Blueprint for Change: Ending Chronic
Homelessness for Persons with Serious
Mental Illnesses and Co-Occurring Substance Use Disorders
Chapter 3: Establish Core Values
The values that underlie development of community-based services for people with serious mental illnesses and/or co-occurring substance use disorders who are homeless are as important as the individual service components themselves. Each of these values has at its center an abiding belief in the dignity and worth of the individual.
Putting people first not only is the humane thing to do; but also it
is the most effective way to help people with serious mental illnesses or
co-occurring disorders escape homelessness. Research reveals that services
that respect an individual’s right of self-determination are more likely to
result in residential and psychiatric stability and sobriety (Srebnik et
al., 1995; Shern et al., 2000). This chapter examines (1) the concept and
practice of recovery, (2) person-centered values, and (3) system-level
values that form the foundation for effective services to prevent and end
homelessness among people with serious mental illnesses or co-occurring
disorders.
The Concept and Practice of Recovery
The good news is that people with serious mental illnesses and/or
co-occurring substance use disorders can and do recover. Understanding
the concept and practice of recovery is fundamental to the development of
effective services for people with serious mental illnesses and/or
co-occurring disorders who are homeless.
A Definition of Recovery
There are as many different definitions of recovery as there are
individuals who recover. However, as mental health and substance abuse
treatment systems move toward recovery-based systems of care, many have
developed working definitions to guide their efforts. The Connecticut
Department of Mental Health and Addiction Services has endorsed a broad
vision of recovery as:
a process of restoring or developing a positive and meaningful sense of
identity apart from one’s condition and then rebuilding a life despite or
within the limitations imposed by that condition (Evans et al., 2002).
For many, if not most, homeless individuals who have mental illnesses and
substance use disorders, recovery will involve some type of professional
intervention, including the use of medication, where appropriate. Evidence-based
and promising treatment practices for people with serious mental illnesses or
co-occurring disorders who are homeless are discussed in the next chapter. The
following discussion examines other critical facets of the recovery process.
Recovery from Substance Use Disorders
The term "recovery" has been used extensively in the field of substance use,
where it refers to a return to sobriety (Ralph, 2000). For many individuals,
spirituality and peer support are critical to their recovery from addictions.
Thus, for example, individuals in 12-step groups for recovery from addictions
express their belief in a power greater than themselves. Secular substance use
recovery groups, such as Women for Sobriety and Self-Management and Recovery
Training (SMART), focus on individual empowerment and emotional growth. They
share with the 12-step tradition a belief in the importance of self-help as a
way to obtain and maintain sobriety.
People with both a mental illness and a co-occurring substance use disorder
face the daunting task of recovering from both disorders. Self-help groups
specifically designed to meet the needs of people with co-occurring disorders,
such as Double Trouble in Recovery, provide individuals the opportunity to share
common problems and to help others in their recovery from both mental illnesses
and substance use (Double Trouble in Recovery, 1997).
Recovery from Mental Illness
Use of the term "recovery" only recently has been applied to people with
mental illnesses, in part because of the mistaken belief that having a serious
mental illness is a lifelong condition. The most frequently cited study that
disproves this notion is a longitudinal study of severely disabled individuals
in Vermont. Investigators found that 34 percent of former hospital inpatients
who received mental health services, including psychiatric rehabilitation, in
the community achieved full recovery in both psychiatric status and social
functioning, and an additional 34 percent improved significantly in both areas
(Harding et al., 1987). Twenty-seven studies (including Harding’s) published
between 1960 and 1991 show equally promising rates of recovery from serious
mental illnesses (Ralph, 2000).
More recent research examines the relationship between illness
self-management, an evidence-based practice in the mental health field, and
recovery from serious mental illnesses. Researchers found that illness
self-management skills—including greater knowledge of mental illnesses, coping
skills, and relapse prevention strategies—play a critical role in people’s
recovery from mental illnesses (Mueser et al., 2002).
However, much of what is known about mental health recovery comes from the
writings of mental health consumers themselves and supports what has been called
the "simple yet powerful vision" (Anthony, 1993) of mental health recovery.
Ultimately, recovery from a serious mental illness is a very personal
process that involves the recovery of hope, of meaningful activities and
relationships, and of self-esteem and self-worth. Many consumer advocates
believe that recovery involves the development of both key relationships with
supportive individuals and core beliefs about mental illnesses (Ahern and
Fisher, 1999). Accordingly, they believe an individual can recover regardless of
whether he or she takes medication.
Recovery from Homelessness
Recovery from homelessness also is a process, according to a study conducted
by SRI Gallup, Inc. Researchers defined recovery from homelessness as being
sober, employed, and housed; they identified six themes that support this
process: spirituality, self-insight, security, self-awareness, support, and
suppression of poor self-concepts and negative attitudes (www.agrm.org/gallup.html,
retrieved May 2, 2003).
Lack of support or connection to others may be the single most important
reason why people are homeless, according to the SRI Gallup survey. For many
homeless people, outreach workers are the first to break through the isolation
and begin to move people toward a life of greater health and personal stability.
Outreach is about "compassion translated into concrete action. It is about
regarding all human beings as intrinsically valuable." (Kraybill, 2002).
Person-centered values are at the heart of a system that empowers people with
mental illnesses and substance use disorders to recover.
Person-Centered Values
The key values that support recovery can be described in a number of ways.
For example, people with mental illnesses and substance use disorders who have
survived trauma (defined as physical or sexual abuse) speak of "safety, voice,
and choice" as the values that must guide services designed by and for them (NASMHPD,
1998). Researchers trying to quantify recovery to make it measurable use the
terms "hope, taking personal responsibility, and getting on with life" (Noordsy
et al., 2002). Spirituality and self-help are key tenets of the 12-step approach
to addictions.
While these values are described similarly, some important points stand out.
Choice. People with serious mental illnesses and/or co-occurring
substance use disorders who are homeless should be given real choices in
housing, treatment, and support services. They should be informed of the full
array of options available to them. Services cannot be "one size fits all"; they
should be tailored to the individual’s needs.
Voice. A well-known tenet of the mental health consumer movement says, "Nothing
about us without us." People who have serious mental illnesses or
co-occurring disorders should have a say in the programs, policies, and services
designed to serve them.
Empowerment. Many people with serious mental illnesses or co-occurring
disorders, especially those who are or have been homeless, are disillusioned
with services they have received in the past and are disenfranchised from the
service system. They should be educated and empowered to make
choices in matters affecting their lives and to accept responsibility for
those choices (Federal Task Force on Homelessness and Severe Mental Illness,
1992). For most, this should include participation in developing their treatment
goals and recovery plan.
Dignity and Respect. The use of people first language (e.g.,
people who have serious mental illnesses, people who are homeless) is
more than an exercise in semantics. Language shapes thought, and treatment
service providers must recognize that the people they serve deserve the same
respect that providers expect from them.
Hope. Hopelessness breeds helplessness and despair. For many, recovery
of hope is essential for recovery from serious mental illnesses or co-occurring
disorders. Recovery from these disorders is an achievable goal that makes
all other goals possible.
System-Level Values
A recovery-oriented system of care, according to the Connecticut Department
of Mental Health and Addiction Services, "identifies and builds upon each
individual’s assets, strengths, and areas of health and competence to support
achieving a sense of mastery over his or her condition while regaining a
meaningful, constructive sense of membership in the broader community" (Evans et
al., 2002). Specific system-level values that can help achieve this vision
include:
Believe in Recovery. Optimism is essential. Osher (1996) notes:
"Consumers, families, and practitioners who maintain a hopeful attitude toward
recovery are associated with effective [co-occurring disorders] treatment
programs."
Make "Any Door the Right Door" to Services. People who are homeless and
have serious mental illnesses and/or co-occurring substance use disorders should
be able to enter the service system through any service "door" (e.g., mental
health services, substance abuse treatment, welfare office, jail), should be
assessed, and should have access to the full range of comprehensive services and
supports they want and need (National Technical Assistance Center for State
Mental Health Planning [NTAC], 2000).
Use Mainstream Resources to Serve People Who Are Homeless. People with
serious mental illnesses or co-occurring disorders who are homeless should be
educated and empowered to gain access to mainstream resources (e.g., housing,
mental health, and income support) for which they are eligible (Federal Task
Force on Homelessness and Severe Mental Illness, 1992). Many people who become
homeless are or have been clients of public systems of care and assistance, but
they have been ill-served. Homeless assistance providers should help connect or
reconnect individuals to mainstream programs, which is the only way to provide
the long-term housing and services individuals require to break the cycle of
homelessness (NAEH, 2000).
Be Flexible/Offer Low-Demand Services. Services should be flexible enough
to be delivered in sufficient amounts, duration, and scope to support recovery,
based on an individual’s changing needs and preferences. Participation in
treatment and receipt of services should not be required to gain access to
housing. Individuals reluctant to enter treatment may require some type of
low-demand service, such as a Safe Haven, to help engage them in more intensive
interventions (see more about Safe Haven in Chapter 6). These strategies can
provide safety and help meet immediate survival needs while providing an
opportunity to engage individuals in more intensive interventions.
Tailor Services to Meet Individual Needs. Each individual’s preferences,
treatment history, strengths, needs, and motivations must be recognized and
addressed in plans designed to help him or her avoid or exit homelessness
(Federal Task Force on Homelessness and Severe Mental Illness, 1992).
Develop Culturally Competent Services. Race, ethnicity, and culture
influence everything, from how individuals express problems to whether or not
they seek help and the type of services they will accept. At its core, cultural
competence involves improved access to services and cultural adaptations that
make services appropriate in cross-cultural settings (PATH Cultural Competence
Workgroup, 2001). At a minimum, providers should be multilingual and
multicultural (Federal Task Force on Homelessness and Severe Mental Illness,
1992; HHS, 2001).
Involve Consumers and Recovering Persons. Mental health consumers and
individuals in recovery from substance use disorders play an important role in
helping to empower their peers to recover from serious mental illnesses or
co-occurring disorders. They make valuable contributions as agency staff and as
active members of planning councils and advisory boards. Many consumers and
recovering persons operate programs and services designed to help their peers
recover.
Offer Long-Term Followup Support. Recovery from mental illnesses and
co-occurring substance use disorders is neither a linear nor a short-term
process. Relapse is to be expected, and individuals may require long-term
followup support, especially after they move into housing or gain employment.
Short-term fixes are neither cost-effective nor humane.
Establishing a System of Care
Clearly, people with serious mental illnesses and/or co-occurring substance
use disorders who are homeless have significant, complex needs that must be
addressed if care is to be effective and recovery is to be achieved. The many
state and community agencies that serve people with serious mental illnesses or
co-occurring disorders who are homeless must work together to plan a
comprehensive, coordinated system of care that supports their clients’
individual needs for recovery from multiple conditions.
The next two chapters of this report comprise Section II: Plan for Services.
They offer practical approaches for developing strategic partnerships and
securing the support needed to begin.
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