Multilevel Effects of Environmental and Neighborhood Factors on Sober Living House Resident 12-Month Outcomes

OBJECTIVE

Sober living houses (SLHs) are abstinence-based environments designed for individuals in recovery to live with others in recovery. Research shows that SLHs help some individuals maintain recovery and that certain SLH-related factors may be particularly protective. Here we assess how SLH housing and neighborhood characteristics are related to abstinence and psychiatric symptoms over time.

METHOD

Baseline, 6-month, and 12-month data were collected from 557 SLH residents. Multilevel mixed models tested associations between house and neighborhood characteristics and individual-level percent days abstinent (PDA) and the number of psychiatric symptoms (measured with the Psychiatric Diagnostic Screening Questionnaire [PDSQ]) as outcomes. Final models adjusted for sex, age, and race/ethnicity; ratings of house characteristics; and objective measurements of neighborhood-level exposures.

RESULTS

Both PDA and PDSQ improved significantly (ps ≤ .05) over time in both unadjusted and adjusted models. More self-help groups and fewer alcohol outlets within one mile were significantly protective for PDA, whereas walkability was significantly related to worse PDA and PDSQ (ps ≤ .05). For house-level factors, better ratings of house maintenance were related to significantly fewer psychiatric symptoms, whereas higher scores on SLH's safety measures and personal or residence identity were related to more psychiatric symptoms (ps ≤ .05). No house-level factor was significantly related to PDA.

CONCLUSIONS

Neighborhood-level factors such as increased availability of self-help groups and fewer nearby alcohol outlets may increase abstinence among individuals living in SLHs. House-level factors related to better maintenance may also facilitate improved mental health.

Six-month length of stay associated with better recovery outcomes among residents of sober living houses

Background: Sober living houses are designed for individuals in recovery to live with others in recovery, yet no guidelines exist for the time needed in a sober living house to significantly impact outcomes.Objectives: To examine how the length of stay in sober living houses is related to substance use and related outcomes, focusing on early discontinuation (length of stay less than six months) and stable residence (length of stay six months or longer).Methods: Baseline and 12-month data were collected from 455 sober living house residents (36% female). Longitudinal mixed models tested associations between early discontinuation vs. stable residence and abstinence, recovery capital, psychiatric, and legal outcomes. Final models were adjusted for resident demographics, treatment, 12-step attendance, use in social network, and psychiatric symptoms, with a random effect for house.Results: Both early discontinuers (n = 284) and stable residents (n = 171) improved significantly (Ps ≤ .05) between baseline and 12 months on all outcomes. Compared to early discontinuation, stable residence was related to 7.76% points more percent days abstinent (95% CI: 4.21, 11.31); 0.88 times fewer psychiatric symptoms (95% CI: 0.81, 0.94); 0.84 times fewer depression symptoms (95% CI: 0.76, 0.92); and lower odds of any DSM-SUD (OR = 0.65, 95% CI: 0.47, 0.89) and any legal problems (OR = 0.58, 95% CI: 0.40, 0.86).Conclusion: In this study of sober living houses in California, staying in a sober living house for at least six months was related to better outcomes than leaving before six months. Residents and providers should consider this in long-term recovery planning.

Dropout from Treatment and Desistance from Crime among Released Prisoners in Jerusalem Halfway House for Prisoners with Substance Misuse Disorder

The study aims to investigate the rates of recidivism among prisoners on parole with a substance misuse disorder who participated in the Jerusalem halfway-house, which combines supervision, employment, and a comprehensive therapeutic program. The study population included all participants who have been treated in the halfway-house (N = 125), whereas the comparison group included all prisoners with a substance misuse disorder who were released after serving their full sentences (N = 321). To reduce possible selection biases, the Propensity Score Matching method was used. Findings show that prisoners, who were treated at the Jerusalem halfway-house, are characterized by higher and frequent rates of recidivism. However, when only completers of the halfway-house were evaluated, it was found that they had lower and slower rates of recidivism. Findings suggest that completing treatment contributes to desistance from crime in the critical post-release years among participants and indicates the importance of optimal diagnostic processes before admitting prisoners to a halfway-house.

Optimizing a Halfway House to Meet Mental Health Care Users' Occupational Needs : Optimisation d'une maison de transition pour répondre aux besoins occupationnels des usagers des soins de santé mentale

Background. Halfway houses (HwH) may support community reintegration of mental health care users and can be effective in meeting occupational needs of residents. However, they are not optimally used in South Africa. Purpose. This study aimed to improve the functioning of a HwH so that it better meets occupational needs of the resident mental health care users. It draws on Doble & Santha; (2008) seven occupational needs. Method. A four-phase Participatory Action Research methodology was used. We conducted thematic analysis to describe met and unmet needs within PAR phases. Findings. Occupational needs of accomplishment, renewal, pleasure and companionship were being met. However, coherence, agency and affirmation needs were not being met. An additional occupational need for interdependence, based on the African ethic of Ubuntu, was identified. Implications. HwH functioning affected residents' experiences of health and wellbeing. Engagement in collective occupations can contribute to meeting the occupational need of interdependence.

Resident and house manager perceptions of social environments in sober living houses: Associations with length of stay

AIMS

Studies have shown persons living in recovery homes for drug and alcohol problems make significant, sustained improvements. However, there is limited information about factors associated with outcomes. This study examined how perceptions of social environment of one type of recovery home, sober living houses (SLHs), were associated with length of stay (LOS).

METHODS

SLH residents and their house managers (N = 416) completed the recovery home environment scale (RHES) that assessed social model recovery characteristics and the community-oriented program evaluation scale (CPES) that evaluated perceptions of the program environment.

RESULTS

Scales completed by residents predicted LOS, but those completed by house managers did not. Larger discrepancies between the two groups were associated with shorter LOS. The RHES was shown to be a stronger predictor of LOS than the CPES.

CONCLUSION

Results highlight the importance of the social environment in SLHs, particularly those most closely aligned with social model recovery principles.

Harm Reduction Strategies and Disinhibitors Among Women Who Use Heroin

People who use illicit drugs face significant physical risks in the acquisition, use, and aftermath of their use. This is particularly the case among those who use heroin in view of recent spikes in heroin-associated overdoses, injuries, and deaths. Using a restrictive deterrence framework, we identify the risks that women associate with chronic heroin use and the ways they seek to manage those risks. We also examine psychological and physiological disinhibitors that contribute to women reducing use of risk reduction strategies. We find from the narratives that nearly all of the women initially engaged in specific strategies to manage risk; however, as they continued using the drug, they began to abandon even the simplest of measures. Our findings shed light on the limitations of harm reduction strategies and inform the theoretical tradition of restrictive deterrence and the importance of disinhibitors.

Halfway Out: An Examination of the Effects of Halfway Houses on Criminal Recidivism

Halfway houses are a form of community supervision and correctional programming that have become a staple intervention in recent years. Despite the ingrained belief in their benefits with respect to successful reintegration, this assumption may not be justified based on the existing literature. The current study provides a systematic review and meta-analysis of nine studies examining the effects of halfway houses on recidivism. Overall, the findings suggest that halfway houses are an effective correctional strategy for successful reentry (log odds ratio [LOR] = 0.236, z = 9.27, p < .001). Further work is needed to determine best practices for programming and meeting the needs of different participants.

Supportive Care Network: Evaluation of Its Impact on the Performance of a Urology Department

INTRODUCTION

Hospitals are dealing with patients who may have clinical discharge but cannot return to their home due to non-medical issues.

MATERIAL AND METHODS

Cross-sectional analysis of all the cases referred to the Integrated Care Network during the year 2016. Evaluation of waiting times, typology, reason for referral and clinical parameters. IBM SPSS 24.0 software was used for all statisticalanalyses.

RESULTS

In the evaluated period, 2294 patients were discharged from our department. Of these, 55 were referred to Integrated Care Network. The mean length of hospitalization of the patients referred to the network was 20.6 ± 11.4 days, and the mean overall length of hospital stay in the period analyzed was 4.8 ± 0.9 days. The mean time between hospitalization and referral for continuing care was 10.7 ± 7.2 days. The time between referral and discharge of the hospital was 10.0 ± 8.7 days. Thirty-nine (70.9%) patients were hospitalized for oncological diseases. The most common referral was to Palliative Care units (n = 16; 29.1%). Patients referred to Palliative Care units showed the largest waiting times between the referral for the network and the hospital discharge, 12.2 ± 10.51 days. We observed 289 hospitalization days with patients who had no need of specialized urological care.

DISCUSSION

In order to reduce time between referral to the network and hospital discharge, there is a need for enhanced cooperation and coordination among doctors, nurses and social workers.

CONCLUSION

Early identification by physicians and nurses of patients who will require care after discharge will provide a better response from social workers and increased hospital performance.

[Therapeutic apartments: feeling 'at home' in order to recover]

There is no recovery without a transformation. This is conveyed by a greater ability to adapt to the demands of daily life and a significant reduction in the behavioural expression of symptoms. This is combined with a positive experience of oneself in the present and a firm belief in the continuity of oneself in the future, over the medium term. Therapeutic apartments are an example of schemes favouring the patient's recovery. This article presents the example of the Foyer Damidot, near Lyon.

Social Relationships and Group Dynamics Inside a Community Correction Facility for Women

This article presents research on women's perceptions and experiences residing in a female community correction facility. Qualitative interview data and field observations are used to examine resident relationships, perceptions of on-site group treatment, and benefits of receiving off-site treatment. Findings from this study indicate an overwhelming feeling of tension and lack of trust among residents, resulting in most women withdrawing from social interactions. Relationship dynamics also played a role in women's participation during on-site group treatment and desiring off-site treatment. This study supports the need to create, and sustain, therapeutic environments within community correction settings for women.

Dimensions of Culture Care for Substance-Dependent African American Women

Substance abuse, now in epidemic proportions in many cultures, is of major concern nationally and transculturally. It is important for nurses and other health care providers working with an increasingly multiculturally diverse client population to understand the cultural implications of caring for clients with alcohol and drug dependence. The purpose of this ethnonursing research study was to discover meanings and expressions of care for substance-dependent African American women in the research context of an inner-city transitional home. A convenience sample of 12 key and 18 general participants was included in this study. The study was conceptualized within Leininger’s culture care theory. Ethnonursing techniques of participant observation and focused in-depth interviews were used to collect data. Results included four universal care themes discovered in this study. Gender/cultural-specific care needs in relation to social structure, ethnohistory, and cultural context were discovered to influence the women’s health/well-being as they moved through recovery.

A New Way of Doing Time on the Outside: Sex Offenders' Pathways In and Out of a Transitional Housing Facility

Although housing has been highlighted as a key element of successful reentry experiences, little research has considered the perspectives of sex offenders living in transitional housing upon release from prison. This topic is important given the increasing legal restrictions faced by this offender population. The current study utilizes qualitative data to explore the pathways from prison to transitional housing, the experience of residing in these facilities, and how transitional housing is perceived to affect the overall reentry experience. In general, results suggest that sex offenders reside in the facility because of lack of access to a suitable home, and report a need for service provisions. However, most view their experiences in the transitional facility (TF) as contrary to the rehabilitative ideal, and some indicate that this type of programming has collateral consequences for reentry. The proliferation of sex offender restriction laws has only exacerbated the challenges faced by sex offenders living in the TF.

[Psychological containment at home]

The mobile care and rehabilitation team offers patients who have been receiving long-term, in-patient care, when they are stabilised, a discharge programme underpinned by considerable support from a nursing team. Through apartments owned by associations and the CATTP (part-time therapy centre), the team will guide the patient along their sometimes precarious pathway. This well thought-out and shared support, takes on the function of psychological containment for the patient, helping to ensure a successful reintegration.

Mental health diagnoses and recidivism in paroled offenders

Although the issue of mental illness among offender populations has received attention in the last number of years, there are a number of issues related to mental illness among such groups that require more study. One such topic relates to the association between mental illness, actuarially assessed risk of recidivism, and observed rates of reoffending. In the present investigation, file information was reviewed to determine the presence of a variety of mental health conditions. Actuarially based risk assessment data were also collected for participants as well as information regarding suspension, new charges, and convictions. A sample of 136 offenders housed in a halfway house operated by Correctional Service of Canada was included in the present investigation. Results indicated very high rates of serious mental illness in this high-risk population. Offenders with borderline personality disorder and attention deficit hyperactivity disorder were significantly more likely to recidivate or be suspended. Suspensions refer to administrative decisions to place an offender in jail due to problematic behaviour (typically involving a breach of his release conditions or new charges/convictions). Offenders with a diagnosis of paraphilic disorder were significantly less likely to recidivate or be suspended. Results are discussed in light of the available literature.

Characteristics of homeless adults with serious mental illness served by a state mental health transitional shelter

Specialized transitional shelters are available in various cities to provide assistance to homeless individuals with serious mental illness. Little is known about the population using such shelters. The authors conducted a retrospective chart review to collect demographic, social, and clinical data of residents in a state-operated mental health transitional shelter in Massachusetts. A total of 74 subjects were included. Schizophrenia-spectrum disorders were present in 67.6 % of the sample and mood disorders in 35.1 %. Substance use disorders were documented in 44.6 %. Chronic medical illness (mostly hypertension, dyslipidemia, asthma, and diabetes) was found in 82.4 %. The co-occurrence of a psychiatric and substance use disorder and chronic medical illness was found in 36.5 %. The majority (75.7 %) of patients had a history of legal charges. Homeless individuals with serious mental illness served by specialized transitional shelters represent a population with complex psychiatric, medical and social needs.

Dynamic social networks in recovery homes

Acute treatment aftercare in the form of sober living environments-i.e., recovery houses-provide an inexpensive and effective medium-term treatment alternative for many with substance use disorders. Limited evidence suggests that house-situated social relationships and associated social support are critical determinants of how successful these residential experiences are for their members, but little is known about the mechanisms underlying these relationships. This study explored the feasibility of using dynamic social network modeling to understand house-situated longitudinal associations among individual Alcoholics Anonymous related recovery behaviors, length of residence, dyadic interpersonal trust, and dyadic confidant relationship formation processes. Trust and confidant relationships were measured 3 months apart in U.S. urban-area recovery houses, all of which were part of a network of substance use recovery homes. A stochastic actor-based model was successfully estimated from this data set. Results suggest that confidant relationships are predicted by trust, while trust is affected by recovery behaviors and length of residence. Conceptualizing recovery houses as a set of independent, evolving social networks that can be modeled jointly appears to be a promising direction for research.

[Difficult teenagers: the challenges of interdisciplinarity]

The adolescents in great distress, because of ruptures in the course of their lives and of their chaotic family environment, need educational and social actions. The consensual point of view is that responding to the needs of the so called "difficult adolescents" implies the involvement of educational, therapeutic and judicial services. Nevertheless, the usual tendency to categorize the users with the idea it will permit to guide them to the appropriate skill field and the transgressive characteristic of these adolescents' behaviours lead all these services to reject them and send them to the two other services.

The systemic model of crime and institutional efficacy: an analysis of the social context of offender reintegration

The systemic model of crime has received considerable empirical attention from criminologists; yet, an often-neglected component of the theoretical framework is the role of social institutions as a source of both formal and informal social control. Accordingly, the current study builds on recent research that considers the importance of institutional strength for the reduction of criminal behavior; in particular, the authors assess the impact of social-structural characteristics on the treatment program integrity (i.e., institutional efficacy) of 38 halfway house programs in Ohio. The authors' results indicate that communities suffering from concentrated resource deprivation have a more difficult time creating and maintaining strong institutions of public social control. The implications for criminological theory and correctional policy are discussed.

The general environment fit scale: a factor analysis and test of convergent construct validity

Person-environment fit (P-E fit) was initially espoused as an important construct in the field of community psychology; however, most of the theoretical and empirical development of the construct has been conducted by the industrial/organizational (I/O) psychologists and business management fields. In the current study, the GEFS-a P-E fit measure that was developed from organizational perspectives on fit-was administered to 246 attendees of an annual convention for residents and alumni of Oxford House, a network of over 1,400 mutual-help addiction recovery homes. The authors conducted confirmatory factor and convergent construct validity analyses with the GEFS. The results suggested that the theoretical factor structure of the measure adequately fit the data and provided limited support for the measure's validity. Sufficient supply of resident needs by the Oxford House and similarity between residents and their housemates predicted satisfaction with the recovery home, but only perceived similarity to housemates predicted how long residents intended to stay in the Oxford Houses.

Dedicated CM coordinates discharges for patients

Montefiore Medical Center in Bronx, NY, has a complex case manager who coordinates post-discharge options for uninsured patients with complex needs. The initiative frees up unit case managers and social workers to manage the care of less complex patients. The hospital has an arrangement with a community-based organization to provide a safe living environment for patients who are homeless and need post-acute services. A complex care advisory team reviews patients with post-discharge issues and makes a recommendation to the hospital's administration.

[Prevalence of diabetes mellitus and impaired fasting glucose of health check-up in a sanatorium of Shanghai in 2003 and 2010]

OBJECTIVE

To examine the prevalence changes of diabetes mellitus (DM) and impaired fasting glucose (IFG) from 2003 to 2010 in the health check-up subjects in Shanghai.

METHODS

Health check-up subjects were divided into ten groups by sex and each 5 years old, and the prevalence of crude DM, crude IFG were calculated first. According to Chinese sex and age structure of China Population Statistics Yearbook 2006, sex and age standardized DM and standardized IFG were computed.

RESULTS

In the same year, the prevalences of crude DM and IFG increased with increasing age for both male and female, reached the summit at 60 - 69 age group, when at ≥ 70 age group, they had a down trend and were still at higher level. The prevalences of crude DM were 3.99% (986/24 699) in male and 1.61% (176/10 948) in female in 2003, and were 7.85% (3366/42 899) and 2.55% (531/20 820) in 2010. The prevalences of crude IFG were 9.97% (2462/24 699) in male and 5.88% (644/10 948) in female in 2003, and were 30.96% (13 283/42 899) and 17.16% (3573/20 820) in 2010. The prevalences of age standardized DM in 2003 and 2010 were 3.89% and 6.90% for male (χ(2) = 371.89, P < 0.01), 2.12% and 3.23% for female (χ(2) = 29.32, P < 0.01), respectively. The prevalences of age standardized IFG in 2003 and 2010 were 9.51% and 28.55% (χ(2) = 3865.56, P < 0.01) for male, 6.97% and 17.88% (χ(2) = 790.81, P < 0.01) for female. The prevalences of age and sex standardized DM were 3.00% and 5.05% (χ(2) = 385.39, P < 0.01), and prevalences of age and sex standardized IFG were 8.23% and 23.17% (χ(2) = 4480.21, P < 0.01).

CONCLUSION

From 2003 to 2010, prevalences of DM and IFG had increased greatly. It concluded that first-level prevention of DM for health check-up subjects should start from youth, and should lay emphasis on population of IFG, especially for male.

Alternative families in recovery: fictive kin relationships among residents of sober living homes

Sober living homes are group residences for people attempting to maintain abstinence from alcohol and drugs in a mutually supportive setting. Residents typically develop strong psychological and economic ties and have been referred to as "alternative families," thus evoking the anthropological concept of fictive kinship. We analyzed data from seven focus groups with sober living home residents to assess the prevalence and functions of fictive kinship in these settings. Results suggest that residents created kinship by exchanging various types of support, and by incorporating other residents into existing family relationships, particularly in homes where there were children. Residents perceived fictive kin as more supportive than actual kin, encouraging them toward greater individuation, in contrast with family backgrounds that were sometimes described as stifling. These accounts of the therapeutic qualities of fictive kin in sober living homes could inform the work of fair housing advocates and other community stakeholders.

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.