The Role of Services for Homeless and Housed People with Mental Illness: The Relationship Between Service Use and Housing Stability, Recovery, and Capabilities

Abstract

People with mental illness and histories of homelessness represent a vulnerable and marginalized population for whom a wide range of health, social, and community services have been developed. Despite the array of services, their role in the lives of currently and formerly homeless people with mental illness is not fully understood. Three studies were conducted that addressed two research questions: [1] How do patterns of service use differ during transitions from homelessness to housing compared to those from housing to homelessness among people with mental illness? and [2] What is role of services in enhancing the lives of housed and homeless people with mental illness? The first research question was addressed in Study 1, which involved secondary data analysis from a multisite randomized controlled trial of Housing First in Canada known as the At Home/Chez Soi demonstration project. The study explored how service use patterns over 24 months differed among people who achieved housing stability compared to those who remained unstably housed or re-experienced housing instability during the second year of the study. Findings showed that, as homeless people with mental illness transition into stable housing, their service use patterns change, with less time being spent in psychiatric hospitals, prison, and emergency shelters. Housing First minimally affected the changes in service use patterns, indicating that housing stability is the key factor in producing the changes as people transition out of homelessness. Study 2 also used data from the At Home/Chez Soi demonstration project to examine predictors of recovery among homeless people with mental illness at baseline and 24 months. Findings showed that health and community factors most strongly predicted mental health recovery at baseline. The housing and service use block of predictors was also significantly associated with most components of recovery, though the effect sizes were small. At 24 months, the model, which included receipt of Housing First, did not significantly predict residual changes in recovery from baseline. Study 3 of this dissertation qualitatively explored how currently and formerly homeless people with mental illness view services in their lives using two theoretical frameworks: recovery (Part 1) and the capabilities approach (Part 2). In-depth interviews were conducted with 52 participants living in Ottawa, Ontario. Participants perceived services to have a range of positive and negative impacts of their recovery and capabilities. However, the limits of service helpfulness in helping people to move forward with their lives was also highlighted. Overall, the findings of this dissertation indicate that the health, social, and community services used by homeless people with mental illness change as people become stably housed yet are limited in their impacts on recovery and capabilities. Implications for transformative change, service delivery, and future research are discussed.