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

Persuasion or coercion? An empirical ethics analysis about the use of influence strategies in mental health community care

Background

Influence strategies such as persuasion and interpersonal leverage are used in mental health care to influence patient behaviour and improve treatment adherence. One ethical concern about using such strategies is that they may constitute coercive behaviour ("informal coercion") and negatively impact patient satisfaction and the quality of care. However, some influence strategies may affect patients' perceptions, so an umbrella definition of “informal coercion” may be unsatisfactory. Furthermore, previous research indicates that professionals also perceive dissonance between theoretical explanations of informal coercion and their behaviours in clinical practice. This study analysed mental health professionals’ (MHPs) views and the perceived ethical implications of influence strategies in community care.

Methods

Qualitative secondary data analysis of a focus group study was used to explore the conflict between theoretical definitions and MHPs’ experiences concerning the coerciveness of influence strategies. Thirty-six focus groups were conducted in the main study, with 227 MHPs from nine countries participating.

Results

The findings indicate that not all the influence strategies discussed with participants can be defined as “informal coercion”, but they become coercive when they imply the use of a lever, have the format of a conditional offer and when the therapeutic proposal is not a patient’s free choice but is driven by professionals. MHPs are rarely aware of these tensions within their everyday practice; consequently, it is possible that coercive practices are inadvertently being used, with no standard regarding their application. Our findings suggest that levers and the type of leverage used in communications with the patient are also relevant to differentiating leveraged and non-leveraged influence.

Conclusion

Our findings may help mental health professionals working in community care to identify and discuss influence strategies that may lead to unintended coercive practices.

Exploring factors related to supportive housing tenure and stability for people with serious mental illness

Overall, the retention of people with serious mental illness (SMI) in supportive housing is high. However, some supportive housing settings report average stays of only 15 months, and others report declines in housing retention over time. Many studies report variables associated with supportive housing stability and tenure, but there are few extensive, focused investigations on the subject. Hence, a literature review was conducted to investigate factors associated with supportive housing stability and tenure among people with SMI. The review of the included 28 papers reveals that the factors associated with supportive housing stability and tenure fell into two general categories of individual factors (including psychiatric factors and prior homelessness), and contextual factors (including program characteristics and sense of community and social support). In conclusion, further focus on contextual factors, as well as a potential reframing of individual factors as contextual, may be helpful in addressing issues related to supportive housing stability and tenure for people with SMI.

Preventing and reducing 'coercion' in mental health services: an international scoping review of English-language studies

This article discusses initiatives aimed at preventing and reducing 'coercive practices' in mental health and community settings worldwide, including in hospitals in high-income countries, and in family homes and rural communities in low- and middle-income countries. The article provides a scoping review of the current state of English-language empirical research. It identifies several promising opportunities for improving responses that promote support based on individuals' rights, will and preferences. It also points out several gaps in research and practice (including, importantly, a gap in reviews of non-English-language studies). Overall, many studies suggest that efforts to prevent and reduce coercion appear to be effective. However, no jurisdiction appears to have combined the full suite of laws, policies and practices which are available, and which taken together might further the goal of eliminating coercion.

Unpacking Clinical Supervision in Transitional and Permanent Supportive Housing: Scrutiny or Support?

Behavioral health organizations use clinical supervision to ensure professional development and practice quality. This qualitative study examined 35 service coordinators' perspectives on supervision in two distinct supportive housing program types (permanent and transitional). Thematic analysis of in-depth interviews yielded three contrast themes: support versus scrutiny, planned versus impromptu time, and housing first versus treatment first. Supervisory content and format resulted in differential perceptions of supervision, thereby influencing opportunities for learning. These findings suggest that unpacking discrete elements of supervision enactment in usual care settings can inform implementation of recovery-oriented practice.

Clinical Relevance of Informal Coercion in Psychiatric Treatment-A Systematic Review

INTRODUCTION

Although informal coercion is frequently applied in psychiatry, its use is discussed controversially. This systematic review aimed to summarize literature on attitudes toward informal coercion, its prevalence, and clinical effects.

METHODS

A systematic search of PubMed, Embase, PsycINF, and Google Scholar was conducted. Publications were included if they reported original data describing patients' and clinicians' attitudes toward and prevalence rates or clinical effects of informal coercion.

RESULTS

Twenty-one publications out of a total of 162 articles met the inclusion criteria. Most publications focused on leverage and inducements rather than persuasion and threat. Prevalence rates of informal coercion were 29-59%, comparable on different study sites and in different settings. The majority of mental health professionals as well as one-third to two-third of the psychiatric patients had positive attitudes, even if there was personal experience of informal coercion. We found no study evaluating the clinical effect of informal coercion in an experimental study design.

DISCUSSION

Cultural and ethical aspects are associated with the attitudes and prevalence rates. The clinical effect of informal coercion remains unclear and further studies are needed to evaluate these interventions and the effect on therapeutic relationship and clinical outcome. It can be hypothesized that informal coercion may lead to better adherence and clinical outcome but also to strains in the therapeutic relationship. It is recommendable to establish structured education about informal coercion and sensitize mental health professionals for its potential for adverse effects in clinical routine practice.

"Life on hold": a qualitative study of patient experiences with outpatient commitment in two norwegian counties

In recent decades, outpatient commitment orders have been increasingly used in the follow-up of persons with serious mental disorders. Most studies on outpatient commitment orders have focused on compliance and consumption of health care services; there is little research on the content of outpatient commitment orders from a patient perspective. The aim of this study is to examine patients' experiences of living with outpatient commitment orders, and is based on qualitative interviews with 16 persons in two Norwegian counties. The data were analysed using a constructivist, interpretive approach to the grounded theory method. The main finding was that patients with outpatient commitment orders felt that their lives were on hold. The feeling of being seen only as patients prevented them from taking responsibility for their own lives. The medical context was perceived as an obstacle to recovery and transition to a more normal life. Patients' daily lives were dominated by the agenda set by health care providers and many said they were subjected to control measures that resulted in a reduced quality of life. However, informants also spoke of positive experiences as outpatient commitment order patients, such as feeling safe and secure and having easy access to health care staff and services.

Examining Provider Perspectives within Housing First and Traditional Programs

Pathways' Housing First represents a radical departure from traditional programs that serve individuals experiencing homelessness and co-occurring psychiatric and substance use disorders. This paper considered two federally funded comparison studies of Pathways' Housing First and traditional programs to examine whether differences were reflected in the perspectives of frontline providers. Both quantitative analysis of responses to structured questions with close-ended responses and qualitative analysis of open-ended responses to semistructured questions showed that Pathways providers had greater endorsement of consumer values, lesser endorsement of systems values, and greater tolerance for abnormal behavior that did not result in harm to others than their counterparts in traditional programs. Comparing provider perspectives also revealed an "implementation paradox"; traditional providers were inhibited from engaging consumers in treatment and services without housing, whereas HF providers could focus on issues other than securing housing. As programs increasingly adopt a Housing First approach, implementation challenges remain due to an existing workforce habituated to traditional services.

Where harm reduction meets housing first: exploring alcohol's role in a project-based housing first setting

BACKGROUND

Housing first (HF) programmes provide low-barrier, nonabstinence-based, immediate, supportive and permanent housing to chronically homeless people who often have co-occurring substance-use and/or psychiatric disorders. Project-based HF programmes offer housing in the form of individual units within a larger housing project. Recent studies conducted at a specific project-based HF programme that serves chronically homeless individuals with alcohol problems found housing provision was associated with reduced publicly funded service utilisation, decreased alcohol use, and sizable cost offsets. No studies to date, however, have qualitatively explored the role of alcohol use in the lives of residents in project-based HF.

METHODS

We collected data in a project-based HF setting via naturalistic observation of verbal exchanges between staff and residents, field notes taken during staff rounds, and audio recorded staff focus groups and resident interview sessions. Qualitative data were managed and coded using a constant comparative process consistent with grounded theory methodology. The goal of the analysis was to generate a conceptual/thematic description of alcohol's role in residents' lives.

RESULTS

Findings suggest it is important to take into account residents' motivations for alcohol use, which may include perceived positive and negative consequences. Further, a harm reduction approach was reported to facilitate housing attainment and maintenance. Residents and staff reported that traditional, abstinence-based approaches are neither desirable nor effective for this specific population. Finally, elements of the moral model of alcohol dependence continue to pervade both residents' views of themselves and the community's perceptions of them.

CONCLUSIONS

Findings suggest it is necessary to set aside traditional models of alcohol use and approaches to better understand, align with, and address this population's needs. In doing so, we might gain further insights into how to enhance the existing project-based HF approach by applying more tailored, alcohol-specific, harm reduction interventions.

Substance Abuse Recovery after Experiencing Homelessness and Mental Illness: Case Studies of Change Over Time

OBJECTIVE: This paper addresses how consumers with dual diagnosis, who were formerly homeless but are now living in supportive housing, understand their recovery from substance abuse (i.e., substance abuse or dependence). Specifically, this study examined: What can be learned about substance abuse recovery from consumers considered to be doing well; how past substance abuse fits into their present-day narratives; and how (if at all) policies of harm reduction versus abstinence are regarded as affecting recovery efforts. METHODS: As part of a federally-funded qualitative study, 38 individuals who met criteria for having achieved a measure of success in mental health recovery were purposively sampled from two supportive housing agencies - one using a harm reduction and the other an abstinence model. Researchers conducted in-depth interviews and used case study analysis, the latter including the development of case summaries and data matrices, to focus on substance abuse recovery in the larger context of participants' lives. RESULTS: Recovery from substance abuse was depicted as occurring either through discrete decisions or gradual processes; achieving recovery was distinct from maintaining recovery. Emergent themes related to achievement included: (a) pivotal events and people (b) maturation, and (c) institutionalization. Central themes to maintaining recovery were: (a) housing, (b) self-help, and (c) the influence of significant others. CONCLUSIONS: These findings capture a complex picture of overcoming substance abuse that largely took place outside of formal treatment and was heavily dependent on broader contexts. Equally important is that consumers themselves did not necessarily view substance abuse recovery as a defining feature of their life story. Indeed, recovery from substance abuse was seen as overcoming one adversity among many others during their troubled life courses.

Predictors of health services utilization among persons with psychiatric disabilities engaged in supported independent housing

OBJECTIVE

Persons with psychiatric disabilities are at greater risk for medical comorbidity, and prior research suggests these persons may underutilize health services. In response, this study examined the impact of engagement in psychiatric rehabilitation services, including case management, on utilization of general health services among persons with psychiatric disabilities engaged in supported housing, while controlling for demographic and clinical characteristics.

METHODS

Poisson regression analyses were used to examine the impact of socio-demographic, clinical, and service characteristics on reported utilization of general health services in the past year.

RESULTS

Findings indicated supported housing residents receiving case management coupled with weekly contact with residential support services visited a general health practitioner more frequently than those with less support services.

CONCLUSIONS AND IMPLICATIONS

Study results suggest psychiatric rehabilitation services provided to persons in the context of safe and affordable housing may represent an important mechanism for enabling persons with psychiatric disorders to access needed medical care.

The role of housing: a comparison of front-line provider views in housing first and traditional programs

PURPOSE

Within the mental health system, there are two distinct service models for adults who have severe mental illness and are homeless: one prioritizes treatment before accessing permanent housing (Treatment First) while the other provides permanent housing upfront followed by clinical support (Housing First). Investigating front-line providers working within these two models affords an opportunity to learn more about their implementation from an insider perspective, thus shedding light on whether actual practice is consistent with or contrary to these program models' contrasting philosophical values.

METHODS

Forty-one providers were recruited from four agencies as part of a NIMH funded qualitative study. Multiple, in-depth interviews lasting 30-45 min were conducted with providers that explored working within these agencies. Thematic analysis was utilized to compare the views of 20 providers working in Housing First versus the 21 providers working in Treatment First programs.

RESULTS

Providers viewed housing as a priority but differences emerged between Treatment First and Housing First providers along three major themes: the centrality of housing, engaging consumers through housing, and (limits to...) a right to housing.

CONCLUSION

Ironically, this study revealed that providers working within Treatment First programs were consumed with the pursuit of housing, whereas Housing First providers focused more on clinical concerns since consumers already had housing. Clearly, how programs position permanent housing has very different implications for how providers understand their work, the pressures they encounter, and how they prioritize client goals.

The role of an Australian homeless health outreach team. Part 2: a case study

Background

Throughout the western world, the issue of homelessness has been receiving increasing attention. As a government response to homelessness in Australia, the Queensland State Government developed a strategic plan to address this issue, establishing Homeless Health Outreach Teams.

Contents

This article follows on from the previous issue, where the background to a team's formation is discussed. This article continues this discussion by describing a case study of a homeless service user. The areas that are addressed include the team involvement, recommendations for continuing treatment, and the practical ways in which the service user was assisted.

Conclusions

A key feature of team's work was the close working relationships established with both the non-government and government sectors in order to address the service user's complex needs. The work was challenging, but the potential of working in this way with a population experiencing homelessness is only limited by the creativity of the team.

Tracking residential outcomes of supported independent living programs for persons with serious mental illness

This study seeks to document patterns and reasons of leaving housing, and identify factors associated with different types of exits for a cohort of 452 residents with serious mental illness entering supported independent living (SIL) in Philadelphia, PA. The study cohort was tracked through an integrated administrative database comprised information on basic demographic and clinical characteristics, length of stay, homeless shelter use, and publicly funded behavioral health services use. A convenience sample of 46 SIL leavers and their support staff provided data on scenarios of leaving. The findings of this study suggest that departure from SIL is not a unitary phenomenon, but involving plausibly favorable as well as unfavorable circumstances. Multivariate analysis based on administrative tracking data suggests demographic and clinical factors, housing setting, and service use factors to have effects on leaving SIL and distinct types of exit examined in this study. Data procured from the convenience sample highlight the potential roles that program rules and resident-staff relationships play in affecting housing tenure. Implications of the findings for the development of permanent supportive housing for persons with serious mental illness are discussed.

Engagement and retention in services among formerly homeless adults with co-occurring mental illness and substance abuse: voices from the margins

This qualitative study analyzed 72 interviews with 39 formerly homeless psychiatric consumers to develop a grounded theory model of engagement and retention in mental health and substance abuse services. Person-centered themes included severity of mental illness and substance abuse (the latter also conflicting with programmatic abstinence requirements). System-related themes inhibiting service use included program rules and restrictions and a lack of one-on-one therapy. Those promoting service use were acts of kindness by staff, pleasant surroundings, and the promise (or attainment) of independent housing. Implications of these findings are discussed in terms of integrating consumers' opinions about services to enhance treatment engagement and retention.

ACT and recovery: integrating evidence-based practice and recovery orientation on assertive community treatment teams

We examine whether Assertive Community Treatment (ACT), a widely implemented and rigorously studied practice, can successfully incorporate a recovery-oriented approach while continuing to retain program fidelity. We briefly review the effectiveness of ACT as an evidence-based practice, with a focus on adaptations to changing populations and contexts. We explore philosophical similarities and differences between ACT and recovery and examine how fidelity standards, a widely used indicator of how ACT teams operate, support or interfere with the adoption of a recovery-oriented practice. Finally, we provide recommendations on how best to incorporate a recovery orientation into existing ACT teams.

There's no place like (a) home: ontological security among persons with serious mental illness in the United States

As the homelessness 'crisis' in the United States enters a third decade, few are as adversely affected as persons with serious mental illness. Despite recent evidence favoring a 'housing first' approach, the dominant 'treatment first' approach persists in which individuals must climb a ladder of program requirements before becoming eligible for an apartment of their own. Drawing upon the concept of 'ontological security', this qualitative study examines the subjective meaning of 'home' among 39 persons who were part of a unique urban experiment that provided New York City's homeless mentally ill adults with immediate access to independent housing in the late 1990s. The study design involved purposively sampling from the experimental (housing first) group (N=21) and the control (treatment first) group (N=18) and conducting two life history interviews with each participant. Markers of ontological security-constancy, daily routines, privacy, and having a secure base for identity construction-provided sensitizing concepts for grounded theory analyses designed to also yield emergent, or new, themes. Findings revealed clear evidence of the markers of ontological security among participants living in their own apartments. This study expands upon previous research showing that homeless mentally ill persons are capable of independent living in the community. The emergent theme of 'what's next' questions and uncertainty about the future points to the need to address problems of stigma and social exclusion that extend beyond the minimal achievement of having a 'home'.

Group and organizational involvement among persons with psychiatric disabilities in supported housing

This study examined the patterns and correlates of group and organizational involvement among persons with psychiatric disabilities using a cross-sectional, probability sample of 252 residents in supported independent housing (SIH). Groups and organizations were classified according to whether or not they have a behavioral health focus. Demographic, clinical, and service use characteristics were examined as potential predictors of membership using Poisson regression models. Findings indicated that 60% of the sample was involved in some kind of behavioral or nonbehavioral health organization. Similar to the findings from the general population, higher rates of membership were found among older persons, Blacks, those with more years of education, and those with higher incomes. Other correlates specific to the SIH sample included prior homelessness, perceived discrimination, substance abuse history, psychiatric symptoms, psychiatric diagnosis, and contact with service providers. Implications of study findings for developing intervention strategies to enhance organizational membership and for future research are discussed.

From Principles to Practice: A Study of Implementation of Supported Housing for Psychiatric Consumers

In the post-deinstitutionalization era, supported housing has emerged as a housing and service approach considered most conducive to the goal of consumer empowerment and community integration. Although prior research found beneficial effects of supported housing, little empirical work has been done on identifying the gaps between the principles and practice of supported housing. Using multiple data sources on 27 supported independent living (SIL) programs for psychiatric consumers in a large metropolitan community, this paper examines the extent to which these programs are implemented in accordance with supported housing. Findings suggest consistency with as well as deviation from the supported housing approach in regard to consumer choice, typical and normalized housing, resource accessibility, consumer control and provision of individualized and flexible support. This study suggests methods for assessing housing programs for psychiatric consumers along these domains. Implications for the development of housing programs that promote consumer empowerment and community integration are discussed.

Impact of decisional capacity on the use of leverage to encourage treatment adherence

Leverage is often applied to persons with mental illnesses who live in the community to encourage them to adhere to treatment. Given the underlying assumption that the targets of such leverage are unable to make good decisions about treatment on their own, one might expect that decisional incapacity regarding treatment would correlate with the use of leverage. As part of a multi-site study of leverage in community treatment, 120 subjects at two sites reported on their leverage experiences and completed a decisional capacity assessment with the MacCAT-T. No strong or consistent associations were found between capacity and use of leverage, raising questions about the basis on which decisions to employ leverage are being made.

The Use of Housing as Leverage to Increase Adherence to Psychiatric Treatment in the Community

For people with mental disorder, access to subsidized housing may be used as "leverage" to obtain adherence to treatment. Interview data from 200 outpatients at each of five sites provided the first national description of the use of housing as leverage. Results indicated that housing is most likely to be used as leverage when it is "special" housing, available only to people with mental illness. Most frequently, respondents state that the requirement that they participate in treatment is imposed by their landlord, rather than by a clinician. The use of housing as leverage strongly increases respondents' perceptions of coercion. Despite this, however, participants who experience housing as leverage are no less satisfied than other participants with the treatment that they receive, and are much more likely than other participants to believe that using housing as leverage is effective in helping people stay well.

From coercion to contract: reframing the debate on mandated community treatment for people with mental disorders

Approximately half the people receiving treatment in the public sector for mental disorder have experienced some form of "leverage" in which deprivations such as jail or hospitalization have been avoided, or rewards such as money or housing have been obtained, contingent on treatment adherence. We argue in this essay that framing the legal debate on mandated community treatment primarily in terms of "coercion" has become counterproductive and that the debate should be re-framed in terms of "contract." Language derived from the law of contract often yields a more accurate account of the current state of the law governing mandated community treatment, is more likely to be translated into a useful descriptive vocabulary for empirical research, and is more likely to clarify the policy issues at stake than the currently stalemated form of argumentation based on putative rights. Our hope is that adopting the language of contract may help to identify those types and features of mandated community treatment that are genuinely problematic, rather than perpetuating the unhelpful and misleading assumption that all types of leverage amount to "coercion."