Emmy Tiderington

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.

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.

Provider views of harm reduction versus abstinence policies within homeless services for dually diagnosed adults.

Harm reduction is considered by many to be a legitimate alternative to abstinence-based services for dually diagnosed individuals, yet there is limited understanding of how varying approaches affect front-line practice within services for homeless adults. This paper examines how front-line providers working with individuals who have experienced homelessness, serious mental illness, and addiction view policies of harm reduction versus abstinence within two different approaches to homeless services: the traditional or “treatment first” approach that requires abstinence, and the more recent housing first approach that incorporates harm reduction. As part of a federally funded qualitative study, 129 in-depth interviews conducted with 41 providers were thematically analyzed to understand how providers view harm reduction versus abstinence approaches. Themes included the following: (a) harm reduction as a welcomed alternative, (b) working with ambiguity, and (c) accommodating abstinence. Drawing on recovery principles, the authors consider the broader implications of the findings for behavioral health care with this population.Harm reduction is considered by many to be a legitimate alternative to abstinence-based services for dually diagnosed individuals, yet there is limited understanding of how varying approaches affect front-line practice within services for homeless adults. This paper examines how front-line providers working with individuals who have experienced homelessness, serious mental illness, and addiction view policies of harm reduction versus abstinence within two different approaches to homeless services: the traditional or “treatment first” approach that requires abstinence, and the more recent housing first approach that incorporates harm reduction. As part of a federally funded qualitative study, 129 in-depth interviews conducted with 41 providers were thematically analyzed to understand how providers view harm reduction versus abstinence approaches. Themes included the following: (a) harm reduction as a welcomed alternative, (b) working with ambiguity, and (c) accommodating abstinence. Drawing on recovery principles, the authors consider the broader implications of the findings for behavioral health care with this population.

Complex recovery: Understanding the lives of formerly homeless adults with complex needs

Abstract Objective: This report examines mental health recovery in a population neglected in the literature – formerly homeless adults with serious mental illness and co-occurring substance abuse. The term ‘complex recovery’ is used to examine the onset and impact of various types of adversity over the life course. Method: Burawoys extended case method was conducted on in-depth interviews with 74 formerly homeless adults living in housing programs in New York City. Data included verbatim transcripts, interviewer feedback forms, and case summaries. Results: Seven themes emerged: the longstanding influence of poverty, childhood hardship, social support and network depletion, substance abuse and recovery, unequal impact of gender differences, experiences of incarceration and fragmented service system. Structural as well as individual factors were found to comprise complex recovery. Conclusions: Complex recovery, which situates mental health recovery amidst homelessness and other forms of adversity, has implications for policies and practices designed to assist this vulnerable population.

Trajectories of Recovery Among Formerly Homeless Adults With Serious Mental Illness

OBJECTIVE Recovery from mental illness is possible, but individuals with co-occurring disorders and homelessness face challenges. Although a nonlinear recovery course is assumed, few studies have analyzed recovery over time. This mixed-methods study examined recovery trajectories over 18 months after enrollment in supportive housing programs of 38 participants with DSM axis I diagnoses. METHODS Qualitative interview data were quantified through consensual ratings to generate a recovery score for four waves of data collection based on eight recovery domains culled from the literature. Case study analyses were conducted of participants whose scores varied by one standard deviation or more between baseline and 18 months to identify which domains were important. RESULTS Most of the 38 participants (N=23) had no significant change in recovery; seven had a negative trajectory, and eight had a positive trajectory. Case studies of these 15 participants indicated domains that contributed to change: significant-other relationships (N=9), engagement in meaningful activities (N=9), mental health (N=7), family relationships (N=6), general medical health (N=5), housing satisfaction (N=5), employment (N=2), and substance use (N=1). Except for mental health and substance use (which contributed only to negative trajectories), the influence of domains was both positive and negative. Domains were intertwined; for example, variation in relationships was linked to changes in meaningful activities. CONCLUSIONS This study showed little change in recovery over time for most participants and a decline in mental health for a small minority. Findings underscore the importance of social relationships and meaningful activities among individuals with serious mental illness, who experience complex challenges.

Sorting it out: Eliciting consumer priorities for recovery in supportive housing

ABSTRACT This study aims to understand participant priorities in their personal recovery journey and their perspectives of recovery domains. A card-sort data-gathering technique was employed to elicit priorities in recovery from consumers in supportive housing programs serving adults who were formerly homeless with severe mental illnesses in New York City. Participants (N = 38) were asked to sort 12 cards printed with recovery domains in order of importance and describe the meaning attached to each domain. Mental health (95%), physical health (89%), and housing (92%) were the domains most frequently included and prioritized in the top three rankings. Family (76%) and partner (74%) were also frequently included and endorsed as most important second only to mental health. Housing was prioritized yet rated most important less often (58%). Work, school, hobbies, program, friends, and neighborhood were less frequently endorsed. “Card-sort talk” revealed critical understanding of participants’ priorities and their reasons for endorsing other domains less frequently. Most important to participants was regaining functional independence through improved mental and physical health and access to housing. With underlying principles of efficiency and empowerment, card sort is a promising engagement technique for providers to elicit consumer priorities in their own recovery.

Unpacking Clinical Supervision in Transitional and Permanent Supportive Housing: Scrutiny or Support?

Abstract Behavioral health organizations use clinical supervision to ensure professional development and practice quality. This qualitative study examined 35 service coordinators’ perspectives on supervision in two distinct supportive housing program types (permanent and transitional). Thematic analysis of in-depth interviews yielded three contrast themes: support versus scrutiny, planned versus impromptu time, and housing first versus treatment first. Supervisory content and format resulted in differential perceptions of supervision, thereby influencing opportunities for learning. These findings suggest that unpacking discrete elements of supervision enactment in usual care settings can inform implementation of recovery-oriented practice.

“The Apartment is for You, It’s Not for Anyone Else”: Managing Social Recovery and Risk on the Frontlines of Single-Adult Supportive Housing

This multi-method qualitative study examines frontline provider perspectives on consumer social relationships and barriers to social recovery in supportive housing programs for adults with serious mental illness. Thematic analyses show that guest and occupancy policies that enforce the “single” nature of single-adult supportive housing challenge consumer rights to self-determination in the realm of social recovery. Findings also highlight the ways in which providers act to reinforce and subvert these policies while mitigating risk in this service setting. Recommendations for enhancing the recovery orientation of supportive housing and implications for the design of the homeless service system are discussed.

Case Manager Perspectives on the Role of Treatment in Supportive Housing for People with Severe Mental Illness

Objective: Growing recognition exists of housing as a social determinant of health, and thus, health care reform initiatives are expanding the reach of health care beyond traditional settings. One result of this expansion is increased Medicaid funds for supportive-housing programs for people with severe mental illnesses. This qualitative study explores the ways in which case managers working in a supportive housing program approach treatment and how their approach is influenced by both program requirements and their beliefs about mental illness. Method: The study is part of a longitudinal qualitative study on recovery for people with severe mental illnesses living in supportive housing. Multiple interviews (n = 55) with 24 case managers from a residential-continuum supportive-housing program were conducted over 18 months. To provide an in-depth view of case manager perspectives, the study uses thematic analysis with multiple coders. Results: Overall, case managers understand supportive housing as being a treatment program but predominantly characterize treatment as medication management. The following themes emerged: believing medication to be the key to success in the program, persuading residents to take medication, and questioning the utility of the program for residents who were not medication adherent. Conclusions: Case managers understand supportive housing to be a treatment program; however, given the external constraints and their own beliefs about mental illness, case managers often equate treatment with taking medication. Study findings demonstrate the need to train case managers about mental health recovery and integrated health care. The findings also have implications for policies that tie housing to services.