North Carolina Coalition to End Homelessness

Serving Street-Dwelling Individuals With Psychiatric Disabilities: Outcomes of a Psychiatric Rehabilitation Clinical Trial

Homelessness continues to be a serious public health problem in the United States. In addition to their poverty and housing needs, homeless individuals have multiple health and mental health problems. Best estimates indicate that approximately one third of homeless individuals have severe mental illness, with about one half comorbid for alcohol and substance abuse disorders and at least one half comorbid for health problems. Homeless individuals with mental illness also have greater problems with social and family relationships, employment, and the criminal justice system than do homeless individuals without mental illness.  These health, mental health, and social service problems require access to multiple human service systems, each with a unique set of eligibility requirements for participation.  While homeless persons with mental illness have been characterized as resistant to treatment because they often reject help offered by mental-health and other providers, we now believe that these individuals will use services when the services address their self-defined needs and are delivered in ways that facilitate rather than frustrate access.  Designing effective engagement strategies and minimizing barriers to access, however, continue to be major challenges for human service systems, which are typically characterized by limited resources, rigidly controlled eligibility requirements, and highly fragmented structures.  This study tested an alternative approach for organizing and delivering services to streetdwelling persons with severe mental illness. The experimental approach was specifically designed to overcome access barriers and any dissonance between offered services and subject-defined needs.  We hypothesized that owing to the individualized engagement strategies and rehabilitation techniques practiced at the experimental program, experimental subjects would obtain greater access to the full range of resources needed for successful community living. This would be evidenced by increased use of community services by experimental subjects compared with individuals in the standard treatment condition. Next, we predicted that individuals in the experimental condition would experience greater improvements in their housing status, evidenced by less time living on the streets and more in shelters and community housing. We thought that, given an improved housing status and better access to treatment and support resources, individuals in the experimental group would report higher quality of life than would control group participants. Improved access to treatment also suggested that experimental subjects would report a greater reduction in psychiatric symptoms. Finally, since a major focus of psychiatric rehabilitation is on achievement of individually defined goals, we expected that experimental subjects would report higher self-esteem and greater feelings of mastery. On the basis of technology developed at the Boston University Center for Psychiatric Rehabilitation,  an approach was crafted to address key structural and functional New York City service system deficits.
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David Shern
Author: David Shern
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