Housing environments and community adjustment of severely mentally ill persons

Community Mental Health Journal, Vol. 26, No. 6, December 1990

Housing Environments and Community Adjustment

of Severely Mentally H1 Persons

Frank Baker, Ph.D. Charlene Douglas, R.N., M.P.H.

ABSTRACT: This s tudy examined re la t ionships be tween the qual i ty and appropr ia teness of hous ing envi ronments and communi ty ad jus tment of 729 de ins t i tu t iona l ized severe ly men ta l l y ill c l ients in a s ta te-wide communi ty support service program. Env i ronmen ta l measures included ra t ings of the physical condit ion of the cl ient 's residence, i ts adequacy for six key life act ivi t ies , and the overal l appropr ia teness of the res iden t ia l se t t ing for the client. Communi ty ad jus tment measures included global level of functioning, degree of ma ladap t ive behavior and cl ient 's perceived qual i ty of life. Evidence is p resen ted t ha t qua l i ty and appropr ia teness of hous ing envi ronments s ignif icant ly affect aspects of cl ient 's communi ty ad jus tment outcomes over a nine- month period.

Stimulated by the widespread recognition of the plight of the homeless mentally ill, increasing attention is being paid to the housing needs of persons with long-term mental illness (Boyer, 1987; Lipton, Nutt, & Sabatini, 1988). As community support systems are being established around the country, one of the largest gaps in these programs is the

Dr. Baker is Professor of Health Psychology and Ms. Douglas is a doctoral student in Health Psychology at The Johns Hopkins University School of Hygiene and Public Health, 615 N. Wolfe Street, Baltimore, MD 21205.

The author gratefully acknowledges the assistance of James Intagliata, David Mandell, Harry Straus, and David Jodrey in the collection and analysis of the data reported here. These data were collected as part of an evaluation of the New York State CSS program funded by a contract between the New York State Office of Mental Health and the Psychotechnical Applied Research Organization, Inc. of Buffalo, New York. Preparation of this paper has been partially supported by NIMH Grant No. MH 43703. A version of this paper was presented at the American Public Health Association Annual Meeting in Boston, MA on November 16, 1988.

497 �9 1990 H u m a n Sciences Press

498 Community Mental Health Journal

lack of affordable housing that is linked to services and supports, and available on a long-term basis (Randolph, Laux, & Carling, 1987).

However, as important as it is to create housing opportunities for persons with severe mental illness, it is also important to recognize that the quality and appropriateness of this housing for client functioning are also important considerations. The types of housing environments that are made available and their congruence with client needs may be significant in affecting client community adjustment.

Those in the mental health fields have long been aware of the importance of the social and physical environment as they affect the course of mental illness. With regard to the adjustment of persons with severe mental illness to community life, there has been growing agreement that one has to consider the individual needs and competencies of these clients in matching the client to supportive community environments. For example, Bigelow, Brodsky, Steward, & Olson (1982), have argued in support of a conceptual model that would consider various community environments in terms of the opportunities and demands presented by that ecological setting to the client. Other researchers have offered evidence that a person-environment interaction model may best ex- plain the community adjustment and level of functioning of deinstitutionalized psychiatric patients (Anthony, Cohen, & Vitalo, 1978; Test, 1981). Several authors have emphasized the effect of environmental conditions on clients' psychological quality of life (Baker & Intagliata, 1982; Lehman, 1983).

The general purpose of the research reported here was to examine the relationships between the quality and appropriateness of housing environments and adjustment of severely mentally ill clients living in the community. This study of the relation of housing characteristics to client functioning and perceived quality of life was undertaken as a part of a larger evaluation of a state-wide community support services program, which has been discussed in more detail in previous papers (Baker, 1988; Baker & Intagliata, 1984; Intagliata & Baker, 1984).

METHOD

Procedure

The study's basic data source was a questionnaire completed by case managers regarding their clients and administered twice at a nine month interval. Random assignment of clients to experimental and control groups was not feasible in this field research situation.

Frank Baker, Ph.D., Charlene Douglas, R.N., M.P.H. 499

Sample

A stratified random sample of 844 clients was selected from the total population being served in seven community support services (CSS) programs in the four upstate New York Mental Health Department regions (comprising all of New York State except New York City). The CSS program sites included state hospitals, a community mental health center, and other non-state agencies funded by contract with the state for CSS services. There were differences in the quality of housing available at various times in different regions of the state, although each region had a variety of housing alternatives. Assignment to housing related to what was available at a given time, case manager knowledge about various alternatives, client income and level of functioning.

The sample was stratified into three groups of clients according to whether they had entered the program within the last 6 months, had been in the program for 6 months to 2 years, or had been in the program for 2 years or more. Since there was particular concern about the impact of the programs on clients during their initial phase of receiving CSS services, oversampling as necessary at each site was carried out for those clients enrolled in service for shorter periods of time.

Case managers at each site were trained by the project staff in completing the questionnaire. Sixty-seven case managers initially completed questionnaires for 844 clients and again, nine months later, for 729 (86.4%) of this sample.

With regard to the reasons why 115 of the original cohort were not available for the second questionnaire, the largest subgroup consisted of 36 clients who had been re- hospitalized. In addition, 27 refused continued service despite staff belief that they needed it. A mutual decision by the client and staff had been made to terminate service for 15; 11 had moved; 9 had died; and the clinical condition for 7 had markedly deteriorated. It was not possible to find out what happened to 10 of the clients. As compared to those who remained in the cohort, the clients who refused services were generally younger, had been in the community support services program for a shorter period of time, had a greater number of recent previous hospitalizations, participated in fewer adult leisure activities, refused more needed services, and more frequently lived alone or with parents.

The mean age of the clients was 56 years; 16 percent of the clients were under 25, and 27 percent were 65 or older. More than half (56 percent) were women, and 86 percent were white. Only 8.3 percent of the clients were married; 56.7 percent had never been married. About two-fifths (42.8 percent) had graduated from high school, and 14.6 percent had completed at least some college. Almost two-thirds (65.2 percent) of the cohort had a primary psychiatric diagnosis of schizophrenia; affective disorder was the next most frequent diagnosis (13.7 percent).

The subjects in this study were generally similar to clients in community support systems elsewhere as shown by comparisons to a nationwide sample of 1,471 severely mentally ill adults in community support programs sponsored by NIMH (Tessler, et al., 1982; Goldstrom & Manderschied, 1982). The New York sample was comparable with regard to gender and age, but were somewhat older. The proportion who had never been married in each sample was similar, but the percentage of clients currently married was larger by half in the NIMH data. Only 33% of the national sample finished high school, but 20% had at least some college. The diagnostic categories for both samples were similar (Baker & Intagliata, 1984).

Measures

The questionnaire obtained information on the clients' residential situations, global level of functioning, maladaptive behavior, and participation in a variety of available


support services. Case managers also interviewed their clients regarding each client's perceived quality of life as indicated by their satisfaction with 15 major life domains.

Information collected about the housing situation of clients included the type of setting (e.g., group home, boarding or rooming house, private residence), the people, if any, with whom the client shared the residence and three types of ratings of the residential environment by the client's case manager.

Four items dealt with the physical condition of the residential environment. On a scale from 1 (poor) to 5 (excellent) the case managers rated the general physical condition of: 1) the neighborhood in which the residence was located, 2) the exterior of the residence, 3) the interior of the residence, and 4) the client's personal property. Scores on these items were summed to create a total score reflecting the overall physical condition of the individual client's residential edvironment. A Cronbach alpha reliability coefficient of .86 was obtained for this four-item scale.

The adequacy for basic life activities of a client's residence was also rated on a five- point scale by his-her case manager regarding the degree to which the furnishings and physical layout were adequate for: 1) sleeping, 2) maintaining personal hygiene, 3) eating, 4) preparing food, 5) solitary relaxation or leisure activities, and 6) socializing with others. This six-item scale had an alpha of .94. Case managers also provided an overall rating of the appropriateness of the residence for the client's particular needs and capacities.

Service involvement was rated in both the first and second questionnaire surveys by whether clients needed and had received each of sixteen services during the previous month. The sixteen services were empirically grouped into major service clusters as described elsewhere (Baker & Intagliata, 1983). These five service groupings were: 1) day treatment, 2) psychosocial club, 3) evening and weekend recreation activities, 4) on- site rehabilitation, and 5) workshop and vocational programs. Of particular concern were unmet service needs, i.e., services that were needed by the clients but were not being received.

Three measures of community adjustment outcome were collected for each client. One was the Global Assessment Scale (GAS) (Endicott, Spitzer, Fleiss, & Cohen, 1976), which provides a rating of a psychiatric patient's global level of functioning on a scale from 100 to 0. Clients were also rated regarding the frequency and severity of occur- rence of 17 maladaptive behaviors reflecting the client's ability to behave by normative social standards. The scale was comprised of items from the New York State Office of Mental Health's standard functional assessment plus items from other maladaptive behavior scales. Items include: the use of profane language, hyperactivity, extreme with- drawal, rebelliousness, and other troublesome behaviors. The alpha of this scale was .79.

Clients' level of perceived quality of life was assessed through the Satisfaction with Life Domains Scale (SLDS), which was constructed by adapting the "smiley faces" response format developed by Andrews and Withey (1976) to determine a respondent's satisfaction with 15 life domains (Baker & Intagliata, 1982). The respondent is asked to indicate his/her feelings by choosing one of seven faces ranging from a face with a large upturned smile (scored 7) to a frowning face with a deeply down-turned mouth (scored 1). The CSS clients were asked to pick the face that best represented their degree of satisfaction with life areas including: their place of residence, food, clothing, health, friends, the way they spend their spare time, etc. The alpha coefficient obtained for this administration of the 15-item scale was .84.

Reliability o f Case Manager Ratings

At one of the seven study sites, case managers had dual roles, acting as the primary case manager for some clients, while working with other clients in other helping roles.


Thus, they were able to provide secondary ratings that they were confident about on the maladaptive behavior scale and the GAS for 36 of the clients. The interrater reliability for the 17 item maladaptive behavior scale was .84, and the correlation of ratings on the single score GAS was .64. Interrater agreement for other patient status measures collected as part of the larger study, but not considered here, ranged from .53 to .76 (Baker & Intagliata, 1983). The general pattern that seems to characterize these reliability comparisons is what one might expect; the interrater coefficients are higher for longer scales and for measures which call for ratings of observable behavior. It seems tenable to assume that ratings of less subjective phenomena such as receipt of services and condition of residential environment would be at least as high.

RES UL TS

Overall, 34% of clients were judged to be living in residences which were of below average physical condition. With respect to the adequacy for basic life activities, 23% of clients were judged to be living in poor residences. Case managers rated 14% of the clients as living in housing that was inappropriate to their needs.

The extent to which clients' needs for community support services were being met was significantly related to the three measures of residence condition. Clients who lived in housing rated as appropriate at both administrations of the questionnaire had fewer unmet service needs than clients living in inappropriate housing at either or both times the questions were asked (F(3,716) = 14.2, p < .0001).

The physical condition of clients' residence environments was found to be significantly related to unmet service needs (F(2,712) = 20.6, p < .0001) with clients living in below average conditions having an average of more than twice as many unmet service needs as clients living in either average or above average conditions. Finally, ratings of the adequacy of client housing for basic life activities were also significantly related to unmet service needs (F(2,699) = 5.8, p < .01), with clients in housing rated as ~poor" having more unmet service needs than clients in residences rated as 'Tair" or "good" with regard to adequacy.

To determine whether housing conditions and unmet service needs were related to change in functioning, a repeated measures analysis of variance was performed for each of the major outcome variables. In each case the variable involving unmet service needs was entered into the equation first, so that the analyses would measure the effect of residence conditions over and above the effect of unmet service needs. Because the effect of residence conditions on client functioning might be different depending on whether clients live in housing that provides

502 Community Mental Health Journa l

formal supervision, analyses were performed separately for clients in supervised (e.g., family care housing) and in unsupervised settings (e.g., private apartment).

Clients who remained in supervised residences that were rated as either below average, average, or above average in physical condition were compared in terms of change in functioning over the intervening nine months. The only outcome which was found to be significantly influenced by the physical condition of client housing (over and above the influence of services received) was change in maladaptive behavior (F(2,342) = 5.42, p < .01). Post hoc analyses of the three client groups revealed that, regardless of the amount of support services they received, clients in housing with below average physical condit ions showed a significant increase in the number of maladaptive behaviors they manifested (t(121) = - 3.71, p < .001), while clients in average and above average conditions remained about the same.

Residence adequacy was found to have a significant impact on change in clients' Global Assessment Scale rating over and above the impact made by the receipt of support services (F(2,410) = 4.6, p < .05) with clients in residences rated as ~'good" and 'Tair" in adequacy increasing in functioning and tho~e rated as '~poor" remaining about the same.

A significant relationship was also found between residence adequacy and change in maladaptive behavior over and above any influence due to support services (F(2,336) = 8.6, p < .001). Clients in fair or good residences did not increase their level of inappropriate behavior.

For the analyses testing the influence of residence appropriateness (over and above any influence due to receipt of services) on changes in client functioning over time, the study cohort was divided into three subgroups for comparison. These included: 1) clients living in residences judged as appropriate at both times, 2) those living in residences judged as inappropriate at both points, and 3) those living in residences judged as inappropriate at one time but at not the other. Because of the small number of clients in Group 3, the analyses regarding residence appropriateness were not performed separately for those living in supervised and unsupervised residential settings.

A significant relationship was found between residence appropriateness and change in clients' GAS ratings even after controlling for service use (F(3,713) = 3.7, p < .05). Post-hoc analyses revealed that clients who lived in housing rated as appropriate at both waves of the study improved significantly in their overall level of functioning (t(595) = - 3.79, p < .001), while clients who moved from appropriate to inappropriate housing deteriorated significantly (t(9) = 2.66, p < .05).


Independent of service utilization, residence appropriateness related significantly to change in clients' perceived quality of life as measured by the Satisfaction with Life Domains Scale (F(3,589) = 3.0, p < .05). Post-hoc analyses indicated that clients moving from appropriate to inappropriate residential settings showed significant deterioration in their perceived quality of life (t(8) = 3.0, p < .05).

Discussion

The results from this study indicated that clients with severe mental illness enrolled in a community support services program who lived in the worst residential environments also had the greatest number of unmet service needs. However, even when the effect of unmet service needs was controlled for in the analyses, poor housing had significant relationships to poor community adjustment outcomes. It was found that the severity of maladaptive behavior by clients was significantly more likely to increase over time for those who lived in inappropriate or physically inferior environments whatever support services were received. Controlling for the effects of supportive services, clients who lived in adequate housing did not show this significant increase in maladaptive behavior.

Clients living in appropriate housing showed significant improve- ment over time in overall functioning, while clients who moved from appropriate to inappropriate housing showed significant deterioration in global functioning. The effects of inappropriate housing also included decreased levels in clients' perceived quality of life.

Despite some methodological weaknesses related to the infeasibility of exercising control over the assignment of clients to CSS programs, residences, and staff raters, this study strongly suggests that the condition of a client's housing environment can impact significantly on the community adjustment outcomes for clients receiving community support services. The results are consistent with a behavioral-ecology theo- retical position, which views the behavior of individuals in a particular environment as reflecting the types of responses that the environment shapes and reinforces as well as the characteristics and behavioral capabilities and styles that the individuals bring with them to that environment (Wandersman & Moos, 1981). According to this approach the community adjustment displayed by clients is only partially ex- plainable by the effects of the specific medical, rehabilitative and social support services provided; it is also necessary to consider the contribu- tion made by community residential variables as well.


Of course, the particular type of residence that a deinstitutionalized patient with chronic mental illness moves into is not simply an issue of free choice by the individual patient nor is it, as noted above, the result of entirely random factors. Case managers play a role, as do other helpers in assessing the client's needs for supervised versus unsupervised living situations. The availability of living situations in a community is also an important factor and the willingness and ability of family members to provide a home for the patient also make a differ- ence. More needs to be learned about the process by which clients are matched to different housing situations, but clearly, at any given time, this involves a compromise between the needs identified for the client and the availability of housing that may meet these needs.

Another major consideration is the economic situation of the client; most severely mentally ill people not only have their illness to deal with but they must also contend with the additional problem that they are poor. They cannot compete successfully for paid employment nor keep a job if they get one. The New York State CSS cohort who were the subjects in this study had a median monthly income of $550 and were dependent on entit lements including Supplementary Security Income and Social Security disability or retirement payments (Baker & Intag- liata, 1984). Given their impoverished condition, it can hardly be sur- prising that their dwellings are in poor condition. While all these factors help to determine the kind of residence in which a client ends up, once a client is there, the nature of the particular environment and its appropriateness for him or her seems to affect the client's continued level of functioning. This is consistent with the observation by Test (1981) in a review of earlier research on community care of persons with chronic mental illness that living situations which facilitate or demand the independent performance of basic life activities result in better instrumental functioning. Bigelow, et al. (1982), have suggested how this may take place. According to their theory, different environments offer different opportunities for practice of functional skills as well as different demands for certain types of behavior.

This study supports the importance of the relationship between the quality and appropriateness of housing and the clients' level of functioning. In addition, it shows that when people live in housing that is physically unappealing and which by all accounts is ~inappropriate," then their degree of maladaptive behavior also increases. It appears that the issue is not one of merely getting clients off the streets, but of ensuring that their housing is of reasonable quality and appropriate to their needs. For those who are developing and/or operating a compre-


hensive community support program (CSP) for clients with chronic mental illness, these findings highlight the importance of paying attention to the residential component of such a system.

REFERENCES

Andrews, R.F., & Withey, S.B. (1976). Social indicators of well-being: Americans'perceptions of life quality. New York: Plenum Press.

Anthony, W.A., Cohen, M.R., &Vitalo, R. (1978). The measure of rehabilitation outcome. Schizo- phrenia Bulletin, 4, 365-383.

Baker, F., & Intagliata, J. (1982). Quality of Life in the evaluation of community support systems. Evaluation and Program Planning, 5, 69-79.

Baker, F., & Intagliata, J. (1984). The New York State Community Support System: A profile of clients. Hospital & Community Psychiatry, 35, 39-44.

Baker, F., & Intagliata, J. (1983). CSS evaluation final report. Submitted to the New York State Office of Mental Health. Albany, New York.

Baker, F. (1988). An approach to evaluating state-funded community support services for the chronically mentally ill. In B.L. Blackwell & L.K. Cartwright, Program consultation with human with human service programs: A clinical perspectiv~ (pp. 155-163). Oakland~ CA: Third Party Press.

Bigelow, D.A., Brodsky, G., Steward, L. and Olson, M. (1982). The concept and measurement of quality of life as a dependent variable in evaluation of mental health services. In W. Tash and G. Stahler (Eds.) Innovative Approaches to Mental Health Evaluation (pp. 345-366). New York, New York: Academic Press.

Boyer, C.A. (1987). Obstacles in urban housing policy for the chronically mentally ill. In D. Mechanic (Ed.), Improving mental health services: What the social sciences tell us: New directions for mental health services, (no. 36). San Francisco: Jossey-Bass.

Endicott, J., Spitzer, R.L., Fleiss, J.L., & Cohen, J. (1976). The global assessment scale. Archives of General Psychiatry, 33, 766-771.

Intagliata, J., & Baker, F. (1984). The New York State community support system: A profile of clients. Hospital and Community Psychiatry, 35, 45-50.

Lehman, A.F. (1983). The well-being of chronic mental patients, assessing their quality of life. Archives of General Psychiatry, 40, 369-373.

Lipton, F.R., Nutt, S., & Sabatini, A. (1988). Housing the homeless mentally ill: A longitudinal study of a treatment approach. Hospital and Community Psychiatry, 39, 40-45.

Randolph, F.L., Laux, B., & Carling, P.J. (1987). In search of housing. Burlington, VT: University of Vermont Center for Change through Housing and Community Support.

Test, M.A. (1981). Effective community treatment of the chronically mentally ill: What is necessary? Journal of Social Issues, 37, 71-86.

Wandersman, A., & Moos, R.H. (1981). Assessing and evaluating residential environments: A sheltered living environments example. Environment and Behavior, 13, 481-508.

Housing environments and community adjustment of severely mentally ill persons

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