The Relationship Between Serious Mental Illness and Criminal Offending in Persons Experiencing Homelessness: The Role of Substance Use Disorder.

Individuals who live with mental illness are encumbered by related risk factors that increase the probability of legal involvement. The goal was to determine how homelessness and substance use disorder are intervening factors in the relationship between symptoms of serious mental illness (SMI) and criminal offending. A sample of 210 chronically homeless adults receiving SAMHSA-funded outreach and psychiatric rehabilitation services between 2014 and 2016 was recruited in a study of interventions to address housing in homeless persons with a SMI. Participants were interviewed and data collected were analyzed using structural equation modeling. Statistical analysis showed that homelessness severity mediated the relationship between SMI symptom severity and criminal offenses committed in the past 30 days in participants with a substance use disorder but not in those with no substance use diagnosis. Results show that homelessness and substance use are important to address to possibly alter trajectories for criminal justice involvement.

Happiness, well-being, and recovery: Experiences of adults receiving psychiatric rehabilitation services.

OBJECTIVES: Although recovery for people with serious mental illness (SMI) has received considerable attention, there is a research gap on the related topics of well-being and happiness-subjects that have been widely studied in the general population. The objective of this study was to explore the experiences of happiness, well-being, and recovery from the perspectives of persons with SMI, and to examine similarities and differences among these constructs. METHOD: This qualitative study used semistructured interviews with a purposive sample of 30 adults with SMI to explore experiences of happiness, well-being, and recovery. Reflexive thematic analysis was applied to generate themes related to each concept. RESULTS: Happiness was facilitated through relationships with natural and professional supports, engaging in meaningful activities that conferred a sense of accomplishment, using coping skills to reduce distress, engaging in recreational activities, and meeting basic material needs. Well-being was promoted through self-care activities and enhanced through relationships with professional supports. However, nearly one-fourth of participants expressed uncertainty about what well-being meant to them. Recovery was characterized as a process of overcoming illness or adversity through which personal control over symptoms and stressors is increased; recovery is also facilitated by supportive professional relationships. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Most factors relating to the happiness of people with SMI are also factors that have been identified in theory and research as facilitating the happiness of the general population. Findings suggest that happiness should be considered an important new area of research, policy, and practice in the fields of psychiatric rehabilitation. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Organizational conditions that influence work engagement and burnout: A qualitative study of mental health workers.

Objective: Clinician burnout in healthcare is extensive and of growing concern. In mental health and rehabilitation settings, research on interventions to improve burnout and work engagement is limited and rarely addresses organizational drivers of burnout. This study sought to elaborate on the organizational influence of burnout and work engagement in mental health. Methods: We randomly selected 40 mental health clinicians and managers who were participating in a burnout intervention and conducted semi-structured interviews to understand their views of organizational conditions impacting burnout and work engagement. Data were analyzed using a thematic analytical approach. Results: Analyses yielded three major themes where organizational contexts might reduce burnout and increase work engagement: (a) a work culture that prioritizes person-centered care over productivity and other performance metrics, (b) robust management skills and practices to overcome bureaucracy, and (c) opportunities for employee professional development and self-care. Participants also referenced three levels of the organizational context that they believed influenced burnout and work engagement: front-line supervisors and program managers, organizational executive leadership, and the larger health system. Conclusions and Implications for Practice: Findings point to several possible targets of intervention at various organizational levels that could guide the field toward more effective ways to reduce burnout and improve work engagement. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The well-being and perspectives of community-based behavioral health staff during the COVID-19 pandemic.

With high levels of burnout, turnover, and secondary traumatic stress, the well-being of the behavioral health workforce was an area of concern prior to the coronavirus disease 2019 (COVID-19) pandemic. How the COVID-19 crisis has impacted social workers, psychologists, psychiatrists, and other behavioral health professionals is unclear but should be examined. A brief survey evaluated the impact of the pandemic on the well-being of 168 behavioral health clinical and administrative staff serving in an urban behavioral health center in the United States. Staff experienced several personal and organizational-related challenges related to work-life balance, emotional distress, and organizational communication. Nevertheless, staff found an abundance of positive experiences when engaging with clients. Supportive, positive feedback and statements of appreciation from clients, colleagues, and supervisors helped staff to feel at their best. The well-being of behavioral health staff may be facilitated by consistent and supportive communication at the team, supervisory, and organizational levels and by involving staff in planning agency policy.

Improving outcomes for homeless people with alcohol disorders: a multi-program community-based approach.

Background: Relatively few community-based programs have been found to be helpful for homeless people with alcohol disorders, even though this group represents a high-risk, vulnerable population prone to poor outcomes.Aims: This study sought to implement and evaluate intensive community-based programs for homeless people with alcohol disorders.Method: The project worked closely with a homeless outreach team for referrals, and then provided two different, intensive substance abuse treatment approaches matched to the needs of two subgroups: homeless individuals with alcohol disorders without severe mental illness received community reinforcement approach (CRA) and case management services, while those with alcohol and severe mental illness were assigned to assertive community treatment and integrated dual disorders (ACT/IDDT) services. The study enrolled 322 homeless people with alcohol disorders and outcomes were assessed at six months and program discharge.Results: Participants improved significantly over the first six months in a number of outcome areas, including substance abuse, mental health, housing, employment and health; progress generally remained stable between six months and discharge.Conclusions: Community-based programs that coordinate with mobile outreach teams and then provide CRA and ACT/IDDT appear to be promising approaches for helping individuals with alcohol disorders out of homelessness and into recovery.

A brief intervention for posttraumatic stress disorder in persons with a serious mental illness.

OBJECTIVE: Posttraumatic stress disorder (PTSD) is common in people with a serious mental illness, but it is often not diagnosed or treated. Recent progress has been made in developing and validating interventions for PTSD in this population, but dropout from treatment can be problematic. The present study evaluated the feasibility and clinical outcomes of a Brief program (three sessions) for the treatment of PTSD in persons with a serious mental illness. METHOD: An open clinical trial was conducted to evaluate the Brief program, which comprises three individual weekly sessions and includes education about trauma and PTSD, as well as instruction in breathing retraining for the self-management of anxiety. Eighteen predominantly minority persons with serious mental illness and PTSD were enrolled in the Brief program and assessed at baseline, 1-month posttreatment, and 3-month follow-up. RESULTS: Acceptability and tolerability of the program were high, with 15 of 18 (83%) study participants completing all three sessions. Interview-based and self-report assessments indicated significant reductions in PTSD symptoms, depression, and other symptoms at posttreatment, with treatment gains maintained at the 3-month follow-up. CONCLUSION AND IMPLICATION FOR PRACTICE: The results suggest the Brief program may be clinically beneficial to persons with serious mental illnesses and PTSD and indicate that more rigorous research is needed to evaluate the program.

Evaluation of treatment programs for dual disorder individuals: modeling longitudinal and mediation effects.

This study evaluated the effectiveness of the three approaches for treating dual disorder clients who were homeless at intake: integrated assertive community treatment (IACT), assertive community treatment only (ACTO), and standard care (SC). Multilevel Random Coefficient Modeling (MRCM) was used to analyze longitudinal effects and to identify mediators of significant treatment effects. The outcome variables were consumer satisfaction, stable housing, psychiatric symptoms, and substance abuse. The eight mediators were service utilization variables: program contacts, phone contacts, substance abuse contacts, assistance with activities of daily living, transportation assistance, help finding permanent housing, help with emotional problems, and medication assistance. The 191 eligible participants were randomly assigned to one of the three conditions and followed for a period of 30 months. Both ACTO and IACT produced better outcomes than SC on consumer satisfaction and stable housing. There were no differences on any of the outcome variables between ACTO versus IACT when comparing main effects. However, there were several treatment by time interactions. In addition, there were many mediation effects.

Client outcomes and the working alliance in the client-case manager relationship: a causal analysis.

This study investigated the causal relationship between the working alliance and client outcomes in the client-case manager relationship. All 162 study participants received services fiom a case manager who worked as a member of an assertive community treatment team. All participants had both a substance use disorder and a diagnosis of severe mental illness and were homeless at baseline. A brief form of the Working Alliance Inventory (WAI) was used to measure the working alliance after 3 and 15 months of treatment. The Brief Psychiatric Rating Scale was used to measure psychiatric symptoms at baseline, 9, and 18 months. Days per month that clients used alcohol or illegal drugs was also assessed at baseline, 9, and 18 months. The data were analyzed using structural equation modeling (SEM). The correlations between the working alliance and the outcome measures were lower than similar correlations obtained in studies investigating the psychotherapy relationship. The SEM analyses revealed little or no causal relationship between the working alliance and client outcome in this sample.

Treating homeless clients with severe mental illness and substance use disorders: costs and outcomes.

This study compared the costs and outcomes associated with three treatment programs that served 149 individuals with dual disorders (i.e., individuals with co-occurring severe mental illness and substance use disorders) who were homeless at baseline. The three treatment programs were: Integrated Assertive Community Treatment (IACT), Assertive Community Treatment only (ACTO), and standard care (Control). Participants were randomly assigned to treatment and followed for a period of 24 months. Clients in the IACT and ACTO programs were more satisfied with their treatment program and reported more days in stable housing than clients in the Control condition. There were no significant differences between treatment groups on psychiatric symptoms and substance use. The average total costs associated with the IACT and Control conditions were significantly less than the average total costs for the ACTO condition.

Predictors of the working alliance in assertive community treatment.

Past research has found that a positive working alliance between clients and their case managers is modestly correlated with client outcomes. The current study tried to identify the predictors of the working alliance in a sample of 115 clients who were receiving services from Assertive Community Treatment (ACT) teams. All of the clients suffered from severe mental illness, had a substance use disorder and were homeless at baseline. Both the client's rating and the case manager's rating of the working alliance were assessed at 3 months and 15 months post baseline. Client characteristics, particularly motivation to change, explained more of the variance of the client's rating of the alliance than treatment variables or client change on the outcome variables. On the other hand, treatment variables (e.g., the amount of transportation services provided) and client change on the outcome variables explained more of the variance of the case manager's rating of the alliance.

Generalizability of brief psychiatric rating scale prototypical profiles and their use in evaluating treatment outcomes.

The generalizability of previously isolated prototypical profiles of the Brief Psychiatric Rating Scale (BPRS) was examined in a sample of homeless individuals with both severe mental illness and substance-use problems who were part of a 24-month study that evaluated the effectiveness of various treatment interventions. These prototypical profiles (depressed, actively psychotic, and withdrawn) did generalize to the new sample, with a 59.4% coverage rate. In addition, some of the participants' BPRS profiles (10%) were characterized by negative correlations with the withdrawn profile (termed agitated) and others (17%) by minimal within-profile variability (labelled flat). Overall, with these additions, the coverage of the prototypical profiles was 86.4%. These prototypical profiles were then used to evaluate changes in profile elevation and shape over the course of the study. Generally, changes in both profile elevation and shape were moderated by the particular prototypical profile that the participants resembled. The use of these prototypical profiles in evaluating change permits a more precise analysis of what kind of individuals manifest particular effects. The clinical meaning of the BPRS profile changes observed was also discussed.

Impact of assertive community treatment and client characteristics on criminal justice outcomes in dual disorder homeless individuals.

BACKGROUND: People with severe mental illness and substance use disorders (dual disorder) often have considerable contact with the criminal justice system. AIMS: To test the effects of client characteristics on six criminal justice outcomes among homeless (at intake) people with mental illness and substance misuse disorders. METHODS: The sample was of participants in a randomized controlled trial comparing standard treatment, assertive community treatment (ACT) and integrated treatment (IT). Data were analysed using hierarchical logistic regression. RESULTS: Half the sample was arrested and a quarter incarcerated during the two-year follow-up period. The regression models explained between 22% and 35% of the variance of the following criminal justice measures: (1) major offences, (2) minor offences, (3) substance-use-related offences, (4) incarcerations, (5) arrests, and (6) summons. Prior criminal behaviour was the strongest predictor of all of the dependent variables; in general, demographic and diagnostic variables were not. Similarly, neither the type nor the amount of mental health treatment received predicted subsequent criminal behaviour. CONCLUSION: Elsewhere the authors have shown that ACT and IT had advantages for health and stability of accommodation but these analyses suggest that more specialized interventions are needed to reduce criminal behaviour in dual disorder individuals.

Evaluation of treatment programs for persons with severe mental illness: moderator and mediator effects.

This study evaluated several statistical models for estimating treatment effects in a randomized, longitudinal experiment comparing assertive community treatment (ACT) versus brokered case management (BCM). In addition, mediator and moderator analyses were conducted. The ACT clients had improved outcomes in terms of housing and psychiatric symptoms than BCM clients. Case management housing assistance and financial assistance partially mediated housing outcomes. No reliable mediators were found for psychiatric symptoms, and no reliable moderators were found for either housing or psychiatric symptoms. The study also made several important methodological advances in the analysis of longitudinal data in randomized experiments.

Client outcomes and the working alliance in assertive community treatment programs.

This study examined the relationship between outcomes and the working alliance in clients who were receiving assertive community treatment only or integrated assertive community treatment (assertive community treatment plus substance abuse treatment). All 98 participants had a severe mental illness and a substance use disorder. The Working Alliance Inventory assessed the alliance from the perspective of both the client and the case manager at 3 and 15 months into treatment. The six outcome measures were stable housing, client rating of psychiatric distress, interviewer rating of psychiatric symptoms, self-report of days used alcohol or drugs, and interviewer rating of substance use. Only 4 of 24 correlations were significant, indicating little relationship between the strength of the working alliance and client outcome.

A confirmatory factor analysis of the Brief Psychiatric Rating Scale in a homeless sample.

This study used a confirmatory factor analysis procedure, the Oblique Multiple Group Method (OMG), with the Brief Psychiatric Rating Scale (BPRS) on a sample of homeless individuals who had both a severe mental illness and a substance use disorder. The hypothesized five-factor model of Guy (1976) accounted for 93% of the possible variance, and all the appropriate scales had their highest loading on their respective hypothesized factor. In addition, the Guy model accounted for more variance than did an alternative model. The five factors were labelled: thinking disorder, anergia, anxiety-depression, hostility-suspicion, and activity.

Prevalence of human immunodeficiency virus, hepatitis B, and hepatitis C among homeless persons with co-occurring severe mental illness and substance use disorders.

This study was undertaken to determine the prevalence of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) among homeless persons with co-occurring severe mental illness (SMI) and substance use disorders and to determine associated risk factors. As part of a longitudinal study of the effectiveness of integrated treatment for homeless persons with SMI and substance abuse or dependence, serological testing was performed to ascertain the prevalence of HIV, HBV, and HCV. At baseline, 6.2% of participants (11/172) were HIV-positive. Nearly one third of participants (37/114) had evidence of prior exposure to HBV, and 30% (34/114) were antibody positive for HCV. About 44% of participants (50/114) had a reactive test for either HBV or HCV. Having a reactive test was strongly associated with substance use, especially with a history of injection drug use. A significant threat exists to the health and well-being of homeless person with SMI due to high prevalence of blood-borne pathogens. Mental health providers need to play a proactive role in the identification of health-related needs and to assist with access to general health services for persons with SMI.

The case manager's view of the helping alliance.

Although the helping alliance has been a topic of investigation in psychotherapy research for decades, few studies have examined the role of the helping alliance in assertive community treatment programs serving people with severe mental illness. In this article, we describe a series of analyses focused on the case manager's view of the helping alliance. The study addressed two primary questions: What factors facilitate a positive helping alliance in case management? What is the relationship of the helping alliance to client outcomes? Results indicated that few client variables predicted the helping alliance. Providing a wider range of services was associated with a stronger alliance at months but not at 18 months. A strong alliance at 18 months was associated with a strong alliance at 6 months. In addition, the alliance at 18 months was rated more positively for clients who were African-American and who did not have a substance use disorder. The helping alliance predicted client satisfaction, anxiety-depression, and hostility-suspicion outcomes at 6 months. However, the helping alliance did not predict any of the client outcome variables at 18 months.

Moderators and mediators of client satisfaction in case management programs for clients with severe mental illness.

This randomized experiment first determined that clients with severe mental illness who received Assertive Community Treatment (ACT) were more satisfied with their treatment program than were clients in a brokered case management program (BCM). Eight demographic and diagnostic variables were examined as potential moderators of the treatment effect. Only one of the eight varables, diagnosis of depression, interacted with treatment condition to effect client satisfaction. However, there were several important mediators of client satisfaction: intensity of program contacts, continuity of program contacts, supportive services (i.e, assistance with activities of daily living), and the strength of the helping alliance as perceived by the client.

Mental Illness in Homeless Men: A Comparison of Shelter and Street Samples.

This study examined the backgrounds and service needs of 152 homeless men. The sample was divided into three groups: "street sample" (used the shelters less than 50% of the time), moderate users of shelters, and high-frequency users of shelters. No significant differences were found between the groups on background variables, psychiatric distress, prior use of psychiatric services, and willingness to receive services. The street sample did report a longer time since living at a fixed address and a need for more social support than did the other two groups of homeless men. Service implications of these findings are discussed.