Sonya Gabrielian

Developing conceptions of authority and contract across the lifespan: Two perspectives

Abstract Kohlberg’s moral stage scale is but one of a number of “Piagetian” developmental scales proposed during the latter part of this century. Kohlberg claimed that his moral stages fulfilled the criteria for “hard” Piagetian stages—invariant sequence, qualitative change, and structured wholeness. He also argued that his scoring system measures a dimension of thought with a unique structure. To explore these contentions, we compare the concepts that define Kohlbergian stages with those associated with orders of hierarchical complexity as determined with the Hierarchical Complexity Scoring System, a generalized content-independent stage-scoring system. We conclude that the sequence of conceptual development specified by Kohlberg generally matches the sequence identified with the Hierarchical Complexity Scoring System, and that contract and authority concepts identified with a methodology that employs the Hierarchical Complexity Scoring System match the concepts that define theoretically analogous Kohlbergian stages above Kohlberg’s stage 2. However, we argue that Kohlberg’s stages 1 and 2 do not accurately describe the development of moral concepts in young children.

Experiencing community: perspectives of individuals diagnosed as having serious mental illness.

OBJECTIVE Community integration is recognized as a crucial component of recovery from serious mental illness. Although the construct of community integration can be measured with structured instruments, little is known about the subjective and experiential meaning of community and community involvement for persons with serious mental illness. METHODS In 2010, 30 individuals with serious mental illness treated in two public mental health clinics completed semistructured interviews that elicited the places and people that they associate with the experience of community and the larger meaning of community in their lives. RESULTS Participants described four experiences as integral to their concepts of community: receiving help, minimizing risk, avoiding stigma, and giving back. Participants looked for communities that provide reliable support, and they described the need to manage community contact in order to protect themselves and others from their symptoms and from discrimination. Most participants experienced communities centered on mental health treatment or mentally ill peers as providing opportunities for positive engagement. CONCLUSIONS The experience of having a serious mental illness shapes preferences for and perceptions of community in pervasive ways. Participants described community involvement not as a means to move away from illness experiences and identities but as a process that is substantially influenced by them. Mental health communities may help individuals with serious mental illness to both manage their illness and recognize and enjoy a sense of community. The findings indicate the need for further research on the relationship between community integration and outcome in serious mental illness.

VA health service utilization for homeless and low-income Veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles.

Background:The US Department of Housing and Urban Development (HUD)-VA Supportive Housing (VASH) program—the VA’s Housing First effort—is central to efforts to end Veteran homelessness. Yet, little is known about health care utilization patterns associated with achieving HUD-VASH housing. Objectives:We compare health service utilization at the VA Greater Los Angeles among: (1) formerly homeless Veterans housed through HUD-VASH (HUD-VASH Veterans); (2) currently homeless Veterans; (3) housed, low-income Veterans not in HUD-VASH; and (4) housed, not low-income Veterans. Research Design:We performed a secondary database analysis of Veterans (n=62,459) who received VA Greater Los Angeles care between October 1, 2010 and September 30, 2011. We described medical/surgical and mental health utilization [inpatient, outpatient, and emergency department (ED)]. We controlled for demographics, need, and primary care use in regression analyses of utilization data by housing and income status. Results:HUD-VASH Veterans had more inpatient, outpatient, and ED use than currently homeless Veterans. Adjusting for demographics and need, HUD-VASH Veterans and the low-income housed Veterans had similar likelihoods of medical/surgical inpatient and outpatient utilization, compared with the housed, not low-income group. Adjusting first for demographics and need (model 1), then also for primary care use (model 2), HUD-VASH Veterans had the greatest decrease in incident rates of specialty medical/surgical, mental health, and ED care from models 1 to 2, becoming similar to the currently homeless, compared with the housed, not low-income group. Conclusions:Our findings suggest that currently homeless Veterans underuse health care relative to housed Veterans. HUD-VASH may address this disparity by providing housing and linkages to primary care.

Chronic disease management for recently homeless veterans: a clinical practice improvement program to apply home telehealth technology to a vulnerable population.

Background: Although vulnerable populations may benefit from in-home health information technologies (HIT) that promote disease self-management, there is a “digital divide” in which these groups are often unlikely to use such programs. We describe the early phases of applying and testing an existing Veterans Affairs (VA) HIT-care management program, Care Coordination Home Telehealth (CCHT), to recently homeless Veterans in the US Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) program. Peers were used to support patient participation. Methods: CCHT uses in-home messaging devices to provide health education and daily questions about clinical indicators from chronic illness care guidelines, with patient responses reviewed by VHA nurses. Patients could also receive adjunctive peer support. We used medical record review, Veteran interviews, and staff surveys to “diagnose” barriers to CCHT use, assess program acceptability, explore the role of peer support, and inform future quality improvement. Subjects: Fourteen eligible Veterans in HUD-VASH agreed to CCHT participation. Ten of these Veterans opted to have adjunctive peer support and the other 4 enrolled in CCHT usual care. Results: Although barriers to enrollment/engagement must be addressed, this subset of Veterans in HUD-VASH was satisfied with CCHT. Most Veterans did not require support from peers to engage in CCHT but valued peer social assistance amidst the isolation felt in their scattered-site homes. Conclusions: HIT tools hold promise for in-home care management for recently housed Veterans. Patient-level barriers to enrollment must be addressed in the next steps of quality improvement, testing and evaluating peer-driven CCHT recruitment.

Relationship of community integration of persons with severe mental illness and mental health service intensity.

OBJECTIVE Community integration is integral to recovery for individuals with severe mental illness. This study explored the integration of individuals with severe mental illness into mental health and non-mental health communities and associations with mental health service intensity. METHODS Thirty-three ethnically diverse participants with severe mental illness were categorized in high-intensity (N=18) or low-intensity (N=15) mental health service groups. Community integration was assessed with measures of involvement in community activities, social capital resources, social support, social network maps, and subjective integration. RESULTS Although participants rated themselves as being more integrated into the mental health community, their social networks and social capital were primarily derived from the non-mental health community. The high-intensity group had a higher proportion of members from the mental health community in their networks and had less overall social capital resources than the low-intensity group. CONCLUSIONS The findings suggest opportunities and possible incongruities in the experience of community integration.

Factors Affecting Exits From Homelessness Among Persons With Serious Mental Illness and Substance Use Disorders

OBJECTIVE We sought to understand the housing trajectories of homeless consumers with serious mental illness (SMI) and co-occurring substance use disorders (SUD) and to identify factors that best predicted achievement of independent housing. METHOD Using administrative data, we identified homeless persons with SMI and SUD admitted to a residential rehabilitation program from December 2008 to November 2011. Our primary outcome measure was independent housing status. On a random sample (N = 36), we assessed a range of potential predictors of housing outcomes, including symptoms, cognition, and social/community supports. We used the Residential Time-Line Follow-Back (TLFB) Inventory to gather housing histories since exiting rehabilitation and to identify housing outcomes. We used Recursive Partitioning (RP) to identify variables that best differentiated participants by these outcomes. RESULTS We identified 3 housing trajectories: stable housing (n = 14), unstable housing (n = 15), and continuously engaged in housing services (n = 7). In RP analysis, 2 variables (Symbol Digit Modalities Test [SDMT], a neurocognitive speed of processing measure, and Behavior and Symptom Identification Scale [BASIS-24] Relationships subscale, which quantifies symptoms affecting relationships) were sufficient to capture information provided by 26 predictors to classify participants by housing outcome. Participants predicted to continuously engage in services had impaired processing speeds (SDMT score < 32.5). Among consumers with SDMT score ≥ 32.5, those predicted to achieve stable housing had fewer interpersonal symptoms (BASIS-24 Relationships subscale score < 0.81) than those predicted to have unstable housing. This model explains 57% of this samples variability and 14% of this populations variability in housing outcomes. CONCLUSIONS Because cognition and symptoms influencing relationships predicted housing outcomes for homeless adults with SMI and SUD, cognitive and social skills training may be useful for this population.

Social Support and Housing Transitions Among Homeless Adults With Serious Mental Illness and Substance Use Disorders.

Objective: Research suggests that social supports are associated with housing retention among adults who have experienced homelessness. Yet, we know very little about the social support context in consumers find and retain housing. We examined the ways and identified the junctures in which consumers’ skills and deficits in accessing and mobilizing social supports influenced their longitudinal housing status. Method: We performed semi-structured qualitative interviews with VA Greater Los Angeles consumers (n = 19) with serious mental illness, substance use disorders, and a history of homelessness; interviews explored associations between longitudinal housing status (categorized as: stable, independent housing; sheltered housing, continually engaged in structured housing programs; and unstable housing) and social supports. We compared data from consumers in these 3 mutually exclusive categories. Results: All participants described social support as important for finding and maintaining housing. However, participants used formal (provider/case managers) and informal (family/friends) supports in different ways. Participants in stable housing relied on formal and informal supports to obtain/maintain housing. Participants in sheltered housing primarily used formal supports, for example, case management staff. Unstably housed participants used formal and informal supports, but some of these relationships were superficial or of negative valence. Interpersonal problems were prevalent across longitudinal housing status categories. Conclusions and Implications for Practice: Social context, including patterns of formal and informal support, was associated with participants’ longitudinal housing status. Within interventions to end homelessness, these findings suggest the value of future research to identify, tailor, and implement practices that can help consumers improve their social resources.

Diagnoses Treated in Ambulatory Care Among Homeless-Experienced Veterans: Does Supported Housing Matter?

Purpose: Little is known about how permanent supported housing influences ambulatory care received by homeless persons. To fill this gap, we compared diagnoses treated in VA Greater Los Angeles (VAGLA) ambulatory care between Veterans who are formerly homeless—now housed/case managed through VA Supported Housing (“VASH Veterans”)—and currently homeless. Methods: We performed secondary database analyses of homeless-experienced Veterans (n = 3631) with VAGLA ambulatory care use from October 1, 2010 to September 30, 2011. We compared diagnoses treated—adjusting for demographics and need characteristics in regression analyses—between VASH Veterans (n = 1904) and currently homeless Veterans (n = 1727). Results: On average, considering 26 studied diagnoses, VASH (vs currently homeless) Veterans received care for more (P < .05) diagnoses (mean = 2.9/1.7). Adjusting for demographics and need characteristics, VASH Veterans were more likely (P < .05) than currently homeless Veterans to receive treatment for diagnoses across categories: chronic physical illness, acute physical illness, mental illness, and substance use disorders. Specifically, VASH Veterans had 2.5, 1.7, 2.1, and 1.8 times greater odds of receiving treatment for at least 2 condition in these categories, respectively. Among participants treated for chronic illnesses, adjusting for predisposing and need characteristics, VASH (vs currently homeless) Veterans were 9%, 8%, and 11% more likely to have 2 or more visits for chronic physical illnesses, mental illnesses, and substance use disorder, respectively. Conclusion: Among homeless-experienced Veterans, permanent supported housing may reduce disparities in the treatment of diagnoses commonly seen in ambulatory care.

Risk factors for diabetic retinopathy among homeless veterans.

Homeless patients have high rates of visual impairment and lower rates of glycemic control than housed patients. Although diabetic retinopathy (DR) is the most common cause of new visual impairment and legal blindness in the developed world, little is known about differential risk factors for and rates of DR in homeless versus housed populations. This study aimed to compare the rates of DR between homeless and housed patients with diabetes at the Greater Los Angeles Veterans Affairs Health care System (GLA) and identify clinical and psychosocial predictors of DR rates. We performed secondary database analyses of veterans with diabetes who received care at GLA between October 1, 2013 and September 30, 2015. We described differences in demographic, clinical, and psychosocial characteristics associated with DR in homeless versus housed patients, and created a logistic regression model to identify independent predictors of DR. We found that diabetic veterans who were homeless, as compared with those who were housed, had higher rates of substance use disorders and mental health diagnoses, more primary care and mental health visits, and were more likely to have had diabetic retinopathy eye screening according to guidelines. Multiple logistic regression modeling predicting having DR, revealed that having DR was independently associated with not being homeless (i.e., being housed), older age, having had retinal screening, anemia, higher systolic blood pressure, insulin use, microalbuminuria, and higher HbA1c. Homeless diabetic veterans’ lower rates of DR may be due to the GLA VA’s tailored and intensive psychological and medical resources for homeless veteran patients.

Serving homeless Veterans in the VA Desert Pacific Healthcare Network: A needs assessment to inform quality improvement endeavors

This report describes a needs assessment of VA programs for homeless Veterans in Southern California and Nevada, the geographic region with the most homeless Veterans in the nation. The assessment was formulated through key informant interviews. Current service provisions are discussed, along with salient unmet needs for this vulnerable population.