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This chapter defines the basic concepts used in this book. Evidence-based practice (EBP) refers to the application of empirically-supported treatments in work with clients. As an EBP, family psychoeducation (FPE) is a time-limited structured intervention that reduces relapse and rehospitalization of clients with serious mental illness by enhancing their families' knowledge and coping skills. Serious mental illness is defined in terms of diagnosis, severity, and persistence, along with prevalence data from national population-based studies. The chapter presents data on the scope of families' involvement with persons with serious mental illness, in residential caregiving and/or ongoing social support. With few service providers offering education on illness management, education programs were largely developed outside of mental health systems, by organizations such as NAMI and MHA. Within systems, FPE emerged with research support of treatment efficacy by focusing on illness education and training in communication and problem-solving techniques.

This book offers five recommendations to fix America's broken mental health care system and transform it into an effective and innovative system of care for those with mental disorders. When implemented together, these recommendations are expected to result in improved mental health services that will enable persons with even the most serious mental illnesses to actually recover and regain their place in the home community—with real homes, fulfilling jobs, and deep relationships. These recommendations envision a mental health system of care that is results oriented, innovative, consumer friendly, well funded, and committed to change. This chapter provides an overview of the history of mental health treatment, a working definition of mental illness and serious mental illness, symptoms and treatment of serious mental illness, mental health care provided in psychiatric hospitals/facilities, and the importance of community resources in meeting less-severe mental health needs.

There has been relatively little policy in Canada that takes mental health housing as its particular focus. Despite this, a number of forces have shaped where people with mental illness live. This chapter recognizes this reality by using a very broad notion of the term “policy,” defined as a course of action adopted and pursued by groups of social actors who may be organized as governments, professional bodies, consumer groups, private entrepreneurs, or community agencies. This approach emphasizes that policy is best defined by its actual impact on people with mental illness. Following this approach, the chapter not only looks at written policy documents but also traces the evolution of ideas about where people with serious mental illness should be located from a historical perspective, examining the broader political and cultural shifts that have situated people with mental illness in Canadian society.

This chapter tracks the evolution of housing in Australia—from deinstitutionalization up to present day. It highlights the diversity of forms housing that have evolved as across Australia well as the differences that emerged in the various states that have the primary responsibility for the delivery of housing. It highlights more recent national level efforts to form a national vision for housing and to ensure that it is a foundation of community mental health systems. The chapter concludes by examining some of the ongoing challenges in ensuring that all Australians with mental illness are able to access their right to appropriate housing

This chapter provides an overview of the recent history of housing for people with serious mental illness, with an emphasis on developments in North America. It identifies approaches to community housing in the early years of deinstitutionalization from the 1960s through the 1980s. It then reviews subsequent developments in housing, from the 1990s to the present day, including key programmatic initiatives that have emerged. The review uses a framework that adapted from Prilleltensky that includes the following elements: (1) context, (2) assumptions, (3) values, and (4) practices. The purpose is to understand not only the practices in housing for people with serious mental illness during these two time periods but also the assumptions and values that underlie them and the context in which they developed.

Economic analysis is important when there is great demand for services but resources are limited. This chapter presents a social-ecological framework of the larger social context of housing for people with mental illness. Next, it reviews theory and research that is pertinent to the three dimensions of this framework that are relevant to housing: (1) policy and planning systems, (2) informal systems, and (3) the geosocial environment. It is important to understand these larger social systems because the relationships between housing programs and individuals with mental illness are influenced by these dimensions of the social context. The review identifies 16 studies that offer some insight into the economic implications of housing interventions for people with severe and persistent mental illness, and calls for a continued expansion of this knowledge base.

This chapter examines theory and research on supportive housing programs, both scattered-site and single-site, for people with serious mental illness. The first section of the chapter focuses on housing program theory, while the second section focuses on housing program research.

This chapter addresses the intersection of mental health and the criminal justice system. Individuals with serious mental illness (SMI) are at higher risk of involvement with the criminal justice system and at greater risk of more severe sentencing. Mental Health America estimates that 20% of persons on death row have a serious mental illness. Someone who was actively mentally ill at the time of a crime, but who has received treatment and is now stable, will proceed to trial as death eligible. This chapter holds that, as the majority of mental health professionals, social workers have a responsibility for educating lawmakers, community members, and those in the criminal justice system, as well as other practitioners about the multiple levels of injustice and inequity surrounding individuals with SMI and the criminal justice system. These issues range from inadequate and inconsistent treatment in the community, jails, and prisons to differential sentencing practices.

It is difficult to differentiate housing models for people with serious mental illness. Previous reviews have made distinctions between custodial, supportive, and supported housing and between residential care and treatment, the residential continuum, permanent supported housing, and nonmodel housing. Attempting to sort programs into categories entails distinguishing housing models based on particular characteristics that are presumed to be shared by programs following a particular model and different from the characteristics of other models. However, making distinctions between different types of housing models is not always clear-cut. This chapter proposes a three-step process for understanding different housing models that combines categorical and dimensional approaches. It first introduces the three steps in the process, then uses this process to examine past and present housing models. The goal is to clearly delineate the key components of different housing models.

This chapter examines the cost-benefit and cost-effectiveness research on housing in the context of the community mental health system. It reviews the extant research on the economic benefits associated with stable, high-quality housing.

This chapter focuses on the effectiveness of community-based support available to people with severe mental illness living in various forms of housing. This review distinguishes among professional forms of support such as assertive community treatment (ACT) and intensive case management (ICM) that are offered to individuals with, but are separate from, housing. This includes other forms of support that are integrated into single-site housing (formerly termed “supportive housing”). This chapter reviews the research on the effectiveness of these different kinds of community-based support associated with both single-site and independent scattered-site supportive housing. The chapter concludes by noting the effectiveness of the combination of scattered-site supportive housing with more intensive individual support for enabling individuals exit homelessness, by calling for the need to develop more of this programming.

The chapters in this book testify to a field that is vibrant, growing, and making a significant contribution to bettering the lives of people with serious mental illness. Since deinstitutionalization, too many people with serious mental illness have experienced social isolation, marginalization, and poverty; problems that persist today. There are a number of causes including inappropriate and ineffective treatment, stigma, and inadequate support. Other noteworthy causes have been the lack of or the poor quality of, housing in the community. There is reason to hope that this is changing. This chapter summarizes common findings and themes across the chapters in the book, and provides some suggestions for moving forward, in theory, research, practice, and policy.

This chapter discusses the contributions that the concept of citizenship can make to practice, policy, and research on housing for people with serious mental illness. The chapter is concerned with whether people can access housing, their relationships to the housing, and how the housing and its characteristics affect them. It is also concerned with how housing can enable people to take control over their lives, to influence their surroundings and the communities in which they live. The chapter considers three conceptions of citizenship: (1) legal citizenship, (2) normative citizenship, and (3) lived citizenship. It proposes a citizenship framework for practice, policy, and research. Then, the chapter uses the citizenship concept to examine the strengths and weaknesses of single-site, independent, and Housing First approaches. The chapter concludes by comparing the citizenship concept with other concepts that have been associated with housing, evaluating its relative merits and weaknesses.

This chapter describes and discusses methods for studying the lives of people who have experienced serious mental illness and who are living in housing in the community. To date, much of the research that has captured attention has been quantitative and nomothetic in nature. This chapter considers the merits of other methods. First, it examines roles that participants may play in the production of knowledge in research. Then it considers how the contributions of research from a citizenship perspective might be appraised. Finally it selectively presents and discusses research approaches and methods that may contribute to a citizenship-informed research agenda.

The literature on landlords in independent supportive housing is surprisingly sparse, given that landlords are fundamental to the coordination and provision of housing for participants in programs like Housing First. Landlords are important stakeholders in housing programs because they directly impact program participants’ ability to get and keep housing. Additionally, landlords represent novel stakeholders in housing and services for program participants insofar as they are “normal” community members contractually related to participants through tenancy agreements, but with no clinical role. This chapter reviews the roles, experiences, and needs of landlords in independent supportive housing. The chapter begins with a review of literature on landlords and independent supportive housing. Next, the main body of the chapter focuses on research with landlords in four sites of the Canadian At Home/Chez Soi Housing First initiative. The chapter concludes with lessons learned from the At Home/Chez Soi experience.

This chapter approaches the important subject of mental health and wellbeing through the lens of public health. Drawing on his own experience as a physician who specializes in psychiatry before moving into public health the author describes the struggle to move upstream from a sole focus on treating serious mental illness to the recent developments in public mental health and offers a framework for action. This draws on a historical overview of the differing emphases that have played in over the past two hundred years. This framework focuses on public health aspects as well as prevention and mitigation of harm from serious mental illness, and addresses the need for whole population approaches to mental health and mental health promotion. Examples of interventions that draw on public health interventions are given. These include the importance of planned parenthood and sexual health, the appropriate use of psychiatric expertise in support of population and community mental health, the centrality of concepts such as self-esteem, and the necessity to take a public health approach to the new challenge of dementia. Behavioural contagion, the role of the media, and the prevention of suicide are among the topics covered.

This chapter explores the introduction of Housing First services for homeless people with severe mental illness in Europe. Housing First, already becoming characterized by paradigm drift as it spread across the United States, might appear to have become ever more mutable as it crossed the Atlantic to Europe. Yet while the differences in operational detail are numerous, the core philosophy followed by Housing First services, being piloted and rolled out across the European Union, is actually very close to the pioneer model. The chapter argues that what may be termed a philosophical consistency with the core principles of Housing First, rather than very high fidelity with the operational detail of the pioneer model, has led to a practical and effective use of Housing First in the European context.

Main Street Housing (MSH) provides affordable, independent, rental housing for people with psychiatric disabilities, across the state of Maryland. One of its guiding principles is supportive accountability, which means establishing clear expectations for tenants’ rights and responsibilities and providing support to meet those expectations. This chapter is informed by the author’s experiences as executive director, and those of his colleagues and tenants at MSH. The chapter highlights the emergence and significance of MSH by discussing it in the context of what is commonly called the consumer/survivor movement. The chapter begins with an outline of the progression and movement of housing for people with mental health needs from institutions to the community and also examines how policy at a national level has shifted from promoting an institutional/maintenance system of care to a system that is working to embrace the delivery of consumer-centered services.

This chapter discusses the challenges and rewards that frontline providers experience when working with a Housing First approach. The discussion is based on qualitative research on frontline provider practice and the author’s in-depth knowledge stemming from real-world experience providing and supervising Housing First services. Topics covered include the importance of a values-based approach rooted in a recovery orientation and guided by a desire for social justice, and support of client self-determination. Examples are used to help illustrate the difficulty of embracing a harm-reduction framework and supporting clients whose decisions cause them harm, the limits or restrictions on client choice, and the responsibilities (and ambiguity) of working in the community with individuals who may be actively using drugs or being disruptive or both.