Daniel Poremski

Barriers to obtaining employment for people with severe mental illness experiencing homelessness

Abstract Background: The rate of unemployment among homeless people is estimated to exceed 80%. A high prevalence of mental illness partially explains this figure, but few studies about the relationship between employment and homelessness have focused on homeless people with mental illness. Aim: The present study explores the self-reported barriers to employment in a sample of individuals with mental illness when they were homeless. Methods: A sample of 27 individuals with mental illness and recent experiences of homelessness, who had expressed an interest in working, participated in semi-structured qualitative interviews. Inductive analysis was used to identify barriers to employment. Findings: The prominent barriers include: (1) current substance abuse, (2) having a criminal record, (3) work-impeding shelter practices, and (4) difficulties obtaining adequate psychiatric care. Conclusion: Individuals who have been homeless and have a mental illness report facing specific barriers associated with mental illness, homelessness, or the interaction between the two. Additional research should explore how supported housing and employment interventions can be tailored to effectively serve this group.

Improving continuity of care for frequent users of emergency departments: service user and provider perspectives

OBJECTIVE This study explored service user and provider perspectives on barriers and facilitators of continuity of care for frequent users of emergency departments (ED) participating in a brief intensive case management intervention. METHOD We conducted semistructured interviews with 20 frequent ED users with mental health and addiction challenges participating in a brief intensive case management intervention, eliciting experiences of care and care continuity. We interviewed 13 service providers working with this population. We used thematic analysis to determine shared and unique barriers and facilitators to continuity of care, and we gave priority to themes reported by both service users and providers. RESULTS Within fragmented systems of care, strong working relationships between service users and providers, timely access to coordinated services and seamless transitions to needed supports increased perceived care continuity. Barriers to continuity of care included difficulties engaging this population, short intervention duration and the lack of a single accountable service provider to address health and social needs. CONCLUSION Although brief intensive case management interventions have the potential to improve continuity of care for frequent ED users, continuity of care, especially for people with complex health and social needs, may be compromised by program and personal characteristics as well as lack of broader system integration.

Employment and Income of People Who Experience Mental Illness and Homelessness in a Large Canadian Sample.

Objectives: Research suggests that homeless people with mental illness may have difficulty obtaining employment and disability benefits. Our study provides a comprehensive description of sources of income and employment rates in a large Canadian sample. Methods: Participants (n = 2085) from the 5 sites of the At Home/Chez Soi study were asked about their income, employment, and desire for work during the pre-baseline period. The proportion of participants employed, receiving government support, and relying on income from other activities were compared across sites, as were total income and income from different sources. Generalized linear models were used to identify participant characteristics associated with total income. Results: Unemployment ranged from 93% to 98% across 5 sites. The per cent of participants who wanted to work ranged from 61% to 83%. Participants relied predominantly on government assistance, with 29.5% relying exclusively on welfare, and 46.2% receiving disability benefits. Twenty-eight per cent of participants received neither social assistance nor disability income. Among the 2085 participants, 6.8% reported income from panhandling, 2.1% from sex trade, and 1.2% from selling drugs. Regression models showed that income differed significantly among sites and age groups, and was significantly lower for people with psychotic illnesses. Conclusion: These results suggest that homeless people with mental illness are predominantly unemployed, despite expressing a desire to work. In Canada, this group relies predominantly on welfare, but has access to disability benefits and employment insurance. These findings highlight the importance of developing effective interventions to support employment goals and facilitate access to benefits.

Effects of Housing First on Employment and Income of Homeless Individuals: Results of a Randomized Trial

OBJECTIVE Housing First is emerging as an evidence-based practice for housing and supporting people who are homeless and have a mental illness. The objective of this study was to determine whether Housing First increases the odds of obtaining competitive employment in this population and affects income, including income from informal and illegal sources. METHODS A total of 2,148 people with a mental illness were recruited from five Canadian cities while they were homeless, classified as having moderate or high needs, and randomly assigned to Housing First or usual care. Housing First participants with high needs received assertive community treatment (ACT), and those with moderate needs received intensive case management (ICM). Every three months, participants were interviewed about employment and earnings in the previous months (median follow-up=745 days). Regression models were estimated via generalized estimating equations. RESULTS ICM recipients had lower odds of obtaining employment compared with the control group with moderate needs. The odds of obtaining employment among ICM recipients increased but their employment rate never exceeded that of the control group. For ACT recipients, the odds of obtaining employment were not significantly different from those of the control group. Among Housing First participants, persons employed at baseline, men, and younger participants had greater odds of employment compared with control participants. Housing First did not appear to significantly increase income. CONCLUSIONS This was the first large-scale randomized controlled study of Housing Firsts effects on employment. Further research is needed to determine how Housing First may be enhanced to increase odds of obtaining employment.

Building trust with people receiving supported employment and housing first services.

OBJECTIVES The developing literature on supported employment for people who have a mental illness and recent history of homelessness has yet to explore the relationship between clients and their employment specialists. The objective of the present article is to explore and understand the way in which service users experience supported employment services and how these experiences differ from those receiving usual services. METHOD Semistructured qualitative interviews were conducted with 27 people from a randomized controlled trial of supported employment, 14 receiving supported employment, and 13 receiving usual services. Thematic content analysis was used to generate themes and compare experiences between the 2 groups. RESULTS Trust emerged as an important facilitator to development of a collaborative relationship. It developed with time and featured in the narratives of participants who found jobs. Lack of trust and communication was associated with greater difficulty finding work. People receiving usual services rarely had repeated contact with service providers and therefore did not develop working alliances to the same extent as people receiving supported employment. CONCLUSIONS AND IMPLICATIONS Without the support of an employment specialist, participants receiving usual services relied more on internal motivation to search for employment opportunities. Programs assisting people to reach their employment goals must be sensitive to homelessness-specific experiences that may make establishing trust difficult. Vocational services should be designed to allow clients to deal exclusively with 1 service provider to permit the development of a working alliance.

Changes in the nature and intensity of stress following employment among people with severe mental illness receiving individual placement and support services: an exploratory qualitative study

Abstract Background: Most people with severe mental illness (SMI) want to work. Individual placement and support (IPS) programs have proven effective in helping them obtain and keep competitive jobs. Yet, practitioners often fear that competitive jobs might be too stressful. Aims: To explore how the nature and intensity of stress experienced by IPS clients changed after the transition from looking for work to being employed. Methods: Semi-structured interviews explored the experiences of 16 clients of an IPS program who had recently been competitively employed. Grounded theory was used to structure the analysis. Results: Most participants reported that their stress level decreased once they found work. Stress following work was associated with fear of failure, pressure to perform and uncertainty. The support that people perceived in their return-to-work project, and where they were on their recovery journey, modulated their perception of stress. Many cited IPS as a source of support. Conclusions: Competitive work changed the nature of stress and was mostly associated with a decrease in stress level. Adjunctive interventions aiming to buffer self-stigma or help participants use more adaptive coping mechanisms may merit investigation.

Perceived Case Management Needs and Service Preferences of Frequent Emergency Department Users: Lessons Learned in a Large Urban Centre.

Objectives This study aimed to explore the service needs and preferences of frequent emergency department users with mental health and addictions concerns who participated in a brief intensive case management intervention. Methods We conducted semi-structured individual interviews with 20 frequent emergency department users with mental health and addictions challenges, 13 service providers involved in the delivery of a brief case management intervention, and a focus group with intervention case managers. Thematic analysis was used to explore perceived service user profiles, service needs and preferences of care. Results Service users experienced complex health and social needs and social isolation, while exhibiting resilience and the desire to contribute. They described multiple instances of stigmatization in interactions with healthcare professionals. Components of the brief intensive case management intervention perceived to be helpful included system navigation, advocacy, intermediation, and practical needs assistance. Frequent service users valued relational responsiveness, a non-judgmental stance, and a recovery orientation in case managers. Conclusion Interventions for frequent service users in mental health may be enhanced by focusing on the engagement of formal and informal social supports, practical needs assistance, system navigation, advocacy and intermediation, and attention to the recovery goals of service users.

Food security among individuals experiencing homelessness and mental illness in the At Home/Chez Soi Trial

OBJECTIVE Individuals experiencing homelessness are particularly vulnerable to food insecurity. The At Home/Chez Soi study provides a unique opportunity to first examine baseline levels of food security among homeless individuals with mental illness and second to evaluate the effect of a Housing First (HF) intervention on food security in this population. DESIGN At Home/Chez Soi was a 2-year randomized controlled trial comparing the effectiveness of HF compared with usual care among homeless adults with mental illness, stratified by level of need for mental health services (high or moderate). Logistic regressions tested baseline associations between food security (US Food Security Survey Module), study site, sociodemographic variables, duration of homelessness, alcohol/substance use, physical health and service utilization. Negative binomial regression determined the impact of the HF intervention on achieving levels of high or marginal food security over an 18-month follow-up period (6 to 24 months). SETTING Community settings at five Canadian sites (Moncton, Montreal, Toronto, Winnipeg and Vancouver). SUBJECTS Homeless adults with mental illness (n 2148). RESULTS Approximately 41 % of our sample reported high or marginal food security at baseline, but this figure varied with gender, age, mental health issues and substance use problems. High need participants who received HF were more likely to achieve marginal or high food security than those receiving usual care, but only at the Toronto and Moncton sites. CONCLUSIONS Our large multi-site study demonstrated low levels of food security among homeless experiencing mental illness. HF showed promise for improving food security among participants with high levels of need for mental health services, with notable site differences.

Willingness of Housing First Participants to Consider Supported-Employment Services.

OBJECTIVE People who had a recent history of homelessness and had mental illness were studied to determine how many wished to be employed and were willing to accept supported-employment services and the factors associated with a decision to decline services. METHODS People (N=194) with mental illness receiving Housing First were assessed at three-month intervals over 24 months. Analyses determined variables that were associated with accepting or declining randomization to supported-employment services. A regression model was used to determine the odds of obtaining employment. RESULTS Of the 133 (69%) participants who wanted work, 75 (56%) accepted and 58 (44%) declined randomization to services. Those who declined had lower odds of obtaining employment (OR=.42, p=.022), less education, and fewer arrests and had spent less time homeless. CONCLUSIONS People with a recent history of homelessness who have a mental illness want work. People who declined randomization to supported-employment services had fewer barriers to employment but had reduced odds of obtaining employment.

The Impact of Stakeholder Preferences on Service User Adherence to Treatments for Schizophrenia and Metabolic Comorbidities

Objective To determine how stakeholder opinions of treatments influence service user decisions to adhere to courses of actions necessary to treat metabolic conditions. Methods Qualitative open-ended interviews were conducted with 20 service providers, 25 service users, and 9 caregivers. Grounded theory was used to generate an understanding that linked preferences of care with adherence to follow-up treatments. Results Participants spoke about several considerations when discussing adherence: Resource limitations were the predominant consideration. Social considerations such as stigma and support surfaced in caregiver and service-user interviews. The influence of symptoms, especially their absence could reduce adherence, and organizational considerations related to the opinions they had about the qualifications of professionals. Discussion A rational patient model partially organizes our findings, but emotional components related to stigma and the opinion of service providers do not fit well into such a model. If service providers do not consider components of the decision making process which fall outside of the rational patient model, they may incorrectly be leveraging suboptimal values to bring about adherence to treatment plans. Being sensitive to the values of service users and their caregivers may allow service providers to better act on points that may bring about change in non-compliant service users with schizophrenia and metabolic comorbidities.