Benjamin F. Henwood

Life Course Adversity in the Lives of Formerly Homeless Persons With Serious Mental Illness: Context and Meaning

This qualitative study assessed the frequency and subjective meaning of adverse experiences using case study analyses of interviews with 38 formerly homeless adults with co-occurring serious mental illness (SMI) and substance abuse histories. Adverse life events were inventoried using an adaptation of Lloyd and Turners (2008) 41-item checklist. Participants averaged 8.8 adverse events, with approximately one-third having experienced incarceration (37%), suicidality (32%), abandonment by one or both parents (30%), and death of their mother (34%). Cross-case analyses yielded 3 themes: social losses because of death and estrangement; the significance of chronic stressors as well as acute events; and the cumulative lifetime nature of adversity. Findings suggest that life course experiences of trauma and loss have a cumulative influence in the lives of this population in addition and in relation to SMI, substance abuse, and homelessness. In this context, the mental health recovery movement should address prior adverse experiences beyond comorbid diagnoses in this population.

A Picture Is Worth . . . ? Photo Elicitation Interviewing With Formerly Homeless Adults

We report on the use of photo elicitation interviewing (PEI) with 13 participants in a qualitative study of formerly homeless men and women with serious mental illness. Following a respondent-controlled approach, participants were asked to take up to 18 photographs visually portraying positive and negative aspects of their lives and to subsequently narrate the meaning of the photos in a one-on-one interview. Thematic analysis of the photos (N = 205) revealed two approaches to PEI: (a) a “slice of life” and (b) “then vs. now.” Examples show how PEIs yielded deeper, more elaborate accounts of participants’ lives compared to earlier verbal-only interviews. Participants spoke of the benefits of PEI and preferred taking positive as opposed to negative photographs depicting their lives. Implications of PEI as a means of complementing verbal-only data are discussed. By moving away from predetermined content and meaning, respondent-controlled PEIs enhance empowerment and enable creativity.

Permanent Supportive Housing: Addressing Homelessness and Health Disparities?

Permanent supportive housing (PSH) is an intervention to address long-term homelessness. Evidence has resulted in a shift in US policy toward using PSH rather than shelters and transitional housing. Despite recognizing that individuals transitioning from homelessness to PSH experience a high burden of disease and health disparities, public health research has not considered whether and how PSH improves physical health outcomes. Based on diverse areas of research, we argue that in addition to improved access to quality health care, social determinants of health (including housing itself, neighborhood characteristics, and built environment) affect health outcomes. We identify implications for practice and research, and conclude that federal and local efforts to end long-term homelessness can interact with concurrent efforts to build healthy communities.

Reevaluating the self-medication hypothesis among the dually diagnosed.

The self-medication hypothesis (SMH) is an intuitively appealing explanation for substance use. Conceptually, however, it is not always clear what the hypothesis entails, particularly when applied to persons with mental and substance use disorders. This makes empirical support for SMH difficult to evaluate. By classifying the self-reported reasons for substance use from 33 participants in a NIMH-funded qualitative study of dual diagnosis and homelessness, this study aims to evaluate the applicability of SMH. How one conceptualizes SMH will determine whether SMH is empirically supported. When SMH refers to using substances strictly to cope with symptoms of mental disorders, only 11 out of 72 attributions support it. When SMH refers to using substances to cope with painful feelings in general, more than half of all attributions support SMH. The significance of accurately understanding the various reasons people give for why they use substances is discussed.

Maslow and Mental Health Recovery: A Comparative Study of Homeless Programs for Adults with Serious Mental Illness

This mixed-methods study uses Maslow’s hierarchy as a theoretical lens to investigate the experiences of 63 newly enrolled clients of housing first and traditional programs for adults with serious mental illness who have experienced homelessness. Quantitative findings suggests that identifying self-actualization goals is associated with not having one’s basic needs met rather than from the fulfillment of basic needs. Qualitative findings suggest a more complex relationship between basic needs, goal setting, and the meaning of self-actualization. Transforming mental health care into a recovery-oriented system will require further consideration of person-centered care planning as well as the impact of limited resources especially for those living in poverty.

Implementing Housing First in Rural Areas: Pathways Vermont

The benefits of Pathways Housing First in addressing chronic homelessness for persons with severe mental illness have been well established. However, the implementation and effectiveness of such programs in rural areas has yet to be examined. We described the models adaptations in Vermont, including the use of hybrid assertive community treatment-intensive case management teams, which consisted of service coordinators with geographically based caseloads (staff/client ratio of 1:20) and regional multidisciplinary specialists. The programs innovative and widespread inclusion of technology into operations facilitated efficiency and responsiveness, and a pilot telehealth initiative supplemented in-person client visits. The program achieved a housing retention rate of 85% over approximately 3 years, and consumers reported decreased time spent homeless, demonstrating that program adaptations and technological enhancements were successful.

Moving from street to home: health status of entrants to a housing first program.

Housing First (HF) is an evidence-based practice that ends chronic homelessness for individuals with serious mental illness by providing immediate access to permanent independent housing and team-based community supports. Little is known about the health status of homeless individuals entering HF programs. Through a cross-sectional analysis, this paper reports on the chronic physical disease burden of people entering a newly established HF program and examines whether these individuals recognize and request support for ongoing health-related issues. The authors’ evaluation confirmed significantly higher rates of chronic disease (60%) and fair/poor self-reported health status (47%) than the general urban population of Philadelphia. The majority of clients reported they wanted to address both medical (67%) and mental health (68%) problems, but a much lower percentage reported wanting to reduce substance use (23%) or take psychiatric medications (25%). The authors conclude that formerly homeless entrants to HF programs have a high burden of chronic disease with complex health-related needs. Additionally, these individuals look to the program for health-related assistance. As the HF model is disseminated throughout the United States to end chronic homelessness, these findings support the development of flexible, integrated, person-centered health services within the HF service delivery system as a potentially effective method to address complex health needs.

Transitioning from Homelessness: A “Fresh-Start” Event

Permanent supportive housing (PSH) has been recognized as central to the goal of ending chronic homelessness. This qualitative study considers the positive and negative expectations of 31 men and women in the Skid Row area of Los Angeles who are beginning the transition from homelessness to PSH through a Housing First approach. This study uses in-depth, qualitative interviews and an inductive approach informed by sensitizing concepts derived from the literature and thematic analysis of case summaries, interview transcripts, and interviewer feedback and observation. Three themes emerged from the data: (a) nowhere to go but up, (b) some things stay the same, and (c) neighborhood matters. These findings indicate that PSH is regarded as a fresh start and universally positive experience, and that the role of neighborhood highlights a tension in the pursuit of recovery from homeless between removing people from their neighborhoods versus keeping them close to their previous and familiar environments. Implications for social work practice include that maximizing a successful transition will require understanding and managing people’s expectations and reality.

Substance Abuse Recovery After Experiencing Homelessness and Mental Illness: Case Studies of Change Over Time

Objective: This article addresses how consumers with dual diagnosis who were formerly homeless but are now living in supportive housing understand their recovery from substance abuse (i.e., substance abuse or dependence). Specifically, this study examined what can be learned about substance abuse recovery from consumers considered to be doing well; how past substance abuse fits into their present-day narratives; and how (if at all) policies of harm reduction versus abstinence are regarded as affecting recovery efforts. Methods: As part of a federally funded qualitative study, 38 individuals who met criteria for having achieved a measure of success in mental health recovery were purposively sampled from two supportive housing agencies, one using a harm reduction and the other an abstinence model. Researchers conducted in-depth interviews and used case study analysis, the latter including the development of case summaries and data matrices, to focus on substance abuse recovery in the larger context of participants’ lives. Results: Recovery from substance abuse was depicted as occurring either through discrete decisions or gradual processes; achieving recovery was distinct from maintaining recovery. Emergent themes related to achievement included (a) pivotal events and people, (b) maturation, and (c) institutionalization. Central themes to maintaining recovery were (a) housing, (b) self-help, and (c) the influence of significant others. Conclusions: These findings capture a complex picture of overcoming substance abuse that largely took place outside of formal treatment and was heavily dependent on broader contexts. Equally important is that consumers themselves did not necessarily view substance abuse recovery as a defining feature of their life story. Indeed, recovery from substance abuse was seen as overcoming one adversity among many others during their troubled life courses.

Quality of life after housing first for adults with serious mental illness who have experienced chronic homelessness

This 1-year longitudinal study of adults who have recently transitioned from homelessness to Permanent Supportive Housing (PSH) focuses on quality of life as a primary outcome of interest. Eighty of 103 new tenants participated in structured interviews at the time of entry into their new home and at 12-months post-housing. t-tests assessed differences in community participation and quality of life measures at the 2 time points. Mixed effects models examined the impact of community participation on quality of life. Results show that time in independent housing was significantly associated with several domains of quality of life. Symptom severity was also significantly and negatively related to quality of life domains. Community participation was significantly related to frequency of social contacts only. These findings suggest that community participation is not critical to improving quality of life, and that despite concerns that individuals may feel isolated and lonely when living independently, satisfaction with one׳s living situation and family relationships nevertheless improves with housing tenure.