Victoria Stanhope

Substance Use Outcomes Among Homeless Clients with Serious Mental Illness: Comparing Housing First with Treatment First Programs

The Housing First (HF) approach for homeless adults with serious mental illness has gained support as an alternative to the mainstream “Treatment First” (TF) approach. In this study, group differences were assessed using qualitative data from 27 HF and 48 TF clients. Dichotomous variables for substance use and substance abuse treatment utilization were created and examined using bivariate and logistic regression analyses. The HF group had significantly lower rates of substance use and substance abuse treatment utilization; they were also significantly less likely to leave their program. Housing First’s positive impact is contrasted with the difficulties Treatment First programs have in retaining clients and helping them avoid substance use and possible relapse.

From adherence to self-determination: evolution of a treatment paradigm for people with serious mental illnesses.

Treatment adherence and nonadherence is the current paradigm for understanding why people with serious mental illnesses have low rates of participation in many evidence-based practices. The authors propose the concept of self-determination as an evolution in this explanatory paradigm. A review of the research literature led them to the conclusion that notions of adherence are significantly limited, promoting a value-based perspective suggesting people who do not opt for prescribed treatments are somehow flawed or otherwise symptomatic. Consistent with a trend in public health and health psychology, ideas of decisions and behavior related to health and wellness are promoted. Self-determination frames these decisions as choices and is described herein via the evolution of ideas from resistance and compliance to collaboration and engagement. Developments in recovery and hope-based mental health systems have shepherded interest in self-determination. Two ways to promote self-determination are proffered: aiding the rational actor through approaches such as shared decision making and addressing environmental forces that are barriers to choice. Although significant progress has been made toward self-determination, important hurdles remain.

Conceptualizing community: a comparison of neighborhood characteristics of supportive housing for persons with psychiatric and developmental disabilities.

Housing and services for persons with developmental disabilities (DD) have been shaped by the normalization approach, a commitment to full integration within the general community. In contrast, housing and services for persons with psychiatric disabilities (PD) have had various and sometimes conflicting goals, including provision of custodial care, promotion of therapeutic community, and community integration. This cross-field study compares the neighborhood characteristics of publicly-funded housing for the PD and DD populations in a metropolitan community. The aim of the study was to examine whether the contrasting housing approaches are reflected at an ecological level and to consider how these findings relate to the goal of community integration for people with PD and DD. Administrative databases provided residential addresses of 1932 residents with PD living in 297 locations and 1716 residents with DD living in 749 locations in the city of Philadelphia. The 2000 U.S. Census and citys police department database provided information on neighborhood characteristics. Geographic information system (GIS) methodology generated maps displaying the distribution of housing locations in relation to spatial dispersion, distress, stability, safety, and race/ethnic diversity. Statistical analyses compared neighborhood characteristics of the DD and PD populations. Findings indicated that the DD population in supportive housing was more spatially dispersed, and lived in less distressed, less unstable, more secure, but equally racially/ethnically diverse neighborhoods when compared to the PD population in supportive housing. Greater geographic dispersal among persons with DD may be the result of more emphasis on normalization within policies and programs determining the location of their housing. The higher funding levels for housing and residential support for persons with DD also provided programs with the option of placing people in higher income neighborhoods. Given that community integration has emerged as an organizing principle within mental health services over other models, policymakers in the field of psychiatric disabilities may have much to learn from the normalization movement for people with developmental disabilities.

Moving Toward Integrated Health: An Opportunity for Social Work

With the passage of the Patient Protection and Affordable Care Act (PPACA) and ongoing health care reform efforts, this is a critical time for the social work profession. The approaches and values embedded in health care reform are congruent with social work. One strategy is to improve care for people with co-morbid and chronic illnesses by integrating primary care and behavioral health services. This paper defines integrated health and how the PPACA promotes integrated health care through system redesign and payment reform. We consider how social workers can prepare for health care reform and discuss the implications of these changes for the future of the profession.

Understanding the Role of Individual Consumer-Provider Relationships Within Assertive Community Treatment

The widespread adoption of assertive community treatment has resulted in a shift from an individual model to a team model of case management. The shift has had implications for individual relationships between case managers and consumers, but still little is known about how these relationships develop in teams. This exploratory mixed methods study looked at how case managers and consumers negotiate individual relationships within a team model. Quantitative methods identified high and low service intensity relationships between consumers and case managers and qualitative methods explored and compared these relationships. Consumers in high service intensity relationships described a preference for certain case managers and the burden of working with multiple people. Case managers invested high service intensity relationships with special therapeutic value, articulated the challenges of coordinating care across the team, and utilized team limit setting techniques. In contrast, low service intensity relationships were more likely to reflect integration with the entire team. Findings suggest that teams need to consider how individual relationships enhance care for their consumers and how to nurture these relationships while maintaining the support necessary for case managers and consumers.

Examining the Relationship between Choice, Therapeutic Alliance and Outcomes in Mental Health Services

Background: Self-determination within mental health services is increasingly recognized as an ethical imperative, but we still know little about the impact of choice on outcomes among people with severe mental illnesses. This study examines whether choice predicts outcomes and whether this relationship is mediated by therapeutic alliance. Method: The study sample of 396 participants completed a survey measuring choice, therapeutic alliance, recovery, quality of life and functioning. Multivariate analyses examined choice as a predictor of outcomes, and Sobel tests assessed alliance as a mediator. Results: Choice variables predicted recovery, quality of life and perceived outcomes. Sobel tests indicated that the relationship between choice and outcome variables was mediated by therapeutic alliance. Implications: The study demonstrates that providing more choice and opportunities for collaboration within services does improve consumer outcomes. The results also show that collaboration is dependent on the quality of the relationship between the provider and consumer.

Evaluating the Impact of Cultural Competency Trainings from the Perspective of People in Recovery

Many behavioral health providers are now being trained in cultural competence but still little is known about the impact of these trainings on persons-in-recovery. This study reports on the evaluation of a state wide cultural competency (CC) training for behavioral health providers. A sample of persons-in-recovery receiving services from trainees were asked how important cultural factors were in their treatment and rehabilitation and to what extent their providers were culturally competent. Most persons-in-recovery reported that their providers were culturally competent, but the majority did not prioritize cultural factors in their treatment. The article discusses the complex relationship between culture and satisfaction with services and the need to explore further the person-in-recovery understanding of culture in the context of their mental health.

Training Mental Health Providers in Cultural Competence: A Transformative Learning Process

Cultural competence training is viewed as a strategy to reduce cultural disparities in mental health (Dougherty, 2004). The purpose of this article is to examine the process of becoming more culturally competent. This process evaluation study applied Bennetts Developmental Model of Intercultural Sensitivity to logs written by four cohorts of mental health and psychiatric rehabilitation teams of administrators, mental health practitioners and peer providers who participated in intensive, multicultural, recovery-oriented, continuing education over a 10-month period. Participants submitted logs later coded using Bennetts categories. A nonlinear process of group transformation from ethnocentric to ethnorelative was demonstrated. During the initial and midpoints of the training, there was often a spike in ethnocentrism followed by acceleration in the movement toward ethnorelativism. Findings are discussed in relation to transformative learning theory and implications for design of multicultural training that promotes transformational, second order change are considered.

Shared decision making within the context of recovery-oriented care

Purpose The purpose of this paper is to consider the role of shared decision making (SDM) as one component of recovery-oriented care. Design/methodology/approach This paper is conceptual and reviews the literature relevant to recovery-oriented care, person-centered recovery planning (PCRP), and SDM. Findings To the degree to which SDM offers tools for sharing useful information about treatment options with service users and family members or other loved ones, it can be considered a valuable addition to the recovery-oriented armamentarium. It is important to emphasize, though, that recovery-oriented practice has a broader focus on the person’s overall life in the community and is not limited to formal treatments or other professionally delivered interventions. Within the more holistic context of recovery, SDM regarding such interventions is only one tool among many, which needs to be integrated within an overall PCRP process. More emphasis is given within the recovery-oriented care to activating and equipping persons for exercising self-care and for pursuing a life they have reason to value, and the nature of the relationships required to promote such processes will be identified. In describing the nature of these relationships, it will become evident that decision making is only one of many processes that need to be shared between persons in recovery and those who accept responsibility for promoting and supporting that person’s recovery. Originality/value By viewing SDM within the context of recovery, this paper provides a framework that can assist in the implementation of SDM in routine mental health care.

Activating people to address their health care needs: Learning from people with lived experience of chronic illnesses.

One of the primary goals of health care reform is improving the quality and reducing the costs of care for people with co-morbid mental health and physical health conditions. One strategy is to integrate primary and behavioral health care through care coordination and patient activation. This qualitative study using community based participatory research methods informs the development of integrated care by presenting the perspectives of those with lived experience of chronic illnesses and homelessness. Themes presented include the internal and external barriers to addressing health needs and the key role of peer support in overcoming these barriers.