The Paradigm Shift in Residential Services: From the Linear Continuum to Supported Housing Approaches

Psychosocial Rehabilitation Journal 03/1990; 13(4):11-31. DOI: 10.1037/h0099479


Describes a paradigm shift, beginning in the 1950s and reaching its zenith in the 1970s, toward supported housing models and deinstitutionalization of the mentally ill. The linear residential continuum model formed the basis for residential treatment and the provision of specialized environments that prepared patients/clients for life in the community. A supported housing paradigm shifts the primary role of the service recipient from patient to community and shifts the locus of control from staff to client. Other elements of the shift include an emphasis on (1) social integration rather than homogeneous grouping by disability and (2) the most facilitative environment and best functioning rather than the least restrictive environment and independence. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

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    • "Models for Assisting Homeless Individuals with Substance Abuse Two prominent models have emerged in response to the need for housing for persons with cooccurring substance abuse and unstable housing: linear and Housing First. The linear approach (Kertesz, et al., 2009; Ridgway & Zipple, 1990) emphasizes abstinence from substances as an explicit goal. "
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    ABSTRACT: Communities throughout the U.S. are struggling to find solutions for serious and persistent homelessness. Alcohol and drug problems can be causes and consequences of homelessness, as well as co-occurring problems that complicate efforts to succeed in finding stable housing. Two prominent service models exist, one known as “Housing First” takes a harm reduction approach and the other known as the “linear” model typically supports a goal of abstinence from alcohol and drugs. Despite their popularity, the research supporting these models suffers from methodological problems and inconsistent findings. One purpose of this paper is to describe systematic reviews of the homelessness services literature, which illustrate weaknesses in research designs and inconsistent conclusions about the effectiveness of current models. Problems among some of the seminal studies on homelessness include poorly defined inclusion and exclusion criteria, inadequate measures of alcohol and drug use, unspecified or poorly implemented comparison conditions, and lack of procedures documenting adherence to service models. Several recent papers have suggested broader based approaches for homeless services that integrate alternatives and respond better to consumer needs. Practical considerations for implementing a broader system of services are described and peer managed recovery homes are presented as examples of services that address some of the gaps in current approaches. Three issues are identified that need more attention from researchers: 1) improving upon the methodological limitations in current studies, 2) assessing the impact of broader based, integrated services on outcome, and 3) assessing approaches to the service needs of homeless persons involved in the criminal justice system.
    Journal of Social Distress and the Homeless 07/2015; DOI:10.1179/1573658X15Y.0000000004
    • "More troubling questions concern the actual treatment availability for the HUD-VASH clients in this case series. The Housing First approach requires consumer-centered recovery services to engage clients and reduce substance use–related harms (Gilmer et al., 2013; Ridgway and Zipple, 1990). Although addiction treatment is not compulsory, regular and intensive engagement with clients to promote recovery is required . "
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    ABSTRACT: Over the last 5 years, community policies in response to homelessness have shifted toward offering permanent housing accompanied by treatment supports, without requiring treatment success as a precondition. The US Department of Veterans Affairs (VA) has embraced this "Housing First" approach. A 2013 report sounds a contrarian note. In a 16-person quasi-experimental study, 8 veterans who entered VA's permanent supportive housing did poorly, whereas 8 veterans who remained in more traditional treatment did well. In this commentary, we suggest that the report was problematic in the conceptualization of the matters it sought to address and in its science. Nonetheless, it highlights challenges that must not be ignored. From this report and other research, we now know that even more attention is required to support clinical recovery for Housing First clients. Successful implementation of Housing First requires guidance from agency leaders, and their support for clinical staff when individual clients fare poorly.
    The Journal of nervous and mental disease 07/2015; 203(7):559-62. DOI:10.1097/NMD.0000000000000328 · 1.69 Impact Factor
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    • "Interventions for homeless individuals with mental illness have traditionally focused on a treatment first approach, in which program participants typically progress in a stepwise fashion from emergency shelters to transitional housing before they access permanent supportive housing, often after meeting strict requirements of sobriety and acceptance of psychiatric treatment [6,7]. More recently, Housing First (HF), developed by Pathways to Housing, has emerged as a popular treatment option for meeting the unique needs of this population [8-10]. "
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    ABSTRACT: Housing first has become a popular treatment model for homeless adults with mental illness, yet little is known about program participants' early experiences or trajectories. This study used a mixed methods design to examine participant changes in selected domains 6 months after enrolment in a Canadian field trial of Housing First. The study sample included 301 participants receiving the Housing First intervention at the Toronto site of the At Home/Chez Soi project. This study used a pre-post design to compare quantitative 6-month outcome data to baseline values in key domains and multivariate regression to identify baseline demographic, clinical or service use variables associated with observed changes in these domains. In addition, qualitative data exploring participant and service provider perspectives and experiences was collected via stakeholder interviews and focus groups, and analyzed using thematic analysis. The majority (60 to 72%) of participants followed the expected trajectory of improvement, with the remaining experiencing difficulties in community integration, mental health symptom severity, substance use, community functioning and quality of life 6 months after program enrolment. Diagnosis of psychotic disorder was associated with a reduction in quality of life from baseline to 6-months, while substance use disorders were associated with reduced mental illness symptoms and substance use related problems and an improvement in quality of life. Participants housed in independent housing at 6-months had greater improvements in community integration and quality of life, and greater reduction in mental illness symptoms, compared to those not independently housed. The quality of the working alliance was positively associated with improvements in physical and psychological community integration and quality of life. Qualitative data provided a unique window into the loneliness and isolation experienced by Housing First participants, as well as problems related to substance use and a need for life skills training and support. Additional strategies can help support Housing First participants in the early stages of program participation and address potential causes of early difficulties, including lack of life skills and social isolation. This study highlights the importance of early and ongoing evaluation, monitoring and program adaptations to address consumer support needs.Trial registration: Current Controlled Trials ISRCTN42520374.
    BMC Health Services Research 04/2014; 14(1):167. DOI:10.1186/1472-6963-14-167 · 1.71 Impact Factor
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