Housing Histories of Assertive Community Treatment Clients: Program Impacts and Factors Associated with Residential Stability

Article excerpt

Objective: Although housing is widely recognized as a crucial issue for people with severe and persistent mental illness, there is much to learn about the ongoing housing experiences of this group of people. Using secondary data, this study examined the housing histories of 65 assertive community treatment (ACT) clients from 2 years prior until up to 7 years after intake, totalling 407 addresses.

Method: We used statistical process control to assess the significance and longevity of preand post-ACT changes in residential tenure and independent living. We used multivariate survival analysis to explore participant and residence characteristics associated with residential stability.

Results: After 6 months in ACT, the client population showed a significant, sustained improvement in housing stability. Similarly, shortly after ACT entry, there was a marked increase in the proportion of participants living independently. At the participant level, substance abuse was the strongest predictor of residential instability; other predictors included age (30 years or younger) and sex (female). Residence characteristics also proved important; independent housing, neighbourhood income (a proxy for housing quality), and receipt of a rental subsidy were associated with significantly longer tenure, controlling for client characteristics.

Conclusions: The timing and magnitude of the observed changes imply that ACT was effective in helping clients to achieve stable housing and to live independently. The results also underscore the importance of high-quality housing in promoting residential stability.

Can J Psychiatry. 2010;55(3):150-156.

Clinical Implications

* ACT increases housing stability over the long term.

* People with cooccurring problems (severe and persistent mental illness combined with substance abuse) have ongoing difficulty attaining stable housing.

* In conjunction with ACT involvement, greater access to independent, high-quality housing (for example, through subsidies) can significantly increase residential stability.

Limitations

* Our study was observational rather than experimental.

* Our study followed the client population of only one ACT team.

* There were a small number of gaps in the available data on client housing experiences.

Key Words: assertive community treatment, housing, program evaluation

Abbreviations used in this article

ACT assertive community treatment

CAUS Clinicians Alcohol Use Scale

CDUS Clinicians Drug Use Scale

SPMI severe and persistent mental illness

Housing is increasingly recognized as an important determinant of quality of life for people with SPMI. ' Previous research has demonstrated the positive impact of independent housing,2 and several studies have also highlighted the importance of housing quality.3'4 In addition, rental subsidies have been found to facilitate both independent housing and longer periods of continuous housing.5'6

Another body of research has examined the effectiveness of various community-based services, such as ACT and intensive case management, in promoting stable and independent housing. A recent systematic review concluded that both programs outperformed standard services in reducing homelessness among people with SPMI; ACT showed larger and more consistent effects than intensive case management.7 Both programs have also been shown to increase the proportion of people in independent housing.7'8 While programs encompassing housing and support - so-called supportive housing - may have the greatest impact on housing stability, this may come at the cost of consumer satisfaction, empowerment, and quality of life.7'9 In contrast, ACT and other supportive housing approaches (in which services are not attached to housing) have been found to have positive impacts in such areas.

Whereas the literature provides solid evidence of ACT' s effectiveness in improving housing outcomes, there is much left to learn about ACT clients' housing experiences. …

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