Qualitative Study of Mental Health Recovery in Dual Diagnosed Homeless

描述（由申请人提供）：由总统的新自由委员会推动的精神健康恢复的愿景预示着为精神病残疾人提供的服务的转变，但对恢复的实证研究并没有跟上其修辞的吸引力。对于“双重诊断”的无家可归者来说，康复的途径更是少之又少，尽管他们的医疗费用高得不成比例，而且生活在集中的劣势之中。与20世纪90年代的康复运动相巧合的是，“住房第一”的兴起，这是一种为患有精神病的无家可归成年人提供服务的方法，与通常的护理或“治疗第一”形成鲜明对比。像精神健康恢复一样，“住房第一”已经得到了联邦和州的支持，但还没有广泛推广，而且仍然没有得到充分的研究。 这个多阶段的定性纵向研究将借鉴相关的理论框架，以探讨心理健康恢复之间的“双重诊断无家可归”的成年人进入住宅服务在纽约市。具体目标是：1）确定共同的元素和背景的双重诊断无家可归的成年人（DDHAs）的“住房第一”（HF）和“治疗第一”（TF）方案服务的恢复。这一目标将通过使用独立提名标准抽样来实现，以选择在进入TF计划（n=10）或HF计划（n=10）后两年内表现出相对较高功能水平的个体。将对另外10份长期（>5年）HF和TF样本进行标准采样和招募。这40个人将进行深入访谈和案例研究分析，用于开发一个或多个恢复模型，为目标2提供信息; 2）对进入HF和TF计划的双重诊断无家可归成年人（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“真实的时间”顺序和背景。目标1中开发的模型将为目标2中的个人（目标2a）、提供者（目标2b）和组织（目标2c）因素调查提供信息。目标2a将包括在18个月内与50名新入学者（HF和TF计划各25名）进行4次深入访谈，与他们的担保人进行3次访谈，并对10名入学者的子样本进行“跟踪”观察（每人6天）。目标2b将包括与其病例经理的3次访谈，目标2c将包括对项目研究中心进行有针对性的人种学访视（n=24次访视）。以个案为中心的数据收集和分析将用于开发一个与寻求退出无家可归的双重诊断成年人相关的恢复归纳模型。以提供者和组织为中心的数据收集和分析将用于确定服务系统背景下产生的以恢复为导向的服务的障碍和激励因素。目标3：建议改变，这将有利于实施恢复为导向的做法（ROP）在工作与双重诊断无家可归的人口。这一目标将涉及综合目标1和2的调查结果，以建议促进残疾人保健机构康复所需的组织和提供者相关变革。为达致这个目的，我们会进行初步研究，探讨人事登记计划的建议在三个地区（纽约市、费城和华盛顿）是否“可接受、适当和可行”。这一目标旨在将研究结果“向上和向外”，以探索其在HF和TF项目（3个城市的6个项目）中的可翻译性。具体而言，我们将在每个HF和TF计划中开展15个焦点小组，一个由前线人员组成，另一个由监督人员组成，每个城市有一个消费者焦点小组。这些小组的数据分析将为考虑到不同环境和方案的ROP提供一系列建议。 拟议的研究旨在广泛地从消费者的角度出发，扩大到包括重要的其他人（抵押品，个案经理和组织），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“真实的世界”的服务，为严重弱势群体。

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.