A clean and sober place to live: philosophy, structure, and purported therapeutic factors in sober living houses

The call for evidence-based practices (EBPs) in addiction treatment is nearly universal. It is a noteworthy movement in the field because treatment innovations have not always been implemented in community programs. However, other types of community-based services that may be essential to sustained recovery have received less attention. This article suggests that sober living houses (SLHs) are a good example of services that have been neglected in the addiction literature that might help individuals who need an alcohol- and drug-free living environment to succeed in their recovery. It begins with an overview of the history and philosophy of this modality and then describes our five-year longitudinal study titled, "An Analysis of Sober Living Houses." Particular attention is paid to the structure and philosophy of SLHs and purported therapeutic factors. It ends with the presentation of baseline data describing the residents who enter SLHs and six-month outcomes on 130 residents.

Path models of quality of life among people with schizophrenia living in the community in Hong Kong

The utilization of quality of life (QOL) in psychiatric community rehabilitation could be enhanced by developing an appropriate conceptual model of QOL. The focus of this study was to construct and test, using path analytic techniques, a pertinent conceptual model of QOL among people with schizophrenia living in the community. A total of 201 participants with schizophrenia living in the community were assessed with regard to their clinical characteristics and QOL. Findings largely supported the proposed model in which community/social functioning was the strongest predictor of QOL, followed by symptom levels. Important implications for the design and implementation of appropriate services in functioning augmentation that resulted in QOL enhancement were highlighted. Further recommendations on both clinical and environmental interventions to promote QOL were suggested.

[Is disulfiram (Antabus) indicated in the treatment of offenders with alcohol use disorders?]

BACKGROUND

Research studies and clinical experience provided us with valuable information about the efficacy of disulfiram. Although supervised disulfiram treatment has been shown to improve outcome in court-referred patients too it is obviously rarely used in German forensic hospitals.

METHOD

Two cases illustrated the application of disulfiram to constitute an adjunct to treatment of forensic inpatients.

RESULTS

Disulfiram can be used as an adjunct for maintenance of abstinence when the relapse risk is due to insufficient impulse control.

DISCUSSION

The decision to use disulfiram to assure sobriety for high risk groups, e.g. criminal offenders is discussed.

Relationship commitment and its implications for unprotected sex among impoverished women living in shelters and low-income housing in Los Angeles County

OBJECTIVE

To examine how relationship commitment among impoverished women is associated with their frequency of unprotected sex.

DESIGN

Cross-sectional analyses were conducted on survey data from a probability sample of 445 women initially sampled from shelters and low-income housing in Los Angeles County.

MAIN OUTCOME MEASURE

Frequency of unprotected sex in a typical month was derived as the product of 2 items: how often the woman had sex with her partner in a typical month and how often a male condom was used.

RESULTS

For both sheltered and housed women, relationship commitment predicted more frequent engagement in unprotected sex with their partner, even after controlling for the type of relationship (primary vs. casual). However, this association could not be accounted for by perceived partner monogamy, ability to refuse unwanted sex, perceived HIV susceptibility, and condom use self-efficacy. Among housed women only, never asking the partner to use a condom partially accounted for more frequent engagement in unprotected sex among women with stronger relationship commitment.

CONCLUSION

Results emphasize the importance of relationship commitment issues in HIV prevention interventions with impoverished women, and the need for a better understanding of relationship commitment and its influence on condom use in this population.

An examination of main and interactive effects of substance abuse recovery housing on multiple indicators of adjustment

AIMS

To assess the effectiveness of community-based supports in promoting abstinence from substance use and related problems.

DESIGN AND PARTICIPANTS

Individuals (n = 150) discharged from residential substance abuse treatment facilities were assigned randomly to either an Oxford House recovery home or usual after-care condition and then interviewed every 6 months for a 24-month period.

INTERVENTION

Oxford Houses are democratic, self-run recovery homes.

MEASUREMENTS

Hierarchical linear modeling was used to examine the effect of predictive variables on wave trajectories of substance use, employment, self-regulation and recent criminal charges. Regressions first examined whether predictor variables modeled wave trajectories by condition (Oxford House versus usual after-care), psychiatric comorbidity, age and interactions.

FINDINGS

At the 24-month follow-up, there was less substance abuse for residents living in Oxford Houses for 6 or more months (15.6%), compared both to participants with less than 6 months (45.7%) or to participants assigned to the usual after-care condition (64.8%). Results also indicated that older residents and younger members living in a house for 6 or more months experienced better outcomes in terms of substance use, employment and self-regulation.

CONCLUSIONS

Oxford Houses, a type of self-governed recovery setting, appear to stabilize many individuals who have substance abuse histories.

Community integration of adults with psychiatric disabilities and histories of homelessness

This study tests components of Wong and Solomon's (2002, Mental Health Services Research, 4(2), 13-28) model of community integration, identifying both the dimensions and predictors of integration. It evaluates community integration among adults with psychiatric disabilities assigned randomly to receive either independent scatter-site apartments with the Housing First approach (experimental) or services as usual (control). Factor analysis supported a definition of community integration that includes psychological, physical, and social domains, but also suggested the existence of another factor, independence/self-actualization. Regression analysis suggested that choice and independent scatter-site housing were predictors of psychological and social integration respectively. Psychiatric hospitalization, symptomatology and participation in substance use treatment were also found to influence aspects of integration. We discuss several issues that future studies should explore including the possibility that the same factor can differentially influence discrete aspects of integration, the role of person-environment fit, integration that is not based in the neighborhood, and, finally, conceptions of community integration from the perspective of consumers themselves.

[Expressed emotions (EE) towards schizophrenic patients among staff members of psychiatric wards and hostels: comparison and clinical implications]

Expressed emotion (EE) is an interactive criterion that describes the amount and quality of emotional communication between schizophrenic patients and their families or institutional care takers. EE is empirically related to the prognosis of the disease across cultures and therapeutic settings. This study compares results of EE assessments among psychiatric wards staff and hostels staff members. Our findings indicate that in each therapeutic milieu there is correlation between the institutional culture and the expected roles and behaviors of the patient. In the psychiatric hospital the most rejected patient is the psychotic patient presenting disturbances in thought and behavior, while the patient that is not rejected is the withdrawn non-active and not disturbing individual. In the hostel, the situation differs: the expectations from the patients are high functional levels in all fields, and therefore, the most rejected patients are those who are less functional in their initiative and occupational skills. Our findings also relate to the ability of staff members to change their attitudes towards patients in the two milieus. The findings of the comparison we performed indicate the advantages of the hostel staff's characteristics in the treatment of schizophrenia patients, and suggest specific recommendations for staff training in both milieus. The study highlights issues to be considered to ensure optimal functioning of the hostel as an appropriate setting for the treatment of schizophrenic patients.

The barriers to patient-driven treatment in mental health: why patients may choose to follow their own path

PURPOSE

The paper aims to explore the barriers that currently exist to patient-driven treatment within the field of mental health care and reform.

DESIGN/METHODOLOGY/APPROACH

This study represents action learning research using grounded theory to explore a possible causal basis for recidivism related to non-compliance with medication. Interviews addressed concerns from the literature around perceived barriers to patient-driven treatment evidenced by non-compliance with medically recommended pharmaceutical treatment. Results were correlated to look for emergent themes that were used to form the basis for subsequent interview questions.

FINDINGS

An analysis of the resulting emergent themes illustrated the importance of participatory treatment and coaching rather than medically applied paternalistic care, which is seen as encouraging learned helplessness on the part of patients. Similar helplessness was also revealed in clinicians themselves. Patients' awareness of their own needs and demands for more services place clients and the caregivers at odds over appropriate care in an environment of limited resources.

RESEARCH LIMITATIONS/IMPLICATIONS

The research was limited to only a small number of interviewees in one institution, all of whom were closely associated with mental illness in various capacities. The grounded theory nature of the research does, however, provide a framework for more research in other institutions to test and further explore some of the findings.

PRACTICAL IMPLICATIONS

The study demonstrated a reinforcement of Maslow's theory of needs hierarchy. The study illustrated a step-wise approach to treatment to decrease the rate of failure and recidivism in mental health care. The provision of a stable living environment was viewed as instrumental in improving patients' compliance with pharmaceutical treatment. An action plan was therefore created to initiate the support of a transitional/emergency house by various community groups in partnership with pharmaceutical manufacturing companies.

ORIGINALITY/VALUE

Recidivism in mental health-created by non-compliance in pharmaceutical treatment, is a major issue in Canada's health care system. This study brings to the forefront issues from a number of perspectives in order to form a course of action in response to its findings.

Sex differences in social support and self-efficacy within a recovery community

This study examined similarities and differences in social support and self-efficacy for abstinence between women and men recovering from substance addiction. The sample consisted of 87 residents of Oxford House (OH) self-run, community-based recovery homes. Analyses revealed similarities between women and men in terms of the composition and utilization of support networks and abstinence self-efficacy. Also, for both sexes, length of residency in OH was significantly related to decreased social support for alcohol and drug use and increased self-efficacy for abstinence. However, multiple-group SEM analyses demonstrated that social support for alcohol/drug use fully mediated the link between length of residency and abstinence self-efficacy for women, but not for men. Findings suggest that the process of gaining self-efficacy to remain abstinent is distinct for women and men, and that social support plays a different role in women's recovery than it does in men's.

Screening offenders with histories of mental illness and violence for supportive housing

This article describes a community mental health agency's process of screening supportive housing applicants with histories of violent felonies and serious mental illness. The agency adopted its corporate intranet as a tool so that geographically dispersed senior staff could participate in information gathering in order to ensure expert input in admissions decisions. This broad-based participation was designed to maintain community safety, while making the agency's residential resources available to people with mental illness and criminal histories. Considering the high recidivism rate of ex-offenders with mental illness and lack of clearly established best practices to serve them in the community, the authors believe that it is timely for housing providers to reevaluate how to better serve these individuals.

Substance abuse treatment and hospitalization among a cohort of HIV-infected individuals with alcohol problems

BACKGROUND

We examined the association of substance abuse treatment services on hospitalization among participants in the HIV-Alcohol Longitudinal Cohort (HIV-ALC) study of HIV-infected individuals with a history of alcohol problems.

METHODS

A standardized questionnaire that inquired about demographics, substance use, use of substance abuse treatment services, and hospitalization was administered to 349 HIV-ALC participants. We defined substance abuse treatment services as any of the following in the past 6 months: 12 weeks in a half-way house or residential facility, 12 visits to a substance abuse counselor or mental health professional, or participation in any methadone maintenance program.

RESULTS

Almost one third of this cohort were hospitalized in the past 6 months. Substance abuse treatment was not significantly associated with hospitalization [adjusted odds ratio (AOR) 1.0; 95% confidence interval (CI) 0.7-1.5), whereas homelessness (AOR 2.3; 95% CI 1.5-3.6), injection drug use (AOR 1.7; 95% CI 1.0-2.7), severity of alcohol dependence (AOR 1.02; 95% CI 1.00-1.05), CD4 cell count (AOR 0.999; 95% CI 0.998-1.00), and HIV RNA (AOR 1.1; 95% CI 1.0-1.2) were independently associated with increased odds of hospitalization over time.

CONCLUSIONS

Engagement in substance abuse treatment was not associated with a decrease in hospital use by HIV-infected individuals with a history of alcohol problems. The period of substance abuse treatment may present an opportunity to address health care utilization patterns of HIV-infected individuals.

Educating the Staff at a Homeless Shelter About Mental Illness and Anger Management

The purpose of this project was to assess the educational needs of the staff working at an urban homeless shelter for women and children, in terms of their knowledge about mental illness, and to provide educational sessions at the site based on the needs assessment. Needs were determined through a variety of sources including a survey designed to assess knowledge about mental illness and perceived learning needs, observations of staff interactions, and discussions with the director of the shelter. The ultimate goal was to have a positive impact on the treatment outcomes of the residents at this shelter by increasing the knowledge and skill level of the staff regarding working with clients with mental health conditions and with clients who exhibit angry behaviors. Most staff members interviewed several weeks after the educational sessions demonstrated application and retention of the information taught.

Community care manager who stole money from her clients

Marion was a registered nurse for patients with learning disabilities. She had worked in many residential settings for people with learning disabilities and was sent on secondment to her local social services to take up a post as a care manager for a group of vulnerable clients in the community. Her experience of community care was very limited but she was given the chance of the role because of her excellent employment record and her enthusiasm for the care of this type of client.

Nonviolent offenders' and college students' attachment and social support behaviors: implications for counseling

This study examines the relationships between adult attachment orientations and the ability to seek social support as factors in mediating behavior. Data were collected on non violent offenders (n = 57) and college students (n = 89). The results indicated the non-normative group of nonviolent offenders reported being more securely attached and having more satisfaction with their social supports than the normative group of college students. Fewer college students reported being securely attached than the nonviolent offenders but had a larger number of social supports. In the insecure categories, nonviolent offenders reported being more dismissively attached whereas college students reported being preoccupied in their attachment orientation. The study suggests that attachment and social-support-seeking behaviors across different populations may be potential factors in designing counseling services that are used for risk classification and needs assessment.

Goals of new long-stay patients in supported housing: a UK study

AIM

This study assessed the goals 'new' long-stay clients aim to achieve by being in supported housing (SH), compared the goals stated by clients and staff, and tested whether subgroups of clients can be identified on the basis of their goals, quality of life and psychopathology.

METHOD

Interviews were conducted with 41 clients and 39 staff of supported houses in London and Essex, UK. Descriptive, content and cluster analyses were used to analyse the results.

RESULTS

Clients' most frequently reported goal was moving to independent housing, followed by staying healthy, and increasing living skills. A comparison of goals reported by clients and staff showed poor or no agreement between them. Cluster analyses identified two clusters of clients. Cluster A (n = 23) contained those with no stated goals (or with the aim of staying healthy), lower quality of life, and more psychopathology; cluster B (n = 18) included those with an aim to move to independent housing, better quality of life, and less psychopathology.

CONCLUSION

In the UK, more staff training may be needed to identify and achieve the goals of the 'new' long-stay clients. For a subgroup of these clients, SH may still be a long-term care setting; while for another subgroup, new forms of rehabilitation in SH and better opportunities to leave SH may have to be developed. More conceptual and practical efforts are needed to manage the transformation of many settings from homes for life to transitional places where residents receive specific interventions.

Employment outcomes in Massachusetts Clubhouses

Employment outcomes of individuals participating in 17 Massachusetts Clubhouses certified by the International Center for Clubhouse Development were examined through an annual survey. Major components of employment programs in contemporary clubhouses are identified and individual employment outcomes are described. Within contemporary practice in ICCD clubhouses in this sample, clubhouses provided a three-pronged approach to employment. Between 1998-2001, 1702 individuals worked in 2714 separate job placements, employed in Transitional (TE), Supported (SE), and Independent Employment (IE). Forty percent of members with more than one job (N = 385) participated in at least one TE. Individuals with longer memberships tended to work longer and had higher job earnings.

[Assessing deinstitutionalization of the nursing home area of a large state mental hospital from the point of view of patients and staff]

OBJECTIVE

Within the deinstitutionalization process of a large psychiatric hospital, the development of two cohorts of patients with chronic schizophrenia is compared over a two-year period: patients living in the hospital's nursing-home area (n = 50) vs. patients already released to two social therapeutic hostels (n = 51). Results of the cohort study were compared with assessments of nurses working in the nursing home (n = 55), focusing on their subjective views of the deinstitutionalization process and its impact on their working conditions.

METHODS

Patients are assessed through yearly home-visits in their place of residence. The instruments used measure several outcome parameters: psychopathology, social disabilities, subjective quality of life, and normative needs for care. Concurrent staff assessments were conducted using standardized survey instruments focusing on current working conditions and quality of teamwork. Nineteen nurses participated in qualitative interviews evaluating the deinstitutionalization process.

RESULTS

For all measures, patients living in the nursing home show significantly worse outcomes. Furthermore, during the study period 34 % experienced a change in their living situation with which they were dissatisfied. Needs for care and the number of areas of "unmet" need increased significantly for this subgroup. Patients living in social therapeutic hostels demonstrate stable levels of psychopathological symptoms, social disabilities, and needs for care. Assessments indicating a deterioration in patients' subjective quality of life focus mainly on areas important for social contacts. Regarding "personal concerns" and "insecurity at work", ratings from nursing home staff were significantly worse than those of a reference group from several other health care institutions (n = 224). Staff showed a tendency to give higher ratings for their opportunities to participate in decisions, in contrast with the low ratings for chances to improve their knowledge in the workplace, a result which may indicate a lack of prospects. In general, staff faces the conundrum of being asked to adopt a new mental health care paradigm while organisational structures are being eliminated and insecurity about career opportunities is increasing.

CONCLUSION

To adequately manage deinstitutionalization of care, all participating parties must be involved in the process as early as possible to clarify expectations and to demonstrate commitment to future opportunities in the new system.

Evaluation of treatment programs for persons with severe mental illness: moderator and mediator effects

This study evaluated several statistical models for estimating treatment effects in a randomized, longitudinal experiment comparing assertive community treatment (ACT) versus brokered case management (BCM). In addition, mediator and moderator analyses were conducted. The ACT clients had improved outcomes in terms of housing and psychiatric symptoms than BCM clients. Case management housing assistance and financial assistance partially mediated housing outcomes. No reliable mediators were found for psychiatric symptoms, and no reliable moderators were found for either housing or psychiatric symptoms. The study also made several important methodological advances in the analysis of longitudinal data in randomized experiments.

Mental health, burnout and job satisfaction among professionals in sheltered living in Flanders. A pilot study

BACKGROUND

Interest has been growing over the last few years in the working conditions of professionals who deal with clients with severe and chronic mental illnesses. In this study, the relationship between the affective climate, as measured by the construct of expressed emotion, and professionals' feelings of well-being and burnout was investigated. It was hypothesised that high expressed emotion (EE) (= a high amount of criticism, hostility or emotional overinvolvement) would be related to high burnout scores.

METHODS

Fifty-six professionals were interviewed about their schizophrenic clients who resided in sheltered-living houses in Flanders. EE was measured with two instruments, the Camberwell Family Interview (CFI) and the Perceived Criticism Scale (PCS). The professionals' characteristics were mental health (Symptom Checklist, SCL-90), job satisfaction (VEVAK), and burnout (a Dutch version of the Maslach Burnout Inventory, UBOS-C).

RESULTS

Little indication was found for an association between EE and working conditions as measured with the CFI. For the PCS, a significant relationship was found between the resident version of the PCS and burnout. The professionals who were perceived by the residents as being very critical were less depersonalised and less emotionally exhausted than those who were not so perceived.

CONCLUSIONS

High EE relationships can exist without feelings of stress and burnout.

Optimism, abstinence self-efficacy, and self-mastery: a comparative analysis of cognitive resources

The relationship between optimism, abstinence self-efficacy, and self-mastery was examined by investigating levels of these cognitive resources among two samples of recovering substance abusers: Oxford House residents who attended twelve-step groups and twelve-step members who had never lived in an Oxford House. Participants 'levels of optimism were significantly and positively related to both abstinence self-efficacy and self-mastery scores, as abstinence self-efficacy was significantly and positively related to participants' number of days abstinent. Participants who reported having more than 180 days abstinent reported significantly higher levels of abstinence self-efficacy than participants who reported having less than 180 days abstinent. In addition, among participants who reported having less than 180 days abstinent, Oxford House residents reported significantly higher levels of abstinence self-efficacy than twelve-step members. Overall, findings suggest that cognitive resources facilitate substance abusers' recovery and that the Oxford House model might provide high levels of support in their ongoing abstinence.

The MICA Case Conference Program at Tewksbury Hospital, Mass.: an integrated treatment model

This report describes the MICA (Mentally Ill Chemically Abusing) Program at the Tewksbury Hospital campus in Tewksbury, Massachusetts. Several campus facilities collaborate in the MICA Program. Through Expert Case Conferences, principles of integrated psychosocial treatment with dual diagnosis patients are demonstrated. An expert clinician focuses on the interplay between psychological pain, characterological traits, defenses, and the patient's drug of choice. Patients who have participated in the program have reported positive experiences. The staff reported that the program has resulted in facility improvement in assessment and treatment of complex dual diagnosis patients.

System flexibility in the rehabilitation process of mentally disabled persons in a hostel that bridges between the hospital and the community

BACKGROUND

Deinstitutionalization and community mental health services have become the focus of mental health care in the United States, Italy and England, and now in Israel.

METHODS

Tirat Carmel MHC developed an intervention model of organizational change implemented in a rehabilitation hostel. It is an interim service based on graduated transition from maintenance care to a transitional Half-way House, followed by a Transitional Living Skills Center oriented for independent community living.

RESULTS

Of 205 rehabilitees who resided in the hostel since the beginning of the project, 138 were discharged to community residential settings: 67 patients were discharged to reinforced community hostels; 27 to sheltered housing and 23 to independent residential quarters; 7 patients were discharged to comprehensive hostels, 3 to old-age homes and 11 returned home to their families. In terms of employment, 79 were placed in sheltered employment facilities, 24 work in the open market and 3 returned to school; 22 work in therapeutic occupational settings and 10 patients discharged to comprehensive hostels and old-age homes are engaged in sheltered employment programs in those settings.

CONCLUSION

The system flexibility model and the rehabilitation processes anchored in normalization supported the relocation of hospitalized psychiatric patients to community-based settings and enabled the rehabilitees to cope with readjustment to community life.