Housing for the disabled mentally ill: moving beyond homogeneity.

Schiff, Rebecca ; Schiff, Jeannette Waegemakers ; Schneider, Barbara 等

Abstract

Housing practices and models of community care for persons disabled by mental illness have undergone significant evolution in the last 30 years. This review of over 750 reports from academic and grey literatures examines the evolution of policy and best practice movements that have linked housing, treatment, and supports for persons with a mental illness disability. A notable gap in this literature is that reports assume homogeneity among this population with the disability as the prime criteria for housing type. Canadian acceptance of a diverse society includes acceptance of subpopulations that have significant and unique needs which are unaccounted for in this housing literature. These include people who are "hard to house" because of severe functional impairments, the elderly, those of Aboriginal or non-Western (European) ethnic origin, and people in small town and rural settings. This synthesis of the literature challenges the unspoken assumption that all persons disabled by a mental illness need or accept a uniform housing approach.

Keywords: mental illness, disability, housing, homelessness, continuum of care, housing first

Resume

Les services de logement et de soins communautaires pour les personnes atteintes de maladie mentale ont subi d'importantes transformations depuis les trente dernieres annees. Cerre revue de la litterature, basee sur plus de 750 rapports du domaine public, academique et institutionnel, examine l'evolution de politiques et des pratiques associees au service de logement et des soins communautaires pour les personnes atteintes de maladie mentale. L'on constate un manque frappant au sein de la litterature, a savoir que l'ensemble des rapports et des etudes assument une homogeneite de la population cible comme etant le principal critere pour le type de logement. L'attrait des canadiens pour une societe heterogene inclus l'integration des populations minoritaires ayant des besoins specifiques dont la litterature sur les services de logement ne tient aucunement en ligne de compte. Ceci inclut les gens qui sont "difficile a loger" en raison de leur handicape, les personnes agees, les autochtones, les personnes d'origine ethnique non-europeenne, et les gens du milieu rural. Cette synthese de la litterature remet en question la notion (sous-entendue) que le service de logement et des soins communautaires pour les personnes atteintes de maladie mentale doit-etre base sur une approche uniforme du logement.

Mots cles: personnes atteintes de maladie mentale, sans-abris, logement, soins communautaires

Introduction

The importance of stable, affordable, and adequate housing to meet the community tenure needs of individuals disabled by serious mental illness has become more accepted in the process of transforming long-term psychiatric care from institutional settings to community based services. Along with this transformation a vast body of research has emerged which documents that individuals disabled by mental illness most often identify income and housing as the most important factors in achieving and maintaining their health (Allen and Bazelon 2006). The sheer volume of work, a majority of it emerging from the United Sares, with some contributions from Australia, the UK, and other countries, which examines housing for those disabled by a mental illness, encompasses multiple variables and lenses. The dominant contemporary view has settled on an approach that embraces housing as a human right, empowerment as an important motivator, and recovery as an over-arching value (Parkinson, Nelson, and Horgan 1999; Sohng, 1996). While this view recognizes multiple levels of stakeholders including service recipients, providers, organizations and policy makers, this long history of examining housing approaches and modalities assumes homogeneity among people disabled by a mental illness both in the extent of the disability that engenders the need for a supportive housing environment and in the ethno cultural diversity that hallmarks modern Canadian society.

We argue that subpopulations of people living with a mental illness have significant and unique needs but are unaccounted for in the literature; including people who are "hard to house", the elderly, those of Aboriginal or non-Western ethic origin, and people in small town and rural settings. In addition, this literature lacks consistent and adequate descriptions of housing programs and philosophies. For purposes of clarity, we refer to those "persons disabled by a mental illness" to reflect those people who may experience difficulty in sustaining housing and employment due to challenges presented by a mental illness.

A Historical Overview of Research on Housing Policy and Practice

A review of the research on housing included peer-reviewed journals as well as the "grey" literature (government documents, commissioned reports, and salient information posted on web sites) covering the years 1995-2010, inclusive. We used the search engine Google Scholar to find major contributions and then followed bibliographic references, both on-site and in the literature, to expand the search. We also conducted a systematic search of the following electronic databases: Academic Search Premier, Canadian Reference Centre, CINAHL Plus with Full Text, Family & Society Studies Worldwide, Humanities International Complete, MEDLINE, Psychology and Behavioral Sciences Collection, PsychInfo, SocINDEX, Ovid MEDLINE(R), Journals@Ovid, Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, CDSR, and HealthSTAR. The literature search used the following key words, either alone or in combination: Housing, mentally ill, psychiatric patients, supportive housing, supported housing, program evaluation, continuum of care, homeless mentally ill, community supports, housing outcomes, alternative care, community tenure, housing policy, independent living, and housing supports. Over 980 articles were located. For the final review, inclusion criteria included quantitative and qualitative studies as well as government (federal, provincial, and foreign) commissioned housing reports. Reviews of multiple research studies were compared with the original studies for consistency and clarity of conclusions. Articles presenting single program description were omitted from the final review.

Research on housing programs for people living with a mental illness has mirrored the historical in the types of housing provided. Early studies compared institutional and inpatient treatment with community housing, but often presented the housing as a component of community care (Fakhoury and Priebe 2002; Stein and Test 1980; Kruzich 1985; Nelson and Smith Fowler 1987). That is, treatment and housing continued to be combined (Blanch, Carling, and Ridgway 1988; Lipton, Nutt, and Sabatini 1988). Implicit in these early studies, appearing in the 1970s to 1980s, was the linkage of housing and treatment, usually in some form of congregate care (Lamb 1998). However, most often program descriptions were not provided so these housing efforts are presumed to be characterised by marginal housing and major controls on the activities of persons housed (Segal and Aviram 1978).

As a new cohort of psychiatric patients (i.e. those without institutional experience) emerged, efforts to house them in a more "natural" community setting in the late 1970's resulted in the creation of group homes by local mental health agencies (Colten 1979). These programs generally combined housing and supports in a quasi-institutional setting. Program rules and expectations were clearly laid out and residents were expected to follow a treatment plan. By the 1980's some of this cohort had "graduated" to independent living in apartments, funded with rental supplements and usually with a case plan developed by the local organization supplying community supports. In all cases residents were expected to be treatment compliant and to abstain from the use of alcohol and illicit drugs. Substance use was generally not tolerated and frequently resulted in eviction. Apartment residents were rarely afforded the same landlord-tenant rights as the general population (Allen 1996) This transitioning from highly supervised living arrangements to semi-independent ones retained many of the coercive features of institutional treatment and was geared towards meeting the needs of providers for custody and control rather than that of those diagnosed with a mental illness for independence and freedom of choice.

The end of the 1980's and early 1990's saw an explosion of literature that focussed on the 'homeless mentally ill' (Levine and Rog 1990). As many housing programs failed to accommodate this population and made restrictive demands on their housing tenure, and as governments failed to replace institutional beds with adequate, affordable, and appropriate accommodations in the community, the numbers of the homeless swelled with those diagnosed with a mental illness or co-occurring mental illness and substance abuse disorders (Hopper 1988, Torrey 1988, Levine and Rog 1990, Peressini, McDonald, and Hulchanski 1995). At the same time research on housing for the mentally ill began to focus on various housing models with considerable attention to housing plus supports (Carling 1992). Many focussed on psychiatric outcomes and soon linked (Brown et al. 1991, Left et al. 1994) consumer's quality of life (Nelson, Hall, and Walsh-Bowers 1998) and consumer preferences to housing stability (Onken et al. 2002; Harp 1990; Elliott, Taylor, and Kearns 1990; Keck 1990; Tanzman 1993; Srebnik et al. 1995).

In addition to individual reports, over the last 30 years 18 reviews on housing the mentally ill have examined the cumulative body of research that has been published on selected areas of interest. Together, they point to the trends in housing approaches that began with examining specific housing models, such as half-way houses and group homes (Carpenter 1978; Colten 1979; Rog and Raush 1975) and gradually shifting to look at other models of supportive housing--with both on-site and off-site staffing supports. They also included a comparison of those models that provided housing alone or with supports and then began to define the nature and extent of supports necessary for housing stability (Parkinson, Nelson, and Horgan 1999). Studies of cost effectiveness quickly established the fiscal wisdom of these approaches (Rosenheck 2000). However, all assumed a homogeneity of housing needs and preferences among those disabled by a mental illness and most retained a model of housing plus treatment (Allen 2003).

Types of Available and Acceptable Housing Models

Traditionally, the institution-community interface has been conceptualized using a "Continuum of Care" (COC) model, whereby people diagnosed with a mental illness are expected to pass through successive stages of accommodation (from the street or institutional living to permanent supportive housing) (Brown 2005; Depla, De Graaf, and Heeren 2006; Elliott, Taylor, and Kearns 1990; Hanrahan et al. 2001; Lehman et al. 1997). In this model, therapeutic services may be provided on-site by live-in or day-time staff, or at local and central treatment and day rehabilitation programs. We found 81 articles published between 1980 and 2009 that dealt with this model. The COC, also known as the rehabilitation model, includes group homes, boarding homes, community residences, dedicated apartment buildings and scatter-site supervised apartments. At each stage, clients must demonstrate 'housing readiness', which generally includes demonstrating "activities of daily living" (ADL) skills, maintaining sobriety, and complying with psychiatric treatment. It has been suggested that the COC model may violate human rights (Allen 1996). More recently this model has fallen out of favour as numerous studies support consumer preference and choice, and the finding that the unlinking of housing and treatment is associated with superior outcomes in housing stability.

The prime example of the model uncoupling housing and treatment is exemplified by "Housing First" (HF) initiatives, a housing approach that has gained rapid popularity in the last decade. The HF model rejects the logic of housing readiness in the COC model, instead promoting the position that stable housing is, for many people diagnosed with a mental illness, a precondition to participating successfully in psychiatric treatment and dealing with addictions and that housing choice be a component of this approach (Tsemberis, Gulcur, and Nakae 2004). Concomitantly, research reports have also highlighted the growing demand of consumers to have choice and control over their housing (Greenwood et al. 2005; Nelson, Aubry, and LaFrance 2007), and this converges with HF program philosophies. Consumer preference has been underscored by the growing acceptance of recovery principles as foundational to treatment and housing programs (Everett et al. 2003; Davidson et al. 2005) and the increasing demand for greater housing options and housing independence.

In the rush to enthusiastically embrace the HF model of community tenure that empowers people, supports recovery, and acknowledges individual choice and the right to housing, the issue of necessary supports to maintain housing is often overlooked. The HF approach includes built-in supports and the availability of an Assertive Community Treatment (ACT) team to mitigate against relapse and prevent hospitalization. The required connection with an ACT team continues the relationship of housing and treatment that may be viewed as coercive (Allen 2003), but may be a necessary compromise to prevent symptom return and re-hospitalization and/or housing loss.

While HF may be viewed as a program philosophy as well as a method for prioritizing services, an additional, complementary model that addresses the multiple needs of those diagnosed with a mental illness is described as the Housing Stability Model (HSM). It responds to the housing literature that suggests there are multiple domains which need to be addressed in the quest for housing stability for those with mental health disabilities. The HSM has been described as containing three elements: person, housing, and support influenced by broader systems dynamics (Sylvestre, Ollenberg, and Trainor 2009). This model does not take into account the importance of broad policy movement that determines housing availability. Reports on housing and homelessness in Canada highlight the pivotal role that government withdrawal from housing supports has had on the country's homeless crisis (Laird 2007). An excellent example is the change in social housing supports in Alberta in the last two years that has contributed to a noticeable reduction in homelessness (Calgary Homeless Foundation 2010). Thus we suggest that the HSM, which is generic for all homeless and precariously housed persons, should encompass four interactive components that mutually reinforce each other: person, housing, support, and agency/system, and that foundational values underpinning this model are predicated on HF principles.

Housing Policies and Reports

Housing policy is a critical component to the success of the Housing Stability Model because without relevant policy in place, the delivery of appropriate, adequate, and acceptable supports may be compromised. Focussed studies, evaluations, and reports on housing for people living with a mental illness, and the homeless mentally ill have been commissioned by many provinces and U.S. states as well as municipal and regional authorities in the UK and Australia. We included a review of some of the most comprehensive work since it represents an informative look at how public policy has been informed and shaped by these commissioned studies. This combination of grey and academic literature on housing the mentally ill has grown exponentially, with 22 reports captured prior to 1999 and over 35 in the last 7 years. It reflects a growing concern with the overall problem of homelessness, which recently has subsumed issues of housing for people living with a mental illness. The tendency to place the mentally ill as a special population of the overall homeless group has at times obscured the unique needs among this diverse group of people.

Early housing policy regarding the mentally ill, in response to the deinstitutionalization movement, was concerned with provision of community care and treatment (Carling 1992) and the rights of the mentally ill to be housed in the least restrictive settings. By 1993 the focus had begun to shift to the type of housing that should be provided, indicating that this housing should be coupled with appropriate supports (Alberta Health Mental Health Division 1993). Recommendations for housing with supports came from diverse and widespread directions (Alberta Health Mental Health Division 1993, Kirby and Keon 2006, National Resource Center on Homelessness and Mental Illness Policy Research Associates Inc. 1993, National Association of State Mental Health Program Directors 1996).

Since 1999 the policy debate has shifted to an emphasis on the types of supportive housing most appropriate for this population and whether the housing should be contingent on, or in addition to, various forms of treatment or case plan compliance. Most of the housing policy debate has centred on various forms of custodial or rehabilitative care in the community versus providing housing first and adding support services on an as needed and as requested basis (Hall, Nelson, and Smith Fowler 1987). Some advocates have suggested that community care and rehabilitation models are, for the most part, coercive and compromise the freedoms and rights of individuals (Stickley, Hitchcock, and Bertram 2005). While a strong case against the coercive practices that deny individual freedoms has been put forward by Allen (1996) and Weisberg (1994) it has not yet been subject to court challenge or legislative change in either Canada or the United States. Reports indicate that the province of Ontario has come closest to ensuring a housing first policy for those diagnosed with a mental illness (Weisberg 1994).

In Canada, the most important contemporary development in the entire field of mental health policy and service delivery has been, as a result of the Kirby Report (Kirby and Keon 2006), the establishment of the Mental Health Commission of Canada; which has a broad mandate to develop policy recommendations, develop an anti-stigma campaign, and conduct a broad-based housing intervention project that includes a longitudinal (5 year) approach examining the efficacy and effectiveness of a housing first approach across multiple cities with distinctive populations reflective of the Canadian mosaic (Mental Health Commission of Canada 2010).

The Context for Social Housing and Housing for the Mentally Ill in Canada

In Canada, responsibility for housing is not legislated at the federal, provincial, or local levels. While there were initially some social housing initiatives, for the last 20 years social housing in Canada has been a neglected step-child of federal initiatives and many provincial efforts. In the mid 1980's the federal government cut back on social housing programs and, with the exception of Quebec, most provinces did not address the vacuum that this shift in policy created. By 1993 the annual growth of federal sponsorship had been reduced to zero (Hulchanski and Network 2002).

Provincial responses to this have been uneven, with some provinces such as Ontario developing a Ministry of Housing and making a commitment to gradually include all low income persons, regardless of disability, as eligible for social housing. In the wake of demand to deal with a growing homeless population, Alberta has recently renewed its commitment to some housing supports and rental supplements and established a housing ministry. Local responsibility for housing has also been influenced by provincial supports, or lack thereof, with most cities reluctant to supply anything other than acutely needed emergency shelters, primarily for homeless individuals. The net result is an uneven distribution of housing programs and resources across the country (Hulchanski 2003). The mentally ill, disadvantaged by the disabling nature of most serious mental health conditions, have especially been negatively impacted. While recent funding from the Homelessness Partnering Strategy, and its predecessor the National Homelessness Initiative, have made some development funds available from federal sources, the amounts allocated are minimal compared to the needs (Government of Canada 2009). Furthermore, these funds are subject to the political will of the party in power and may not necessarily survive with a change in leadership.

The Province of Ontario was a notable exception to the prevailing trends to demand treatment compliance, a case plan, and alcohol abstinence for those discharged from institutions and housed in the community. It determined, in the late 1980's, that persons diagnosed with a mental illness should be afforded social housing without treatment or behavioural demands (Weisberg 1994). This has led to a fairly extensive HF program in Ontario that places individuals directly into apartments of their choosing, with support services provided by a local NGO. The Ontario approach has not been well-documented although it has been in place longer than the Pathways HF program in New York, and thus has a considerably longer record of keeping people stably housed.

With the exception of Ontario, in Canada a large proportion of housing spaces available for people diagnosed with a mental illness continue to be in the custodial model (Dorvil et al. 2005; Nelson, Aubry and LaFrance 2007; Trainor, Pomeroy and Pape 1999), even though accommodation of this type does not provide care in line with current best practices and the needs of consumers. While these room and board and group home residences may be most appropriate for those who require support for every day basic care, there is little research evidence to determine who comprises this group of extremely needy and disabled persons, The result is a lack of triage into the most appropriate level of independence and choice in housing. While alternative housing models, emphasizing the rehabilitation model, skills training, and community integration, are gaining prominence in Canada, these approaches perpetuate the "treatment plus housing" approach that is unacceptable to the vast majority of persons diagnosed with a mental illness.

Literature gaps

While the focus of the literature has moved towards greater community integration and less coercive housing options, there are a number of contemporary issues that have emerged as neglected areas of research focus and public policy. Significantly, a number of critical sub-populations have received little attention despite their unique housing needs. Simultaneously, the literature lacks consistent and adequate descriptions of housing programs and philosophies. This makes it difficult for researchers and service providers to compare, evaluate, and provide the most adequate and appropriate housing options. The HF literature suggests that even those with persistent disabling psychiatric symptoms can be housed with intensive supports (Padgett, Gulcur, and Tsemberis 2006), although the evidence for this is not available, especially for that cohort who continues to actively engage in significant abuse of substances such as cocaine and its derivatives (Kertesz et al. 2009).

The hard to house

While the housing needs of a vast majority of those diagnosed with a mental illness can be addressed by the HF model, there is an additional, smaller, but distinct group of people whose mental illness is so disabling that they are not able to be self-sufficient even though they may not require the intensive treatment of an inpatient psychiatric unit. This cohort, distinct from those who are chronically mentally ill, homeless and unable to keep their housing, are sometimes referred to as the "hard-to-house" because of the inability to stabilize the mental health symptoms. Their issues are not of compliance to treatment (Vuckovich 2010) but efficacy of medication regimes (Stroup et al. 2003). Not everyone responds adequately to psychotropic medication, and thus some continue to be symptomatic and a management challenge (Robinson et al. 1999). Many have concomitant physical disorders and some are physically disabled (Hansen et al. 2002). The literature makes scant mention of this sub-group, despite the fact that they require substantial resources, both physical and financial (O'Malley and Croucher 2003). Current housing programs are not equipped to handle their special needs and often they are precluded from other accommodations for the physically disabled.

Some studies suggest that some "hard to house" individuals can be successfully accommodated in a variety of alternative settings; for example, specialized boarding homes and hostels where there are varying degrees of support services and personnel available to meet basic daily needs and, for some, to provide supervision (Lesage et al. 2003). Approved boarding homes which house one to three adults in a family setting provide a type of "family care" that meets the needs of some highly dependent and marginally functional individuals (Puller and Hubbard 2001). This is in contrast to the large scale "boarding homes" that arose in the early 1980's and functioned as quasi-institutional warehouses and are no longer considered acceptable accommodation (Torrey 1988). Some room and board arrangements have been successfully employed in areas as diverse as the UK, Australia, and Canada (among others) (Lesage et al. 2003). However, these models are not well described, often not well supervised, in danger of being a continuation of the older quasi-institutional boarding home arrangements, and not equipped to accommodate those with unremitting symptoms or additional physical disabilities.

One example of a different type of housing arrangement for high needs individuals, a specialized form of nursing home care, was identified in a housing needs assessment project in Calgary. (Waegemakers Schiff, Schneider, and Schiff 2007). In this facility, adults ranging in age from their early 30's to over 65 with severe psychiatric symptoms and co-morbid serious physical conditions were under the care of a specially trained multidisciplinary staff. As an alternative to placement in a general nursing home geared towards the infirm elderly, this facility provided a more sensitive and treatment appropriate mental health environment for residents. As evidenced in this facility, the sub-group of high needs individuals will require supervised, sheltered accommodation which may include, in some instances, continued treatment approaches that supplement those initiated in inpatient units. There is currently a lack of exploration of this type of highly specialized unit for the most severely disabled, which should parallel similar programs for the physically and developmentally disabled.

Those who are ageing and have mental illness disabilities

People are living longer, and that includes an increased life-span for those with disabling mental illness. The mental health literature does not make frequent reference to an increasingly elderly population who have grown up in the community, and may have been living in supportive community housing, but who now face challenges associated with ageing. Surveys that try to determine the prevalence of mental illness and treatment seeking often do not include those over the age of 55 (Kessler et al. 2001), and studies that focus on the elderly, when not concerned with dementia, look primarily at depression with late life onset. Community housing alternatives for a variety of sub-groups such as women, people with dependents and those with co-occurring substance abuse, may purposefully exclude older adults with life-long disabling mental illnesses (Galaway et al. 1992).

The few articles that do look at later in life community care for this distinct but growing group of people have tackled a number of themes: challenges of those with mental health issues in seniors' residences (Robison et al. 2009); formal and informal supports for those living in the community (Kropf and Cummings 2009); and the elderly homeless (Lipmann 2009). Several investigators have begun to examine the dimensions and outcomes of supportive housing in the community for elderly persons with a disabling mental illness (Cummings 2009; Depla, De Graaf, and Heeren 2006; Johnson et al. 2001; Sohng 1996; Johnson 2007). However, there is insufficient research that addresses the challenges of those ageing in place in supportive housing that was established for a younger cohort of residents and consequently has no services for seniors, nor any staff trained in their unique physical and activities of daily life needs. The option of moving into an assisted living residence is often not available, either because no facilities with rent supports exist or because of restrictive admission criteria. While there is some evidence that seniors may require fewer psychiatric services and more medically related services associated with ageing (Abdul-Hamid et al. 2009), this has not had a positive impact on the placement of the frail elderly with long-term psychiatric disabilities in specialized care such as nursing homes (Lane 2010). Thus we face the challenges of an increasing population of persons with long-term mental health disabilities and lack of substantial information about how best to provide for their housing and continuing care needs.

Canada's ethnic mosaic

Canadian studies that have examined housing and support needs for those with a mental illness disability usually utilize the same generic lens as the U.S. research. Thus we have little idea as to the extent to which persons from different countries and cultures are willing to adopt a North American view of individualized housing. Many cultures that are family and multi-generation oriented in lifestyle value family care-giving (Awadalla et al. 2005; Rungreangkulkij and Gilliss 2000; Yamashita 1998), and have brought those values into their Canadian lives, might prefer to live in multi-generational housing and include extended family as members of the family unit. In China (Chang and Horrocks 2006), Japan (Sono, Oshima, and Ito 2008), India (Lloyd et al. 2010), and most non-Western countries and Indigenous societies, persons with a disabling mental illness are cared for within the family. These values have migrated to Canada as our non-Western population has substantially increased. While the newly created Mental Health Commission has recently released a report on the mental health needs of immigrant, refugee, ethno-cultural and racialized groups (IRER), housing is not specifically addressed, even though the literature suggests that these groups are often marginally or precariously housed (Mental Health Commission of Canada 2009). Additionally, we know little about what are culturally appropriate housing and support needs for these persons and their caregivers.

Equally underserved are Aboriginal persons living with a mental illness. Literature on Aboriginal mental health concentrates on endemic issues of depression, substance abuse, and suicide but rarely mentions disabilities created by psychotic, mood (bi-polar), or extreme anxiety disorders, and supportive housing has not been part of the discussion. The needs of Canadian Aboriginal people are also not included in the IRER groups discussed by the Mental Health Commission. As in many Indigenous cultures, values strongly endorse living with the nuclear and/ or extended family. Where there is family dislocation and dysfunction alternative housing may be required, yet nothing has been written about the development or availability of culturally appropriate housing for an Aboriginal person who needs supportive housing but cannot live within the family (Tutty et al. 2009). Sadly, most programs do not have the awareness or staff trained to be sensitive to important culturally appropriate practices (such as smudging ceremonies) that are part of Aboriginal life at home, but may infringe on "no smoking" housing policies. A comprehensive review of the literature indicates that it is devoid of examining culturally appropriate housing and supports for Aboriginal persons disabled by a serious mental illness (Tutty et al. 2009).

Other neglected subgroups

Those with a criminal record who also have a mental health disability are often excluded from housing programs, yet there is little evidence of what types of housing supports work best for this population (Adair et al. 2007), and nothing to refute the assertion that HF approaches are equally applicable to them. Yet many emerging from the justice system have a past history of substance abuse and there is a strong question as to whether an HF unstructured environment may lead to relapse (Kertesz et al. 2009)

This review found that most housing studies, in all of the countries from which reports are available, focus on the urban population: those living near or in large metropolitan areas. With one exception (Grigg et al. 2005), we were unable to locate studies that explored the needs, preferences, or types of housing available to individuals in small towns and rural communities. This issue is of importance since rural communities often lack apartment-style accommodation.

Most housing programs also appear to target single adults, and make no reference to couples or parents who have been diagnosed with a mental illness and also have dependent children. With most people disabled by a mental illness living in community settings, and often with symptoms sufficiently under control to be actively involved in significant relationships, the number of people choosing to live with a significant other, and to have children, will increase. Although there are housing programs in Toronto that report accommodating couples and families in Ontario, they have not been the focus of research activities and thus what is known about them comes from anecdotal evidence and preliminary investigations from an unpublished research project. With mental illness now treated primarily in the community we can expect to see these sub-populations growing and their needs for specific accommodation and support services recognized.

Other significant gaps

Apart from special populations, another noticeable deficit in this housing literature is the under-reporting and lack of reporting of program descriptions. Program evaluations are often restricted to reporting of outcomes without an examination of the process of housing. This includes program philosophy and staffing models. There does not appear to be a template for reporting on these programs. This makes it difficult to impossible to ascertain if the research is reporting on programs that fit the linear, continuum of care, or a supported housing model. Furthermore, these research reports lack sufficient detail to assist other providers interested in establishing housing programs to determine the components essential for acceptable, effective, and efficacious housing.

Conclusion

Approaches to community housing for persons with a mental illness disability have changed dramatically over the last 40 years. They no longer include the high level of paternalism and medicalization of supports and housing that existed in the early days of deinstitutionalization. However, research has relied on mental illness diagnosis, sex, and age as the key factors in evaluating housing programs and has given little attention to additional critical variables that reflect diversity in an increasingly complex society.

Despite the significant volume of research on various housing models and outcomes, there are some notable gaps in this literature. Strikingly, in an era of multiculturalism and ethnic diversity, these investigations have not addressed the question of whether ethnic or cultural affiliation is related to housing preferences in location, or configuration of housing and support services. In the context of diversity, additional sub-populations also need to be considered. The needs of the aged mentally ill have not been addressed nor have those with multiple disabilities such as physical conditions that require special accommodation, brain injury that might include mental health problems, and speech or hearing difficulties. There is also scant attention to appropriate housing for those diagnosed with a mental illness who have been discharged from correctional facilities, are living with their children or partner, or living in rural areas (Montgomery et al. 2008).

Beyond the individual with a mental illness disability is the challenge of understanding how these housing programs function--not merely in organizational characteristics such as staff type, numbers, level of training, and availability of support services, on or off-site. Additional descriptors need to detail how organizational values and practices, important components of service delivery (Glisson 2007; Waegemakers Schiff 2001), are implemented in these housing models and to what extent this impacts on the quality of life and personal satisfaction of residents. This calls for further attention to program evaluation studies that link philosophy and organizational design to effectiveness studies. A template for these programs could assist service delivery organizations and researchers by providing a framework for determining the components essential for acceptable, effective, and efficacious housing.

While we have come a long way in the evolution of humane housing and supports for persons with mental illness, the review we conducted suggests that we are now poised for a next generation of research. This agenda should include the specifics of unique populations as well as critical details of program and service delivery to assure that those who are disabled with a mental illness are able to live with the same degree of autonomy, individuality, and respect equal to all members of civil society.

Acknowledgements

This research was funded by the Mental Health Housing Subcommittee of the Calgary Homeless Foundation

References

Abdul-Hamid, W., S. Johnson, G. Thornicroft, F. Holloway, and S. Stansfeld. 2009. The Camberwell elderly mentally ill and their needs for services. Journal of Social Psychiatry 55 (1): 82-90.

Adair, C., P. Goering, J. Dunn, C. Mitton, F. Barnes, B. Schneider, J. Waegemakers Schiff, L. Simpson, G. Marcoux-Louie, and S. Tucker. 2007. Feasibility study for a two city demonstration of supportive housing for individuals with severe mental illness: Final report of the Calgary component. Toronto, ON: Canadian Association of Mental Health.

Alberta Health Mental Health Division. 1993. Coordinated housing, health, and support services for persons with chronic mental illness. Edmonton, AB: Alberta Health.

Allen, M. 1996. Separate and unequal: The struggle of tenants with mental illness to maintain housing. Washington, D.C: National Clearinghouse for Legal Services, Inc.

--. 2003. Waking Rip van Winkle: Why developments in the last 20 years should teach the mental health system not to use housing as a tool of coercion. Behavioral Sciences & the Law 21 (4):503-521.

Allen, M., and M. Bazelon. 2006. Transforming housing for people with psychiatric disabilities report. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (SAMSHA).

Awadalla, A., J. Ohaeri, A. Salih, and A. Tawfiq. 2005. Subjective quality of life of family caregivers of community living Sudanese psychiatric patients. Social Psychiatry and Psychiatric Epidemiology 40 (9):755-763.

Blanch, A.K., P.J. Carling, and P. Ridgway. 1988. Normal housing with specialized supports: A psychiatric rehabilitation approach to living in the community. Rehabilitation Psychology 33 (1):47-55.

Brown, M.A., P. Ridgway, W.A. Anthony, and E.S. Rogers. 1991. Comparison of outcomes for clients seeking and assigned to supported housing services. Psychiatric Services 42 (11): 1150-1153.

Brown, S.L. 2005. The history of housing and treatment services for people with serious psychiatric disabilities: Models of residential service delivery. Doctoral Dissertation. Hartford, CT: University of Hartford. 128pp.

Calgary Homeless Foundation. 2010. Progress. Calgary: Author.

Carling, P.J. 1992. Homes or group homes? Future approaches to housing, support, and integration for people with psychiatric disabilities. Adult Residential Care Journal 6 (2): 87-96.

Carpenter, M.D. 1978. Residential placement for the chronic psychiatric patient: A review and evaluation of the literature. Schizophrenia Bulletin 4 (3): 384398.

Chang, K.H., and S. Horrocks. 2006. Lived experiences of family caregivers of mentally ill relatives. Journal of Advanced Nursing 53 (4): 435-443.

Colten, S.I. 1979. Community residential treatment strategies. Community Mental Health Review 3 (5/6): 16-21.

Cummings, S.M. 2009. Treating older persons with severe mental illness in the community: impact of an interdisciplinary geriatric mental health team. Journal of Gerontological Social Work 52 (1): 17-31.

Davidson, L., M. O'Connell, J. Tondora, and M. Lawless. 2005. Recovery in serious mental illness: A new wine or just a new bottle? Professional Psychology: Research and Practice 36 (5): 480-487.

Depla, M.F., R. De Graaf, and T.J. Heeren. 2006. The relationship between characteristics of supported housing and the quality of life of older adults with severe mental illness. Aging & Mental Health 10 (6): 592-598.

Dorvil, H., P. Morin, A. Beaulieu, and D. Robert. 2005. Housing as a social integration factor for people classified as mentally ill. Housing Studies 20 (3): 497-518.

Elliott, S.J., S.M. Taylor, and R.A. Kearns. 1990. Housing satisfaction, preference and need among the chronically mentally disabled in Hamilton, Ontario. Social Science & Medidne 30 (1): 95-102.

Everett, B., B. Adams, J. Johnson, G. Kurzawa, M. Quigley, M. Wright, and B. Pape. 2003. Recovery rediscovered: Implications for mental health policy in Canada. Toronto, ON: Canadian Mental Health Association.

Fakhoury, W., and S. Priebe. 2002. The process of deinstitutionalization: An international overview. Current Opinion in Psychiatry 15 (2): 187-192.

Galaway, B., P. Harmon, J. Hudson, and B. Galaway. 1992. Concentrating on programs serving diverse populations in the United States, the United Kingdom, Belgium, and The Netherlands. Community Alternatives: International Journal of Family Care 4 (2): n.p.

Glisson, C. 2007. Assessing and changing organizational culture and climate for effective services. Research on Social Work Practice 17 (6): 736-747.

Government of Canada. 2009. Indicators of well-being in Canada: Housing need. Ottawa, ON: Author.

Greenwood, R.M., N.J. Schaefer-McDaniel, G. Winkel, and S.J. Tsemberis. 2005. Decreasing psychiatric symptoms by increasing choice in services for adults with histories of homelessness. American Journal of Community Psychology 36 (3): 223-238.

Grigg, M., F. Judd, L. Ryan, and A. Komiti. 2005. Identifying marginal housing for people with a mental illness living in rural and regional areas. Australian and New Zealand Journal of Psychiatry 39 (11-12): 995-1000.

Hall, G.B., G. Nelson, and H. Smith Fowler. 1987. Housing for the chronically mentally disabled: Part I--Conceptual framework and social context. Canadian Journal of Community Mental Health 6 (2): 65-78.

Hanrahan, P, D.J. Luchins, C. Savage, and H.H. Goldman. 2001. Housing satisfaction and service use by mentally ill persons in community integrated living arrangements. Psychiatric Services 52 (9): 1206-1209.

Hansen, M.S., P. Fink, M. Frydenberg, and M.L. Oxhoj. 2002. Use of health services, mental illness, and self-rated disability and health in medical inpatients. Psychosomatic Medicine 64 (4): 668-675.

Harp, H. 1990. Independent living with support services: The goal and future for mental health consumers. Psychosocial Rehabilitation Journal 13 (4): 85-89.

Hopper, K. 1988. More than passing strange: Homelessness and mental illness in New York City. American Ethnologist 15 (1): 155-167.

Hulchanski, J.D. 2003. What factors shape Canadian housing policy? The intergovernmental role in Canada's housing system. Conference on Municipal-Provincial Relations in Canada, School of Policy Studies, Queen's University, May 9-10.

Hulchanski, J.D., and F. Network. 2002. Housing policy for tomorrow's cities. Ottawa, ON: Canadian Policy Research Networks.

Johnson, J., G. Thronicroft, M. Phelan, and E.P. Slade. 2001. Assessing needs for mental health services. In Mental health outcomes measures, eds. M. Tansella and G. Thornicroft, 271-284. London, UK: Royal College of Psychiatrists.

Johnson, R. 2007. Housing, home, and recovery: Supported housing can provide the community and peer support that many vulnerable groups need to maintain mental well-being. Mental Health Today. December 2007-January 2008: pp. 27-29.

Keck, J. 1990. Responding to consumer housing preferences: The Toledo experience. Psychosocial Rehabilitation Journal 13 (4): 51-58.

Kertesz, S.G., K. Crouch, J.B. Milby, R. Cusimano, and J.E. Schumacher. 2009. Housing first for homeless persons with active addiction: Are we overreaching? Milbank Quarterly 87 (2): 495-534.

Kessler, R.C., P.A. Berglund, M.L. Bruce, J.R. Koch, E.M. Laska, P.J. Leaf, R.W. Manderscheid, R.A. Rosenheck, E.E. Wakers, and P.S. Wang. 2001. The prevalence and correlates of untreated serious mental illness. Health Services Research. 36 (6) (Pt. 1): 987-1007.

Kirby, M.J.L., and W.J. Keon. 2006. Out of the shadows at last: Transforming mental health, mental illness and addiction services in Canada. Ottawa, ON: Standing Senate Committee on Social Affairs, Science and Technology.

Kropf, N.P., and S.M. Cummings. 2009. Formal and informal support for older adults with severe mental illness. Aging & Mental Health 13 (4): 619-627.

Kruzich, J.M. 1985. Community integration of the mentally ill in residential facilities. American Journal of Community Psychology 13: 553-564.

Laird, G. 2007. Shelter: Homelessness in a growth economy: Canada's 21st century paradox. Calgary, AB: Sheldon Chumir Foundation for Ethics in Leadership.

Lamb, H.R. 1998. Deinstitutionalization at the beginning of the new millennium. Harvard Review of Psychiatry 6 (1): 1-10.

Lane, A. 2010. The textual organization of placement into long-term care: Issues for older adults with mental illness. Nursing Inquiry 17 (1): 2-11.

Left, J., G. Thornicroft, N. Coxhead, and C. Crawford. 1994. The TAPS Project. A five-year follow-up of long-stay psychiatric patients discharged to the community. British Journal of Psychiatry Supplement 25: 13-17.

Lehman, A.F., L.B. Dixon, E. Kernan, B. DeForge, and L. Postrado. 1997. A radomized trial of assertive community treatment for homeless persons with severe mental illness. Archives of General Psychiatry 54 (11): 1038-1043.

Lesage, A.D., D. Galinas, D. Robitaille, A. Dion, D. Frezza, and R. Morissette.

2003. Toward benchmarks for tertiary care for adults with severe and persistent mental disorders. Canadian Journal of Psychiatry 48 (7): 485-489.

Levine, I.S., and D.J. Rog. 1990. Mental health services for homeless mentally ill persons. Federal initiatives and current service trends. American Psychologist 45 (8): 963-968.

Lipmann, B. 2009. Elderly homeless men and women: Aged care's forgotten people. Australian Social Work 62 (2): 272-286.

Lipton, F.R., S. Nutt, and A. Sabatini. 1988. Housing the homeless mentally ill: A longitudinal study of a treatment approach. Psychiatric Services 39 (1): 40-45.

Lloyd, H., P. Singh, R. Merritt, A. Shetty, J. Yiend, S. Singh, and T. Burns. 2010. A comparison of levels of burden in Indian and White parents with a son or daughter with schizophrenia. International Journal of Social Psychiatry. published online first on March 2, 2010 as doi: 10.1177/0020764009354838. Accessed April 5, 2010.

Mental Health Commission of Canada. 2009. Improving mental health services for immigrant, refugee, ethno-cultural and racialized groups: Issues and options for service improvement. Calgary, AB: Author.

--. At Home/Chez Sol research demonstration project. 2010. Calgary, AB: Author.

Montgomery, P., C. Forchuk, C. Duncan, D. Rose, P. Bailey, and R. Veluri. 2008. Supported housing programs for persons with serious mental illness in rural northern communities: A mixed method evaluation. BMC Health Services Research 8 (1): 156-156.

National Association of State Mental Health Program Directors. 1996. Position statement on housing and supports for people with psychiatric disabilities. Alexandria, VA: National Association of State Mental Health Program Directors.

National Resource Center on Homelessness and Mental Illness Policy Research Associates Inc. 1993. Creating Community: Integrating elderly and severely mentally ill persons in public housing. Delmar, NY: Prepared for the U.S. Dept. of Housing and Urban Development, Office of Policy Development and Research; and the U.S. Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.

Nelson, G., T. Aubry, and A. LaFrance. 2007. A review of the literature on the effectiveness of housing and support, assertive community treatment and intensive case management interventions for persons with mental illness who have been homeless. American Journal of Orthopsychiatry 77 (3): 350-361.

Nelson, G., G.B. Hall, and R. Walsh-Bowers. 1998. The relationship between housing characteristics, emotional well-being and the personal empowerment of psychiatric consumer/survivors. Community Mental Health Journal 34 (1): 57-69.

Nelson, G., and H. Smith Fowler. 1987. Housing for the chronically mentally disabled: Part II--Process and outcome. Canadian Journal of Community Mental Health 6 (2): 79-91.

O'Malley, L., and K. Croucher. 2003. Supported housing services for people with mental health problems: Evidence of good practice? Paper read at HSA Conference Housing and Support, University of York, York, UK.

Onken, S.J., J.M. Dumont, P. Ridgway, D.H. Dornan, and R.O. Ralph. 2002. Mental health recovery: What helps and what hinders? A national research project for the development of recovery facilitating system performance indicators. Phase one research report: A national study of consumer perspectives on what helps and hinders mental health recovery. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD) National Technical Assistance Center (NTAC).

Padgett, D.K., L. Gulcur, and S. Tsemberis. 2006. Housing first services for people who are homeless with co-occurring serious mental illness and substance abuse. Research on Social Work Practice 16 (1): 74-83.

Parkinson, S., G. Nelson, and S. Horgan. 1999. From housing to homes: A review of the literature on housing approaches for psychiatric consumer/survivors. Canadian Journal of Community Mental Health 18:145-164.

Peressini, T., L. McDonald, and D. Hulchanski. 1995. Estimating homelessness: Towards a methodology for counting the homeless in Canada. Toronto, ON: Canada Mortgage and Housing Corporation.

Pulier, M.L., and W.T. Hubbard. 2001. Psychiatric rehabilitation principles for re-engineering board and care facilities. Psychiatric Rehabilitation Journal 24 (3): 266-74.

Robinson, D.G., M.G. Woerner, J.M. Alvir, S. Geisler, A. Koreen, B. Sheitman, M. Chakos, D. Mayerhoff, R. Bilder, R. Goldman, and J.A. Lieberman. 1999. Predictors of treatment response from a first episode of schizophrenia or schizoaffective disorder. American Journal of Psychiatry 156 (4): 544-549.

Robison, J., J.J. Schensul, E. Coman, G.J. Diefenbach, K.E. Radda, S. Gaztambide, and W.B. Disch. 2009. Mental health in senior housing: Racial/ ethnic patterns and correlates of major depressive disorder. Aging & Mental Health 13 (5): 659-673.

Rog, D.J., and H.L. Raush. 1975. The psychiatric halfway house: How is it measuring up? Community Mental Health Journal 11 (2): 155-162.

Rosenheck, R. 2000. Cost-effectiveness of services for mentally ill homeless people: The application of research to policy and practice. American Journal of Psychiatry 157 (10): 1563-1570.

Rungreangkulkij, S., and C.L. Gilliss. 2000. Conceptual approaches to studying family caregiving for persons with severe mental illness. Journal of Family Nursing 6 (4): 341-366.

Segal, S. P., and U. Aviram. 1978. The mentally ill in community-based sheltered care: A study of community care and social integration. New York, NY: John Wiley & Sons.

Sohng, Sung Sil Lee. 1996. Supported housing for the mentally ill elderly: Implementation. Community Mental Health Journal 32 (2): 135-148.

Sono, T., I. Oshima, and J. Ito. 2008. Family needs and related factors in caring for a family member with mental illness: Adopting assertive community treatment in Japan where family caregivers play a large role in community care. Psychiatry and Clinical Neurosciences 62 (5): 584-590.

Srebnik, D., J. Livingston, L. Gordon, arid D. King. 1995. Housing choice and community success for individuals with serious and persistent mental illness. Community Mental Health Journal 31: 139-152.

Stein, L.I., and M.A. Test. 1980. Alternative to mental hospital treatment: I. Conceptual model, treatment programs, and clinical evaluation. Archives of General Psychiatry 37 (4): 392-397.

Stickley, T., R. Hitchcock, and G. Bertram. 2005. Social inclusion or social control? Homelessness and mental health. Mental Health Practice 8 (9): 26-30.

Stroup, S.T., J.P. McEvoy, M.S. Swartz, M.J. Byerly, I.D. Glick, J.M. Canive, M.F. McGee, G.M. Simpson, M.C. Stevens, and J.A. Lieberman. 2003. The National Institute of Mental Health clinical antipsychotic trials of intervention effectiveness (CATIE) project: Schizophrenia trial design arid protocol development. Schizophrenia Bulletin 29 (1): 15-31.

Sylvestre, J., M. Ollenberg, and J.A. Trainor. 2009. A model of housing stability for people with serious mental illness. Canadian Journal of Community Mental Health 28 (1): 195-207.

Tanzman, B. 1993. An overview of surveys of mental health consumers' preferences for housing and support services. Psychiatric Services 44 (5): 450-455.

Torrey, E.F. 1988. Nowhere to go: The tragic odyssey of the homeless mentally ill. New York, N.Y: Harper & Row.

Trainor, J., E. Pomeroy, and B. Pape. 1999. Building a framework for support: A community development approach to mental health policy. Toronto, ON: Canadian Mental Health Association.

Tsemberis, S., L. Gulcur, and M. Nakae. 2004. Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health 94 (4): 651-656.

Tutty, L., C. Bradshaw, J. Waegemakers Schiff, C. Worthington, B. McLaurin, J. Hewson, D. Dooley, S. Kean, and H. McLeod. 2009. Risks and assets for homelessness prevention: A literature review for the Calgary Homeless Foundation. Calgary: Calgary Homeless Foundation.

Vuckovich, P.K. 2010. Compliance versus adherence in serious and persistent mental illness. Nursing Ethics 17 (1): 77-85.

Waegemakers Schiff, J. 2001. The measurement of organizational culture in mental health clinics and the correlation of cultural dimensions with satisfaction with service. Dissertation, School of Social Work, Columbia University, New York.

Waegemakers Schiff, J., B. Schneider, and R. Schiff. 2007. Housing needs in the Calgary region f or persons with severe and persistent mental illness. Calgary, AB: Calgary Homeless Foundation, Mental Health Sector.

Weisberg, S. 1994. Housing policy for persons with mental illness in Ontario. Administration and Policy in Mental Health and Mental Health Services Research 21 (3): 227-228.

Yamashita, M. 1998. Family coping with mental illness: a comparative study. Journal of Psychiatric and Mental Health Nursing 5 (6): 515-523.

Rebecca Schiff

Justice Studies

University of Regina

Jeannette Waegemakers Schiff

Faculty of Social Work

Barbara Schneider

Faculty of Communication and Culture

University of Calgary