Qualitative Study of Mental Health Recovery in Dual Diagnosed Homeless

描述(由申请人提供)：总统的新自由委员会倡导的精神健康康复愿景预示着精神残疾人服务的转变，但关于康复的实证研究没有跟上其口头呼吁的步伐。对于“双重诊断”的无家可归者，康复的途径更少被描述或了解，尽管他们承担了不成比例的高医疗费用，并生活在集中不利的环境中。与上世纪90年代的康复运动不谋而合的是，为患有精神病的无家可归成年人提供的一种服务方式--住房优先--的兴起，与通常的护理或治疗优先形成鲜明对比。与心理健康康复一样，“住房优先”已经得到了联邦和州政府的支持，但还没有普及，研究还不够深入。这项多阶段的定性纵向研究将借鉴相关的理论框架，以检查进入纽约市住宿服务的“双重诊断无家可归”成年人的心理健康恢复情况。具体目标是：1)确定由“住房优先”(HF)和“治疗优先”(TF)方案提供服务的双重诊断无家可归成年人(DDHA)康复的共同要素和背景。这一目标将通过使用独立提名标准抽样来选择在进入TF计划(n=10)或HF计划(n=10)两年后表现出相对较高功能水平的个体来实现。另外10个长期(&gt；5年)的HF和TF样本将被标准抽样和招募。这40人将接受深入访谈和案例研究分析，以开发一个或多个康复模式，为目标2提供信息；2)对进入HF和TF计划的双重确诊无家可归成年人(DDHA)进行前瞻性定性研究，以记录恢复的障碍和激励因素及其“实时”序列和背景。在目标1中开发的模型(S)将告知目标2对个人(目标2a)、提供者(目标2b)和组织(目标2c)因素的调查。Aim 2a将包括在18个月期间对50名新参与者(HF和TF方案各25名)进行4次深入访谈，对他们的担保人进行3次访谈，并对10名参与者(每人6天)进行跟踪观察。目标2b将包括与其案件经理的3次面谈，目标2c将包括对方案地点的有针对性的人种学访问(n=24次访问)。将使用以个案为中心的个人数据收集和分析来开发与寻求摆脱无家可归的双重诊断的成年人相关的归纳康复模式。将使用以服务提供者和组织为中心的数据收集和分析，以确定服务系统背景下提供面向恢复的服务的障碍和激励因素。目标3：建议改革，以促进在处理双重诊断的无家可归人口方面实施面向恢复的做法(ROP)。这一目标将涉及整合目标1和目标2的调查结果，以建议促进DDHa恢复所需的组织和与提供者有关的变革。为了实现这一目标，我们将进行一项初步研究，以探索这些人事登记建议在三个地区是否“可接受、适当和可行”：纽约市、费城和华盛顿特区。这一目的是为了把这些研究结果“向上和向外”，以探索它们在HF和TF项目(3个城市的6个项目)中的可译性。具体来说，我们将组织15个焦点小组，一个是一线工作人员，另一个是每个HF和TF项目的监督人员，以及每个城市的一个消费者焦点小组。来自这些小组的数据分析将提供一套针对ROP的建议，其中考虑到不同的设置和计划。拟议的研究试图广泛地从消费者的角度出发，扩大到包括重要的其他人(附属品、病例经理和组织)，并纳入观察数据，以最大限度地提高分析能力和翻译和传播的潜力，以改善为严重弱势群体提供的“现实世界”服务。 公共卫生相关性：这项拟议的定性研究解决了无家可归的患有精神疾病的成年人的精神健康恢复问题，并同时发生了药物滥用。这些人生活在集中的劣势中，并招致高昂的医疗和其他成本，他们挑战了在精神健康服务中已变得突出的“康复范例”。根据总统新自由委员会评估消费者视角的报告，它将制定指导方针，旨在为社会上最难以接触到的人群之一改善以恢复为导向的做法。

DESCRIPTION (provided by applicant): The vision of mental health recovery promoted by the President's New Freedom Commission portends a transformation of services for psychiatrically disabled persons, yet empirical research on recovery has not kept pace with its rhetorical appeal. For 'dual diagnosed' homeless persons, paths to recovery are even less described or understood despite the fact that they incur disproportionately high medical costs and live amidst concentrated disadvantage. Coincidentally with the recovery movement in the 1990s was the rise of 'housing first', a service approach for mentally ill homeless adults that distinctly contrasts with usual care, or 'treatment first'. Like mental health recovery, 'housing first' has received Federal and state endorsements yet is not yet widespread and remains understudied. This multi-phase qualitative longitudinal study will draw on relevant theoretical frameworks to examine mental health recovery among 'dual diagnosed homeless' adults entering residential services in New York City. Specific Aims are: 1) To identify common elements and contexts of recovery among dual diagnosed homeless adults (DDHAs) served by 'housing first' (HF) and 'treatment first' (TF) programs. This aim will be accomplished by using independent nominations criterion sampling to select individuals who manifest relatively high levels of functioning two years after entering a TF program (n=10) or a HF program (n=10). An additional 10 long-term (>5 years) HF and TF samples will be criterion-sampled and recruited. These 40 individuals will be interviewed in-depth and case study analyses used to develop one or more models of recovery to inform Aim 2; 2) To conduct a prospective qualitative study of dual diagnosed homeless adults (DDHAs) entering HF and TF programs in order to document barriers and incentives for recovery and their 'real time' sequences and contexts. Model(s) developed in Aim 1 will inform Aim 2 inquiries into individual (Aim 2a), provider (Aim 2b) and organizational (Aim 2c) factors. Aim 2a will include 4 in-depth interviews over an 18-month period with 50 new enrollees (25 each at HF and TF programs), 3 interviews with their collateral persons, and 'shadowing' observation of a sub-sample of 10 enrollees (6 days per person). Aim 2b will include 3 interviews with their case managers and Aim 2c will involve targeted ethnographic visits to the program sites (n=24 visits). Individual case-centered data collection and analyses will be used to develop an inductive model of recovery relevant to dual diagnosed adults seeking to exit homelessness. Provider- and organization-centered data collection and analyses will be used to identify barriers and incentives to recovery-oriented services emanating from the service system context. Aim 3: To recommend changes that will facilitate implementation of recovery-oriented practices (ROPs) in working with the dual diagnosed homeless population. This aim will involve integrating findings from Aims 1 and 2 to recommend organizational and provider- related changes needed to foster recovery among DDHAs. To accomplish this aim, we will conduct a preliminary study to explore whether these ROP recommendations are "acceptable, appropriate and feasible" in three regional settings: New York City, Philadelphia, and Washington DC. This aim is intended to take the findings 'up and out' to explore their translatability in both HF and TF programs (6 programs in 3 cities). Specifically, we will conduct 15 focus groups, one with front-line staff and another with supervisory staff at each HF and TF program and one focus group of consumers per city. Data analyses from these groups will inform a set of recommendations for ROPs that take into account diverse settings and programs. The proposed study seeks to start broadly from the consumer's perspective, expand to include significant others (collaterals, case managers and organizations) and incorporate observational data to maximize analytic power and the potential for translation and dissemination to improve 'real world' services for a severely disadvantaged population. PUBLIC HEALTH RELEVANCE: This proposed qualitative study addresses mental health recovery among homeless mentally ill adults with co-occurring substance abuse. Such individuals, who live amidst concentrated disadvantage and incur high medical and other costs, challenge the 'recovery paradigm' that has become prominent in mental health services. Drawing upon the President's New Freedom Commission report valuing consumer perspectives, it will produce guidelines designed to improve recovery-oriented practices for one of society's most difficult-to-reach populations.