Stephen M. Goldfinger

Some clinical approaches to the homeless mentally ill

Clinicians who work with homeless people are likely to encounter a very broad spectrum of mental disorders and residential patterns. As with any other patient population, the particulars of clinical interventions must be guided by the specific constellations of biological, psychological, and social needs. However, for individuals who not only suffer from serious psychiatric disorders, but are also homeless, effective approaches may require significant modifications of traditional techniques and changes in the prioritization, timing, and framing of specific interventions. In this article we will focus on people who are severely and persistently mentally ill and who have been sleeping for months or years in shelters or in public spaces such as parks, streets, and bus terminals.

Self-report and observer measures of substance abuse among homeless mentally ill persons in the cross-section and over time

The comparability of self-report and observer measures of substance abuse among 118 homeless mentally ill persons was assessed using cross-sectional and longitudinal measures. Possible correlates of nondisclosure were identified from demographic variables and clinical indicators. Lifetime abuse reported at baseline was a sensitive predictor of subsequent abuse behavior in the project, but cross-sectional measures based only on self-report or observer ratings failed to identify many abusers. A total of 17% of the subjects never disclosed abuse that was observed during the project. The level of substance abuse is likely to be severely underestimated among homeless mentally ill persons when only one self-report measure is used at just one point in time. This problem can, however, largely be overcome by incorporating information from observers and from multiple follow-ups or by focusing on lifetime rather than current abuse. We also conclude that underreporting may bias estimates of some correlates of substance abuse.

Housing costs for adults who are mentally ill and formerly homeless

The goal of this study was to evaluate the costs, under two different housing conditions, to the state mental health agency of caring for adults who are homeless and mentally ill. One hundred and twelve clients of the Massachusetts Department of Mental Health, living in psychiatric shelters, were randomly assigned to one of two housing types: Evolving Consumer Households or Independent Living apartments. For the next 18 months each client was followed so that the cost of treatment, case management, and housing could be collected and compared. The authors found that treatment and case management costs did not vary by housing type, but housing costs were significantly higher for those assigned to Evolving Consumer Households. Regardless of original housing assignment, treatment costs were lower for clients who remained where they were originally placed. The authors conclude that providing support for clients that increases housing stability reduces their need for treatment and that independent living arrangements may be a more costeffective policy choice.

Neuropsychological Function in Homeless Mentally Ill Individuals

Because little data are available on the neuropsychological functioning of severely and persistently mentally ill (SPMI) persons who are homeless, our primary goal was to describe accurately and extensively the general neuropsychological functioning of a large group of such homeless individuals. In addition, we have sought to examine the relationship between some neuropsychological functions and demographic, illness, and clinical state measures in this population. A 5-hour neuropsychological test battery was administered to 116 SPMI homeless individuals. Neuropsychological, diagnostic, substance abuse, clinical, and psychopathology data were obtained in a standardized manner. SPMI homeless individuals were significantly impaired on a wide range of neuropsychological functions. Specific test performances were most significantly related to precursor variables (level of education and parental socioeconomic status) and state variables (level of psychosis and anticholinergic medication dose). Gender and substance abuse had significant effects limited to sustained attention. Neuropsychological performance was impaired in this sample of homeless SPMI persons. Further research, using profile analysis to directly compare groups composed of homeless persons without psychiatric illness or demographically matched persons of comparable psychiatric status who are not homeless will help clarify the role of homelessness and psychosis on neuropsychological function.

Satisfaction with residence and with life: When homeless mentally ill persons are housed

Abstract The disconfirmation model is used to specify hypotheses about the effect of housing type and housing preferences, of clinical status, social characteristics and personality on satisfaction with housing and with life. These hypotheses are tested with data collected from homeless mentally ill shelter users who were randomly assigned to either group or individual housing. As hypothesized, subjects were more satisfied with their residential accommodations after moving into permanent housing and liked independent housing more than group living. Housing satisfaction did not vary as a consequence of the discrepancy between type of housing preferred and obtained. Life satisfaction was related to personality measures but was not affected by the move into housing or by the type of housing obtained. These findings highlight the limits of applicability of the disconfirmation model, the need to treat satisfaction as multidimensional, and the importance of personality in explaining more general aspects of satisfaction.

AIDS education for patients with chronic mental illness

Despite the AIDS epidemics impact, development of prevention and risk-reduction programs has been slow, especially for patients with chronic mental illness. These patients may be at particular risk for HIV transmission and acquisition due to characteristics of their illness. Despite a paucity of such program descriptions in the literature and widespread concern that exposure of such patients to educational material related to sexuality or AIDS would be overstimulating, an effective and safe curriculum to teach risk-reduction can be designed. This paper describes such a program at the Massachusetts Mental Health Center, in Boston.Despite the AIDS epidemics impact, development of prevention and risk-reduction programs has been slow, especially for patients with chronic mental illness. These patients may be at particular risk for HIV transmission and acquisition due to characteristics of their illness. Despite a paucity of such program descriptions in the literature and widespread concern that exposure of such patients to educational material related to sexuality or AIDS would be overstimulating, an effective and safe curriculum to teach risk-reduction can be designed. This paper describes such a program at the Massachusetts Mental Health Center, in Boston.

Adapting a substance abuse court diversion model for felony offenders with co-occurring disorders: initial implementation.

Treatment Alternatives for Dually Diagnosed (TADD) was developed to address the need for criminal justice diversion of seriously mentally ill substance-using felons and persistent misdemeanants. The population served by the TADD program and key elements of the program are described, including identification, screening and assessment, specialized court processing and judicial oversight, case management monitoring, joint case conferencing between community and monitoring staff, enforcement, and key stakeholder collaboration. One hundred and thirteen clients diverted by the TADD program were followed for six months. A description is provided of these clients, the community services accessed, as well as the monitoring of clients drug use. During six months of program involvement 87% remained connected to the diversion team, 80% remained in community treatment and the majority took advantage of the rich service environment created through TADDs case management linkage services. The majority of these clients tested drug-free during this six-month period.

The seriously mentally ill: another perspective on treatment resistance.

There is a subpopulation of the seriously mentally ill who remain acute care recidivists, rarely becoming engaged in follow-up treatment. It has been argued that these individuals are system, rather than treatment resisters. The perceptions they have of their problems are often in conflict with staff evaluations, or with what the system has to offer. In the present study, patients who dropped out of residential care against staffs advice were compared to patients who remained in treatment. The results suggest that the greater the difference between the perceptions a patient and therapist have concerning the patients problem, the greater the likelihood of the patient dropping out of treatment.

The role of psychiatrists in community mental health centers: A survey of job descriptions

There is little data about the role of psychiatrists within CMHCs. To gain perspective on this issue, job descriptions for medical directors and staff psychiatrists were collected from 214 CMHCs. The data demonstrated that most CMHCs want fully trained psychiatrists involved in a variety of activities in addition to prescribing medication. Policy development was specifically included as part of the medical directors job for 69% of the CMHCs, and 50% mentioned training as part of the staff psychiatrists job. Although job descriptions may not accurately reflect the actual roles of the psychiatrist in all cases, these data suggest that CMHCs support a multifaceted role for their psychiatrists.

The contingent rationality of housing preferences: Homeless mentally ill persons' housing choices before and after housing experience

Prior research indicates that homeless consumers of mental health services have a marked preference for independent living, while clinicians tend to recommend staffed, group housing. In order to understand this divergence and identify its consequences for mental health policy, we test influences on housing preferences suggested by rational choice and social structural perspectives. We use a randomized field trial of independent and group housing to identify the consequences for subsequent housing loss and consumer functioning of consumer- and clinician-determined housing placements. We find that consumer preference at baseline for independent living indicates greater vulnerability to housing loss, but the bases of preferences change after consumers gained experience with stable housing. We interpret the results as indicating the contingent rationality of preferences and the susceptibility of preferences to change with experience.