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Community-Based Services for Homeless Adults Experiencing Concurrent Mental Health and Substance Use Disorders: A Realist Approach to Synthesizing Evidence

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Abstract

Consultations with community-based service providers in Toronto identified a lack of strong research evidence about successful community-based interventions that address the needs of homeless clients experiencing concurrent mental health and substance use disorders. We undertook a collaborative research effort between academic-based and community-based partners to conduct a systematic evidence synthesis drawing heavily from Pawson’s realist review methodology to focus on both whether programs are successful and why and how they lead to improved outcomes. We examined scholarly and nonscholarly literature to explore program approaches and program elements that lead to improvements in mental health and substance use disorders among homeless individuals with concurrent disorders (CD). Information related to program contexts, elements, and successes and failures were extracted and further supplemented by key informant interviews and author communication regarding reviewed published studies. From the ten programs that we reviewed, we identified six important and promising program strategies that reduce mental health and, to a far lesser degree, substance use problems: client choice in treatment decision-making, positive interpersonal relationships between client and provider, assertive community treatment approaches, providing supportive housing, providing supports for instrumental needs, and nonrestrictive program approaches. These promising program strategies function, in part, by promoting and supporting autonomy among homeless adults experiencing CD. Our realist informed review is a useful methodology for synthesizing complex programming information on community-based interventions.

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Notes

  1. Community agencies forming the partnership with CRICH: Access Alliance; Ontario Federation of Indian Friendship Centres; Sistering, a Women’s Place; Street Health; South Riverdale Community Health Centre.

  2. CRICH faculty and research fellows had expertise in the following areas: social epidemiology, biostatistics, clinical psychology, sociology, family medicine, aboriginal health, ethics, public health sciences, knowledge translation, and social work.

References

  1. National Law Center on Homelessness and Poverty. Homelessness in the United States and the Human Right to Housing; 2004.

  2. Urban Institute. A New Look at Homelessness in America. Available from the Urban Institute, 2100 M Street, N.W., Washington, DC, 20037 or available at: http://www.urban.org.

  3. Hwang SW. Homelessness and health. Can Med Assoc J. 2001; 164(2): 229-233.

    CAS  Google Scholar 

  4. National Coalition for the Homeless 2006a. Health Care and Homelessness NCH Fact Sheet #8. Available at: http://www.nationalhomeless.org. Accessed on June, 1 2008.

  5. Street Health. The Street Health Report. Available at: http://www.streethealth.ca/Downloads/SHReport2007.pdf.

  6. Lehman AF, Cordray DS. Prevalence of alcohol, drug, and mental disorders among the homeless: one more time. Contemp Drug Probl. 1993; 20: 355-383.

    Google Scholar 

  7. National Coalition for the Homeless 2006b. Mental Illness and Homelessness NCH Fact Sheet #5. Available at: http://www.nationalhomeless.org. Accessed on June, 1 2008.

  8. National Resource and Training Center on Homelessness and Mental Illness 2003. Get the Facts. Available at: http://www.nrchmi.samhsa.gov. Accessed on June, 1 2008.

  9. Smith EM, North CS, Spitznagel EL. A systematic study of mental illness, substance abuse, and treatment in 600 homeless men. Ann Clin Psychiatry. 1992; 4: 111-120.

    Article  Google Scholar 

  10. Toro PA, ed. Homelessness. New York: Pergamon; 1998. Bellack AS, Hersen M, eds. Comprehensive Clinical Psychology, Ch. 8 in Vol. 9, Applications in diverse populations (pp. 119–135).

  11. Toro PA, Wall DD. Research on homeless persons: diagnostic comparisons and practice implications. Prof Psychol Res Pract. 1991; 22(6): 479-488.

    Article  Google Scholar 

  12. Toro PA. Toward an international understanding of homelessness. J Soc Issues. 2007; 63(3): 461-481.

    Article  Google Scholar 

  13. Drake RE, Osher FC, Wallach MA. Homelessness and dual diagnosis. Am Psychol. 1991; 46(11): 1149-1158.

    Article  CAS  PubMed  Google Scholar 

  14. Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. J Am Med Assoc. 1990; 264: 2511-2518.

    Article  CAS  Google Scholar 

  15. Substance Abuse and Mental Health Services Administration [SAMHSA]. Report to Congress on the Prevention and Treatment of Co-Occurring Substance Use Disorders and Mental Disorders. Washington, DC; 2003.

  16. Buckner JC, Bassuk E, Zima B. Mental health issues affecting homeless women: implications for intervention. Am J Orthopsychiatry. 1993; 63(6): 385-399.

    Article  CAS  PubMed  Google Scholar 

  17. Drake RE, Yovetich NA, Bebout RR, Harris M, McHugo GJ. Integrated treatment for dually diagnosed homeless adults. J Nerv Ment Dis. 1997; 185(5): 298-305.

    Article  CAS  PubMed  Google Scholar 

  18. Eberle M, Kraus D, Serge L, Pomeroy S, Hulchanski D. Homelessness—Causes and Effects. Victoria: Ministry of Social Development and Economic Security and BC Housing Management Commission; 2001.

    Google Scholar 

  19. Serge L, Kraus D, Goldberg M. Services to Homeless People with Concurrent Disorders: Moving Towards Innovative Approaches. Vancouver, Canada: 2006.

  20. Gelberg L, Linn LS, Usatine RP, Smith MH. Health, homelessness and poverty. A study of clinic users. Arch Int Med. 1990; 150: 2325-2330.

    Article  CAS  Google Scholar 

  21. Goering P, Pyke J, Bullock H. Health, Mental Health, and Addiction Treatment Needs of People Using Emergency Shelters in Toronto. City of Toronto; 2004.

  22. Goering P, Tolomiczenko G, Sheldon T, Boydell K, Wasylenki D. Characteristics of persons who are homeless for the first time. Psychiatr Serv. 2002; 53: 1472-1474.

    Article  PubMed  Google Scholar 

  23. O’Toole TP, Gibbon JL, Hanusa BH, Fine MJ. Preferences for sites of care among urban homeless and housed poor adults. J Gen Intern Med. 1999; 14(10): 599-605.

    Article  PubMed  Google Scholar 

  24. Denis JL, Lomas J. Convergent evolution: the academic and policy roots of collaborative research. J Health Serv Res Policy. 2003; 8(Suppl 2): 1-6.

    Article  PubMed  Google Scholar 

  25. Dobrow MJ, Goel V, Upshur RE. Evidence-based health policy: context and utilisation. Soc Sci Med. 2004; 58(1): 207-217.

    Article  PubMed  Google Scholar 

  26. Graham ID, Logan L, Harrison M, et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof. 2006; 26: 13-24.

    Article  PubMed  Google Scholar 

  27. Innvaer SGV, Trommald MAO. Health policy-makers’ pecrceptons of their use of evidence: a systematic review. J Health Serv Res Policy. 2002; 7: 239-244.

    Article  PubMed  Google Scholar 

  28. Jacobson N, Butterill D, Goering P. Development of a framework for KT: understanding user context. J Health Serv Res Policy. 2003; 8(2): 94-99.

    Article  PubMed  Google Scholar 

  29. Landry R, Lamari M, Amara N. Extent and determinants of utilization of university research in government agencies. Publ Admin Rev. 2003; 63(2): 193-205.

    Google Scholar 

  30. Lavis JN, Robertson D, Woodside J, McLeodm C, Abelson J. Knowledge Transfer Research Group. How can research organizations more effectively transfer research knowledge to decision makers? Milbank Q. 2003; 81: 171-172.

    Article  Google Scholar 

  31. Drake RE, O’Neal EL, Wallach MA. A systematic review of psychosocial research on psychosocial interventions for people with co-occurring severe mental and substance use disorders. J Subst Abuse Treat. 2008; 34(1): 123-138.

    Article  PubMed  Google Scholar 

  32. Dixon-Woods M, Agaral S, Jones D, Young B, Sutton A. Synthesising qualitative and quantitative evidence: a review of possible methods. J Health Serv Res Policy. 2005; 10(1): 45-53.

    Article  PubMed  Google Scholar 

  33. Mays N, Pope C, Popay J. Systematically reviewing qualitative and quantitative evidence to inform management and policy-making in the health field. J Health Serv Res Policy. 2005; 10(1): 6-20.

    Article  PubMed  Google Scholar 

  34. Petticrew M, Roberts H. Systematic Reviews in the Social Sciences: A Practical Guide. Oxford: Blackwell; 2006.

    Book  Google Scholar 

  35. Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist review: a new method of systematic review designed for complex policy interventions. J Health Serv Res Policy. 2005; 10(S1): 21-34.

    Article  PubMed  Google Scholar 

  36. Dixon-Woods M, Shaw RL, Agarwal S, Smith JA. The problem of appraising qualitative research. Qual Saf Health Care. 2004; 13: 223-225.

    Article  CAS  PubMed  Google Scholar 

  37. Popay J, Roberts H, Sowden A, et al. Guidance on the Conduct of Narrative Synthesis in Systematic Reviews: A Product from the ESRC Methods Programme. Lancaster: Institute for Health Research, Lancaster University; 2006.

    Google Scholar 

  38. Spencer L, Ritchie J, Lewis J, Dillon L. Quality in Qualitative Evaluation: A Framework for Assessing Research Evidence. London, UK; 2003.

  39. Pawson R. Evidence-Based Policy: A Realist Perspective. London: Sage; 2006.

    Google Scholar 

  40. Arai L, Roen K, Roberts H, Popay J. It might work in Oklahoma but will it work in Oakhampton? Context and implementation in the effectiveness literature on domestic smoke detectors. Inj Prev. 2005; 11: 148-151.

    Article  CAS  PubMed  Google Scholar 

  41. Blankertz LE, Cnaan RA. Assessing the impact of two residential programs for dually diagnosed homeless individuals. Soc Serv Rev. 1994; 68: 536-560.

    Article  Google Scholar 

  42. Cnaan RA, Blankertz L, Messinger KW, Gardner JR. Psychosocial rehabilitation: toward a definition. Psychosoc Rehabil J. 1988; 11(4): 61-77.

    Google Scholar 

  43. Lovell AN, Cohen M. The elaboration of “choice” in a program for homeless persons labeled psychiatrically disabled. Human Organ. 1998; 57(1): 8-20.

    Google Scholar 

  44. Greenwood R, Schaefer-McDaniel N, Winkel G, Tsemberis SJ. Decreasing psychiatric symptoms by increasing choice in services for adults with histories of homelessness. Am J Community Psychol. 2005; 36(3/4): 223-238.

    Article  PubMed  Google Scholar 

  45. Calsyn RJ, Morse GA, Klinkenberg WD, Lemming MR. Client outcomes and the working alliance in Assertive Community Treatment programs. Care Manage J. 2004; 5(4): 199-202.

    Article  Google Scholar 

  46. Shern DL, Tsemberis S, Anthony W, et al. Serving street-dwelling individuals with psychiatric disabilities: outcomes of a psychiatric rehabilitation clinical trial. Am J Public Health. 2000; 90(12): 1873-1878.

    Article  CAS  PubMed  Google Scholar 

  47. Padgett DK, Henwood B, Abrams C, Davis A. Engagement and retention in care among formerly homeless adults with serious mental illness: voices from the margins. Psychiatr Rehabil J. 2008; 31(3): 226-233.

    Article  PubMed  Google Scholar 

  48. Morse GA, Calsyn RJ, Klinkenberg WD, et al. Treating homeless clients with severe mental illness and substance use disorders: costs and outcomes. Community Ment Health J. 2006; 42(4): 377-403.

    Article  PubMed  Google Scholar 

  49. Essock SM, Mueser KT, Drake RE, et al. Comparison of ACT and standard case management for delivering integrated treatment for co-occurring disorders. Psychiatr Serv. 2006; 57: 185-196.

    Article  PubMed  Google Scholar 

  50. Meisler N, Blankertz L, Santos AB, McKay C. Impact of assertive community treatment on homeless persons with co-occurring severe psychiatric and substance use disorders. Community Ment Health J. 1997; 33(2): 113-122.

    Article  CAS  PubMed  Google Scholar 

  51. Tsemberis S, Moran L, Shinn B, Shern D, Asmussen S. Consumer preference programs for individuals who are homeless and have psychiatric disabilities: a drop-in center and a supported housing program. Am J Community Psychol. 2003; 32(3/4): 305-317.

    Article  PubMed  Google Scholar 

  52. Giddens A. Consequences of Modernity. Oxford: Polity; 1990.

    Google Scholar 

  53. Laing RD. The Divided Self: An Existential Study in Sanity and Madness. London: Pelican; 1965.

    Google Scholar 

  54. Padgett DK. There’s no place like (a) home: ontological security among persons with serious mental illness in the United States. Soc Sci Med. 2007; 64: 1925-1936.

    Article  PubMed  Google Scholar 

  55. Dupuis A, Thorns DC. Home, home ownership, and the search for ontological security. Socio Rev. 1998; 46(1): 24-47.

    Article  Google Scholar 

  56. Burnam MA, Morton SC, McGlynn EA, et al. An experimental evaluation of residential and nonresidential treatment for dually diagnosed homeless adults. J Addict Dis. 1995; 149(4): 111-134.

    Google Scholar 

  57. Harper E. Making good choices: how autonomy support influences the behavior change and motivation of troubled and troubling youth. Reclaiming Children and Youth. 2007; 16(3): 23-28.

    Google Scholar 

  58. Miquelon P, Vallerand R. Goal motives, well-being, and physical health: an integrative model. Can Psychol. 2008; 49(3): 241-249.

    Google Scholar 

  59. Ryan R, Deci E. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000; 55(1): 68-78.

    Article  CAS  PubMed  Google Scholar 

  60. Williams G, Gagne M, Mushlin A, Deci E. Motivation for behaviour change in patients with chest pain. Health Educ. 2005; 106(4): 304-321.

    Article  Google Scholar 

  61. White KR. The transition from victim to victor: an application of the theory of mastery. J Psychosoc Nurs Ment Health Serv. 1995; 33(8): 41-44.

    CAS  PubMed  Google Scholar 

  62. Pawson R, Tilley N. Realistic Evaluation. London: Sage; 1997.

    Google Scholar 

  63. Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist Synthesis: An Introduction. ESRC Research Methods Programme Working Paper Series. UK: University of Manchester; 2004.

    Google Scholar 

  64. Connelly J, Duaso M, Butler G. A systematic review of controlled trials of interventions to prevent childhood obesity and overweight: a realistic synthesis of the evidence. Publ Health. 2007; 121: 510-517.

    Article  CAS  Google Scholar 

  65. Greenhalgh T, Kristjansson ERV. Realist review to understand the efficacy of school feeding programs. BMJ. 2007; 335: 858-861.

    Article  PubMed  Google Scholar 

  66. Pawson R. Does Megan’s Law Work? A Theory Drive systematic Review. ESRC UK Centre for Evidence Based Policy and Practice: Working Paper 8. London; 2002.

  67. Egan M, Bambra C, Petticrew M, Whitehead M. Reviewing evidence on complex social interventions: appraising implementation in systematic reviews of the health effects of organisational-level workplace interventions. J Epidemiol Community Health. 2009; 63: 4-11.

    Article  CAS  PubMed  Google Scholar 

  68. Herbert R, Bo K. Analysis of quality of interventions in systematic reviews. BMJ. 2005; 331(3): 507-509.

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  70. Padgett D, Gulcur L, Tsemberis S. Housing first services for people who are homeless with co-occurring serious mental illness and substance abuse. Res Soc Work Pract. 2006; 16(1): 74-83.

    Article  Google Scholar 

  71. Srebnik D, Livingston J, Gordon L, King D. Housing choice and community success for individuals with serious and persistent mental illness. Community Ment Health J. 1995; 31(2): 139-152.

    Article  CAS  PubMed  Google Scholar 

  72. Shern DL, Tsemberis S, Winarski J, Cope N, Cohen M, Anthony W. The effectiveness of psychiatric rehabilitation for persons who are street dwelling with serious disability related to mental illness. In: In Breakey WR, Thompson JW, eds. Mentally Ill and Homeless. Amsterdam: Harwood Academic; 1997: 119-147.

    Google Scholar 

  73. McHugo GJ, Bebout RR, Harris M, et al. A randomized controlled trial of integrated versus parallel housing services for homeless adults with severe mental illness. Schizophr Bull. 2004; 30(4): 969-982.

    PubMed  Google Scholar 

  74. Essock SM, Frisman LK, Kontos NJ. Cost-effectiveness of assertive community treatment teams. Am J Orthopsychiatry. 1998; 68(2): 179-190.

    Article  CAS  PubMed  Google Scholar 

  75. Essock SM, Kontos N. Implementing assertive community treatment teams. Psychiatr Serv. 1995; 46: 679-683.

    CAS  PubMed  Google Scholar 

  76. Stecher BM, Andrews CA, McDonald L, et al. Implementation of residential and non-residential treatment for the dually diagnosed homeless. Eval Rev. 1994; 18(6): 689-717.

    Article  Google Scholar 

  77. Anonymous. Supportive residential services to reunite homeless mentally ill single parents with their children. Psychiatr Serv. 2000; 51(11): 1433–1435.

  78. Mares AS, Rosenheck RA. One-year housing arrangements among homeless adults with serious mental illness in the ACCESS program. Psychiatr Serv. 2004; 55(5): 566-574.

    Article  PubMed  Google Scholar 

  79. Bebout RR. Housing solutions. The community connections housing program: Preventing homelessness by integrating housing and supports. Alcohol. Treat Q. (1999); 17(1): 93-112.

    Article  Google Scholar 

  80. Blankertz L, White KK. Implementation of rehabilitation program for dually diagnosed homeless. Alcohol. Treat Q. (1990); 7(1): 149-164.

    Article  Google Scholar 

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Acknowledgements

This research was supported by a Canadian Institutes for Health Research Strategic Training Initiative in Health Research grant (STO-64598), the Ontario Ministry of Health and Long Term Care, and the Alma and Baxter Ricard Chair in Inner City Health (PO). We would like to thank the following individuals who participated in the research activities: Gladis Chow, Susan Clancy, Jessica Hill, Axelle Janczur, Erika Khandor, Kelly Murphy, Rosane Nisenbaum, Lynne Raskin, Anjali Sharma, Janet Smylie, Melissa Tapper, Charoula Tsamis, Qamar Zaidi, Carolyn Ziegler, and Marcqueline Chiona Zulu.

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Authors and Affiliations

  1. The Centre for Research on Inner City Health, The Keenan Research Centre, LiKaShing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada

    Patricia O’Campo, Maritt Kirst, Nicole Schaefer-McDaniel, Michelle Firestone, Allison Scott & Kelly McShane

  2. Dalla Lana School of Public Health, University of Toronto, Toronto, Canada

    Patricia O’Campo & Michelle Firestone

  3. Department of Psychology, Ryerson University, Toronto, Canada

    Kelly McShane

  4. Johns Hopkins Bloomberg School of Public Health, Baltimore, USA

    Patricia O’Campo

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  1. Patricia O’Campo
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Correspondence to Patricia O’Campo.

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O’Campo, P., Kirst, M., Schaefer-McDaniel, N. et al. Community-Based Services for Homeless Adults Experiencing Concurrent Mental Health and Substance Use Disorders: A Realist Approach to Synthesizing Evidence. J Urban Health 86, 965–989 (2009). https://doi.org/10.1007/s11524-009-9392-1

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