Trajectories of recovery among homeless adults with mental illness who participated in a randomised controlled trial of Housing First: a longitudinal, narrative analysis

Abstract

ObjectivesThis study used longitudinal, narrative data to identify trajectories of recovery among homeless adults with mental illness alongside the factors that contribute to positive, negative, mixed or neutral trajectories over time. We expected that participants who received Housing First (HF) would describe more positive trajectories of recovery than those who were assigned to Treatment as Usual (TAU; no housing or support provided through the study).DesignNarrative interview data were collected from participants at baseline and 18 months after random assignment to HF or TAU.SettingParticipants were sampled from the community in Vancouver, British Columbia.ParticipantsFifty-four participants were randomly and purposively selected from the larger trial; 52 were interviewed at baseline and 43 were reinterviewed 18 months after randomisation.MethodSemistructured interviews were conducted at both time points. For each participant, paired baseline and follow-up narratives were classified as positive, negative, mixed or neutral trajectories of recovery, and thematic analysis was used to identify the factors underlying different trajectories.ResultsParticipants assigned to HF (n=28) were generally classified as positive or mixed trajectories; those assigned to TAU (n=15) were generally classified as neutral or negative trajectories. Positive trajectories were characterised by a range of benefits associated with good-quality, stable housing (eg, reduced substance use, greater social support), positive expressions of identity and the willingness to self-reflect. Negative, neutral and mixed trajectories were characterised by hopelessness (‘things will never get better’) related to continued hardship (eg, eviction, substance use problems), perceived failures and loss.ConclusionsHF is associated with positive trajectories of recovery among homeless adults with mental illness. Those who did not receive housing or support continued to struggle across a wide range of life domains. Findings are discussed with implications for addressing services and broader social change in order to benefit this marginalised population.

A Randomized Trial Examining Housing First in Congregate and Scattered Site Formats

“…Qualitative analyses identified substantial deficiencies in shelter and support services in TAU [42]. Notwithstanding these previous findings, the current results indicate that neither CHF or SHF were sufficient to mediate changes over 24 months in measures of quality of life, overall health, or psychiatric symptom severity, beyond what would be expected from prolonged homelessness with minimal supports.…”

“…Additional factors that may have contributed to improvement in CHF were on-site recreational and vocational opportunities, and a supportive peer environment. Qualitative research has found that ongoing substance use and experiences of loneliness and isolation are often reported following the transition to SHF [40–42]. Difficulties transitioning to SHF may explain some of the null findings compared with TAU over 24 months.…”

The Meaning of Recovery from Co-Occurring Disorder: Views from Consumers and Staff Members Living and Working in Housing First Programming

“…A handful of previous studies (all of them qualitative) have attempted to understand recovery (mental health and/or substance abuse) from the perspective of those engaged in Housing First programming. Three of these studies targeting Housing First clients with mental illness have demonstrated how participants viewed housing as an essential foundation for recovery because of its ability to foster hope and stable social relationships (Kirst et al 2014; Patterson et al 2013; Polvere et al 2013). Cabassa et al (2013) recruited individuals with co-occurring disorder from a Housing First program in order to better understand the recovery process through the Photovoice method.…”

Formerly Homeless People Had Lower Overall Health Care Expenditures After Moving Into Supportive Housing

“…Thus, it does not follow the original scatter-site version of the housing-first philosophy. 19 Early studies of housing-first approaches have shown that they improve housing stability, 20,21 decrease criminal activity and jail bookings, [22][23][24] improve recovery trajectories for those struggling with mental illness, 25 and even help reduce substance use. [26][27][28] One study also found a potential reduction in acute care medical costs associated with housing first practices.…”