including demographic data and self-reported food security, and four self-reported physical activity outcomes: any physical activity per week (yes/no) and 2) total, 3) moderate, or 4) vigorous physical activity minutes per week. A logistic regression model examined food se- curity as a predictor of any physical activity; zero-inflated negative binomial regression models were used for the other three physical activity outcomes; demographic and clinical predictors were assessed for inclusion in models. Over half of participants (51.7%) reported low or very low levels of food security. Relationships between food insecurity and three physical activity measures (any physical activity, total weekly minutes, and moderate weekly minutes) were non-significant; those with lower food security were more likely to engage in vigorous physical activity. The high food insecurity prevalence highlights the importance of measuring and addressing food security in populations experiencing SMI; measuring physical activity is also important for tailored lifestyle recommendations. Future studies should examine longitudinal changes in food security and physical activity

Peer-led healthy lifestyle program in supportive housing: study protocol for a randomized controlled trial

Background The risk for obesity is twice as high in people with serious mental illness (SMI) compared to the general population. Racial and ethnic minority status contribute additional health risks. The aim of this study is to describe the protocol of a Hybrid Trial Type 1 design that will test the effectiveness and examine the implementation of a peer-led healthy lifestyle intervention in supportive housing agencies serving diverse clients with serious mental illness who are overweight or obese. Methods The Hybrid Trial Type 1 design will combine a randomized effectiveness trial with a mixed-methods implementation study. The effectiveness trial will test the health impacts of a peer-led healthy lifestyle intervention versus usual care in supportive housing agencies. The healthy lifestyle intervention is derived from the Group Lifestyle Balanced Program, lasts 12 months, and will be delivered by trained peer specialists. Repeated assessments will be conducted at baseline and at 6, 12, and 18 months post randomization. A mixed-methods (e.g., structured interviews, focus groups, surveys) implementation study will be conducted to examine multi-level implementation factors and processes that can inform the use of the healthy lifestyle intervention in routine practice, using data from agency directors, program managers, staff, and peer specialists before, during, and after the implementation of the effectiveness trial. Discussion This paper describes the use of a hybrid research design that blends effectiveness trial methodologies and implementation science rarely used when studying the physical health of people with SMI and can serve as a model for integrating implementation science and health disparities research. Rigorously testing effectiveness and exploring the implementation process are both necessary steps to establish the evidence for large-scale delivery of peer-led healthy lifestyle intervention to improve the physical health of racial/ethnic minorities with SMI. Trial registration www.clinicaltrials.gov; NCT02175641, registered 24 June 201

Examining Place-Based Neighborhood Factors in a Multisite Peer-Led Healthy Lifestyle Effectiveness Trial for People with Serious Mental Illness

People with severe mental illness (SMI) experience significantly higher obesity-related comorbidities and premature mortality rates than healthy populations. The physical and social characteristics of neighborhoods where people with SMI reside can play an important role in promoting or hindering healthy eating and physical activity. However, this is seldom considered when designing and testing health behavior interventions for these populations. This study used baseline data from an obesity control trial for low-income, minority people with SMI to demonstrate the utility of assessing neighborhood- and city-level place-based factors within the context of lifestyle interventions. GIS was used to create a zip-code-level social and built environment geodatabase in New York City and Philadelphia, where the trial occurred. Chi-square and t-tests were used to assess differences in the spatial distribution of health-related built and social environment characteristics between and within cities and diet and physical activity outcomes. All types of neighborhood characteristics showed significant environmental differences between and within cities. Several neighborhood characteristics were associated with participants’ baseline healthy eating and physical activity behaviors, emphasizing that place-based factors may moderate lifestyle interventions for SMI patients. Future behavioral interventions targeting place-dependent behaviors should be powered and designed to assess potential moderation by place-based factors

Full-service partnerships among adults with serious mental illness in California: impact on utilization and costs.

ObjectiveCalifornia's full-service partnerships (FSPs) provide a combination of subsidized permanent housing and multidisciplinary team-based services with a focus on rehabilitation and recovery. The goal of the study was to examine whether participation in FSPs is associated with changes in health service use and costs compared with usual care.MethodsA quasi-experimental, pre-post, intent-to-treat design with a propensity score-matched contemporaneous control group was used to compare health service use and costs among 10,231 FSP clients and 10,231 matched clients with serious mental illness who were receiving public mental health services in California from January 1, 2004, through June 30, 2010.ResultsAmong FSP participants, the mean annual number of mental health outpatient visits increased by 55.5, and annual mental health costs increased by $11,725 relative to the matched control group. Total service costs increased by$12,056.ConclusionsParticipation in an FSP was associated with increases in outpatient visits and their associated costs. As supportive housing programs are implemented nationally and on a large scale, these programs will likely need to be more effectively designed and targeted in order to achieve reductions in costly inpatient services