The vision of mental health recovery promoted by the President's New Freedom Commission portends a transformation of services for psychiatrically disabled persons, yet empirical research on recovery has not kept pace with its rhetorical appeal. For 'dual diagnosed'homeless persons, paths to recovery are even less described or understood despite the fact that they incur disproportionately high medical costs and live amidst concentrated disadvantage. Coincidentally with the recovery movement in the 1990s was the rise of 'housing first', a service approach for mentally ill homeless adults that distinctly contrasts with usual care, or 'treatment first'. Like mental health recovery, 'housing first'has received Federal and state endorsements yet is not yet widespread and remains understudied. This multi-phase qualitative longitudinal study will draw on relevant theoretical frameworks to examine mental health recovery among 'dual diagnosed homeless'adults entering residential services in New York City.
Specific Aims are: 1) To identify common elements and contexts of recovery among dual diagnosed homeless adults (DDHAs) served by 'housing first'(HF) and 'treatment first'(TF) programs.
This aim will be accomplished by using independent nominations criterion sampling to select individuals who manifest relatively high levels of functioning two years after entering a TF program (n=10) or a HF program (n=10). An additional 10 long-term (>5 years) HF and TF samples will be criterion-sampled and recruited. These 40 individuals will be interviewed in-depth and case study analyses used to develop one or more models of recovery to inform Aim 2;2) To conduct a prospective qualitative study of dual diagnosed homeless adults (DDHAs) entering HF and TF programs in order to document barriers and incentives for recovery and their 'real time'sequences and contexts. Model(s) developed in Aim 1 will inform Aim 2 inquiries into individual (Aim 2a), provider (Aim 2b) and organizational (Aim 2c) factors.
Aim 2 a will include 4 in-depth interviews over an 18-month period with 50 new enrollees (25 each at HF and TF programs), 3 interviews with their collateral persons, and 'shadowing'observation of a sub-sample of 10 enrollees (6 days per person).
Aim 2 b will include 3 interviews with their case managers and Aim 2c will involve targeted ethnographic visits to the program sites (n=24 visits). Individual case-centered data collection and analyses will be used to develop an inductive model of recovery relevant to dual diagnosed adults seeking to exit homelessness. Provider- and organization-centered data collection and analyses will be used to identify barriers and incentives to recovery-oriented services emanating from the service system context.
Aim 3 : To recommend changes that will facilitate implementation of recovery-oriented practices (ROPs) in working with the dual diagnosed homeless population.
This aim will involve integrating findings from Aims 1 and 2 to recommend organizational and provider- related changes needed to foster recovery among DDHAs. To accomplish this aim, we will conduct a preliminary study to explore whether these ROP recommendations are """"""""acceptable, appropriate and feasible"""""""" in three regional settings: New York City, Philadelphia, and Washington DC.
This aim i s intended to take the findings 'up and out'to explore their translatability in both HF and TF programs (6 programs in 3 cities). Specifically, we will conduct 15 focus groups, one with front-line staff and another with supervisory staff at each HF and TF program and one focus group of consumers per city. Data analyses from these groups will inform a set of recommendations for ROPs that take into account diverse settings and programs. The proposed study seeks to start broadly from the consumer's perspective, expand to include significant others (collaterals, case managers and organizations) and incorporate observational data to maximize analytic power and the potential for translation and dissemination to improve 'real world'services for a severely disadvantaged population.

Public Health Relevance

This proposed qualitative study addresses mental health recovery among homeless mentally ill adults with co-occurring substance abuse. Such individuals, who live amidst concentrated disadvantage and incur high medical and other costs, challenge the 'recovery paradigm'that has become prominent in mental health services. Drawing upon the President's New Freedom Commission report valuing consumer perspectives, it will produce guidelines designed to improve recovery-oriented practices for one of society's most difficult-to-reach populations.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Research Project (R01)
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Study Section
Mental Health Services in MH Specialty Settings (SRSP)
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Juliano-Bult, Denise M
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New York University
Schools of Social Work
New York
United States
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Tiderington, Emmy (2017) ""We Always Think You're Here Permanently"": The Paradox of ""Permanent"" Housing and Other Barriers to Recovery-Oriented Practice in Supportive Housing Services. Adm Policy Ment Health 44:103-114
Padgett, Deborah K; Tiderington, Emmy; Smith, Bikki Tran et al. (2016) Complex Recovery: Understanding the Lives of Formerly Homeless Adults with Complex Needs. J Soc Distress Homeless 25:60-70
Choy-Brown, Mimi; Padgett, Deborah; Smith, Bikki et al. (2016) Sorting it out: Eliciting consumer priorities for recovery in supportive housing. Am J Psychiatr Rehabil 19:223-234
Choy-Brown, Mimi; Stanhope, Victoria; Tiderington, Emmy et al. (2016) Unpacking Clinical Supervision in Transitional and Permanent Supportive Housing: Scrutiny or Support? Adm Policy Ment Health 43:546-54
Padgett, Deborah K; Smith, Bikki Tran; Choy-Brown, Mimi et al. (2016) Trajectories of Recovery Among Formerly Homeless Adults With Serious Mental Illness. Psychiatr Serv 67:610-4
Henwood, Benjamin F; Derejko, Katie-Sue; Couture, Julie et al. (2015) Maslow and mental health recovery: a comparative study of homeless programs for adults with serious mental illness. Adm Policy Ment Health 42:220-8
Henwood, Benjamin F; Padgett, Deborah K; Tiderington, Emmy (2014) Provider views of harm reduction versus abstinence policies within homeless services for dually diagnosed adults. J Behav Health Serv Res 41:80-9
Padgett, Deborah K; Smith, Bikki Tran; Derejko, Katie-Sue et al. (2013) A picture is worth . . . ? Photo elicitation interviewing with formerly homeless adults. Qual Health Res 23:1435-44
Henwood, Benjamin F; Cabassa, Leopoldo J; Craig, Catherine M et al. (2013) Permanent supportive housing: addressing homelessness and health disparities? Am J Public Health 103 Suppl 2:S188-92
Padgett, Deborah K; Smith, Bikki Tran; Henwood, Benjamin F et al. (2012) Life course adversity in the lives of formerly homeless persons with serious mental illness: context and meaning. Am J Orthopsychiatry 82:421-30

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