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As science and practice regarding the nature of psychiatric disorders and how best to manage them has evolved, the concept of recovery has emerged a central construct within the fields of mental health and addiction services (Gagne, White, Anthony, 2007). According to the Substance Abuse and Mental Health Services Administration (SAMHSA; Substance Abuse and Mental Health Services Administration, 2012), recovery from mental disorders and substance use disorders is defined as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” (p.3). Having a home or a stable and safe place to live is recognized as fundamental to recovery from both mental and substance use disorders. However, being homeless, as well as having unsafe or otherwise untenable housing, is common among individuals with serious mental illness (Folsom et al., 2015) and substance use disorders (Eyrich-Garg et al., 2008) and may present challenges to initiating and/or sustaining recovery (Castellow et al., 2015; Laudet & White, 2010).
Support for housing services has historically been under the auspices of the US Department of Housing and Urban Development (HUD), whereas services for individuals with mental and substance use disorders are under the auspices of the Substance Abuse and Mental Health Services Administration (SAMHSA). Although each system has developed unique, and often highly innovative, ways of meeting the complementary needs of individuals who present in their system with both housing and treatment needs, significant gaps remain. Individuals in recovery with inadequate housing may not qualify for some housing support services because they may not meet definitions of “chronic homelessness”; for those who do access housing services, sustaining recovery may be challenging if they are not engaged in ongoing, supportive services. In recognition of these gaps, two national meetings were held: one convened during the 2014 National Conference on Ending Homelessness (hosted by the National Alliance to End Homelessness) and the other which was co-hosted by CSH and the National Council for Behavioral Health (2014). These meetings brought together researchers, practitioners, and policy leaders to begin a dialogue about promising practices for integrating housing and service delivery programs as well as challenges and opportunities in creating a comprehensive and integrated continuum of housing and service delivery programs for individuals in recovery.
The articles in this special section continue this dialogue. The article by Paquette and Winn (2016) summarizes system-level barriers to integrating recovery housing (i.e., abstinence-based living environments that promote recovery from addiction) and homelessness services. They highlight key differences between recovery housing, which presumes abstinence, and “housing first” approaches, in which neither abstinence nor service use is a precondition to housing, and offer recommendations for research, policy, and practice to better integrate recovery housing into homelessness service continuums. The article by Winn and Paquette (2016) summarizes findings and presents lessons learned from work conducted in Ohio to identify barriers and opportunities to expand recovery housing in that state. The focus of these papers on the integration of recovery housing into homelessness services, and the challenges of expanding recovery housing, is timely given recent policy initiatives that support innovative housing approaches. These include the release of a policy brief by HUD (2015) outlining defining characteristics and effective practices for HUD-funded recovery housing as well as new possibilities for funding of housing through accountable care organizations (ACOs) developed through Medicaid expansion in the Patient Protection and Affordable Care Act (ACA; Viveiros, 2015).
The remaining three articles present findings from studies examining promising practices to simultaneously address housing and recovery needs. Polcin, Korcha, Gupta, Subbaraman and Mericle (2016) report findings from their work studying the outcomes of residents (N=300) entering sober living houses (a type of recovery housing) in California. Sober living houses are communal living environments (generally single-family residences) that are primarily sustained by residents paying monthly fees to live in these houses. They do not provide group counseling, case management, treatment planning, or structured daily activities. However, residents are either encouraged or required to attend 12-step meetings, expected to participate in the household, and can stay as long as they wish provided that they abide by house rules, including abstinence. These authors found that many residents reported recent psychiatric symptoms upon entry into the sober living houses and that, although overall psychological distress and symptoms of depression and anxiety improved over the 18-month follow-up period, overall distress and all symptoms studied were associated with an increased likelihood of relapse. The authors call for more research to understand how psychiatric symptoms are addressed in sober living houses as well as to understand how individuals with co-occurring psychiatric symptoms experience this environment. Research is needed on the development and testing of specific interventions and strategies targeted to improve outcomes, such as training for house managers on the unique needs of residents with psychiatric symptoms and formal linkages with mental health service providers to deliver in-house services to residents.
The article by Clark, Guenther, and Mitchell (2016) presents outcome and fidelity findings from evaluations of two programs, each delivering an evidenced-based model of service management: Assertive Community Treatment (n=90) or Critical Time Intervention (n=144). These programs targeted persons with co-occurring mental and substance use disorders living in permanent supportive housing (i.e., subsidized housing designed to serve people who are homeless and have disabilities that interfere with their ability to maintain housing on their own) operated within a housing first framework. The authors found that both programs operated at high levels of fidelity to their respective models. Separate outcome analyses found that each program was successful in supporting people to transition from homelessness to stable housing (as evidenced by participants being more likely to be housed at 6 month follow-up than at baseline). And although no differences between baseline and follow-up were observed for those in the program implementing Assertive Community Treatment, participants in the Critical Time Intervention program showed significant decreases in alcohol use, illegal drug use and psychiatric symptoms from baseline to 6 month follow-up.
The article by Smelson, Zaykowski, Guevermont, Siegfriedt, Sawh, Modzelewski, Tsemberis, and Kane (2016) presents feasibility and preliminary outcome findings (N=107) from a study of Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking (MISSION). In this study, wraparound support for individuals with co-occurring disorders and chronic homelessness was integrated into receipt of permanent supportive housing following a housing first philosophy and using a Regional Engagement and Assessment of the Chronically Homeless (REACH) approach which emphasizes coordinated housing and support services. These authors found that MISSION was compatible to implement in permanent supportive housing with reasonable fidelity and that client improvements were seen in housing and mental health outcomes, although there were fewer gains made with respect to long-term sobriety. The authors suggest that the encouraging housing outcomes observed (95% were placed in permanent housing with 79% housed at discharge/12-month follow-up) may have been facilitated through the integration of MISSION and housing services. They specifically point to having a unified approach in which both case managers and peer support specialists are trained on the MISSION intervention and the provision of permanent supportive housing.
While the Clark et al. (2016) and the Smelson et al.(2016) articles provide evidence of improved housing outcomes for persons with co-occurring disorders and histories of homeless in permanent supportive housing operated within a housing first framework, findings regarding substance use outcomes were not as strong as findings regarding housing and psychiatric symptoms. The lack of uniform improvements across domains is a robust finding in studies of individuals with multiple disorders and complex service needs; these findings challenge both researchers and providers to think about the best way to conceptualize outcomes. Assessment of incremental changes, as well as non-linear trajectories of change, over longer periods of observation, may better elucidate complicated patterns of changes over time across multiple domains.
These studies, as well as the study conducted by Polcin and colleagues (2016), suggest that a great deal of work still needs to be done to address the housing needs of individuals in recovery, particularly those with co-occurring mental health and substance use disorders. Despite progress in understanding the need to support recovery within housing-based interventions, barriers persist in the integration of recovery housing within the continuum of housing services funded through HUD. Important questions remain about how psychiatric symptoms are addressed in recovery housing as well as how these settings could be used by individuals experiencing chronic homelessness and with families experiencing or at risk for homelessness. Similarly, interventions designed to support individuals with co-occurring disorders within supportive housing show great promise in getting and keeping residents housed, but important questions remain about how substance use recovery is addressed in these settings and how outcomes in this realm can be improved. Finally, it is important that research on housing for individuals in recovery measures outcomes consonant with current notions of recovery—improvements in health, wellness, purpose, and quality of life – and identify how housing serves as a platform for improving quality of life, principles on which there is wide agreement between HUD and SAMHSA.
Preparation of this editorial and special issue was completed with the support of the National Institute on Drug Abuse (R21DA039027; PI: Mericle).
The authors report no financial relationships with commercial interests.
Amy A. Mericle, Alcohol Research Group at the Public Health Institute.
Christine E. Grella, Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at the University of California, Los Angeles.