Provider Perspectives on the Relationship Between Housing and Mental Health Needs Victoria Stanhope, Benjamin Henwood and Deborah Padgett Silver School of Social Work New York University Qualitative Research on Mental Health Conference August 27, 2010 Funded by NIMH: R & F31 MH083372

Background ▪ Problem framed as chronic homelessness ▪ Interrelated agendas of housing and mental health ▪ Continuum of Care Housing: Housing as output ▪ Supported Housing: Housing as input ▪ Provider negotiation between housing and mental health services – Lipsky’s “street level bureaucrat” – Schoen’s “reflective practitioner”

Traditional system Homeless Shelter placement Transitional housing Permanent housing Level of independence Treatment compliance + psychiatric stability + abstinence

Housing First Homeless Shelter placement Transitional housing Permanent housing Level of independence Treatment compliance + psychiatric stability + abstinence

Comparison Housing First Providers ▪ ACT team model ▪ Help clients maintain independent living ▪ Harm reduction Treatment First Providers ▪ Individual case management ▪ Help enforce rules necessary for shared living ▪ Assist in moving through the continuum ▪ Abstinence model Homeless Shelter placement Transitional housing Permanent housing Homeless  Permanent housing

Study Questions ▪ What do providers see as the role of housing in the delivery of services? ▪ How does the process of accessing housing affect providers’ relationships with clients? ▪ How do front-line providers articulate and translate their program’s values and philosophy?

New York Services Study  41 providers were recruited from four agencies as part of a NIMH funded qualitative study  129 in–depth interviews lasting minutes were conducted with providers  Analysis was utilized to compare views of 20 Housing First providers and 21Treatment First providers

Providers Housing First, n=20Treatment First, n=21 Gender Male Female 9 (45%) 11 (55%) 7 (33%) 14 (67%) Race/Ethnicity White African American Latina/o Other 12 (60%) 5 (25%) 1 (5%) 2 (10%) 6 (29%) 9 (43%) 6 (29%) 0 Length of employment < 1 year 1-3 years > 3 years 6 (30%) 8 (40%) 9 (43%) 7 (33%) 5 (24%) Highest educational degree Graduate Bachelor Associate High School 13 (65%) 4 (20%) 2 (10%) 1 (5%) 7 (33%) 9 (43%) 5 (24%) 0 Previous experience Yes No 16 (80%) 4 (20%) 16 (76%) 5 (24%)

Methods 2-phase analysis of provider transcripts 1 Boyatzis (1998) 2 3 Generate and apply codes across transcripts Revise codes and develop themes that fit the data Determine validity or ‘trustworthiness’ by seeking confirming and non-confirming data Phase 2 70 transcripts reviewed and themes revised Phase 1 59 transcripts co-coded and initial themes developed ATLAS.ti software used to separate and sort coded material

Theme 1 Centrality of Housing Treatment FirstHousing First ▪ Mostly focused on housing ▪ Housing trumps treatment ▪ ‘Commodify’ consumers ▪ Necessary but not sufficient ▪ Hierarchy of needs ▪ Platform for recovery

Theme 2 Engagement through Housing Treatment FirstHousing First ▪ Gatekeeping role ▪ Leverage part of system ▪ Discretionary power common ▪ Trusting relational foundation ▪ Reduced hierarchy and promotes trust ▪ Perception is still an issue

Theme 3 (Limits to…) A right to housing Treatment FirstHousing First ▪ Housing must be earned ▪ ‘Housing ready’ criteria ▪ Negative case: Revolving door ▪ Top-down philosophy ▪ Converted providers ▪ Negative case: Extreme addiction

Conclusions Revealed discrepancies between models and practice (irony of HF vs. TF) Reflective of tensions within social welfare system – language of rights versus language of worthiness Discretionary power more prevalent in TF as providers negotiated system constraints Providers views and practice largely reflected the philosophy and structure of their programs