Art work by Anthony Newton, Fountain Gallery

The broad aims of the developing CCHPS services research program are:

• To conduct trials of interventions intended to prevent or ameliorate homelessness among persons with mental disorders, including both efficacy trails of promising new interventions and effectiveness studies in which established interventions are applied and tested in new service delivery settings.
• To conduct dissemination research focusing on the identification of key ingredients of emerging best practices intended to prevent or ameliorate homelessness among persons with mental disorders. This will include research on various methods for promoting successful adoption of such interventions in disparate service settings.
• To initiate research on potentially modifiable population-level factors associated with the occurrence of homelessness among persons with mental disorders. Such research is a critical first step toward designing and testing population-level interventions.
• To conduct studies of the process of policymaking pertaining to the organization of services and housing for mentally ill persons who are homeless or at risk of homelessness. A central focus will be to understand the ways in which research findings have influenced or failed to influence key policy decisions, in order to suggest strategies to improve this process in the future.

Current Projects

Critical Time Intervention (CTI)
HIV Risk Among Homeless Mothers
Joint Crisis Plans for Adults with SMI
Development of Housing First as an Evidence-Based Practice
The Context of Contemporary Homelessness Among the Severely Mentally Ill: A Study of Policymaking at the Nexus of Housing and Mental Health
Shared Living Arrangements: Effects on Housing Stability, Clinical Outcomes and Quality of Life
Streetworks Project
Methods for Trajectory Analysis
Missing Value Imputation


Critical Time Intervention (CTI)     ^top

Investigators: Daniel Herman, Alan Felix, Ezra Susser, Susan Barrow

CTI is a time-limited, manualized case management approach intended to enhance continuity of care for mentally ill individuals at the time of transition from institution to community by bridging the gap between institutional and community-based treatment services. CTI has two components. The first is to strengthen the individual's long-term ties to services, family, and friends. These supports are potentially available in varying degrees, but mentally ill individuals and those upon whom they depend often need assistance to work with one another. The second component is to provide emotional and practical support during the critical time of transition. CTI is time-limited; it is carried out in three consecutive phases in which the level of intensity of contact between worker and client declines over time. A key component of the model is that follow-up services in the community are provided by a person who has already established a relationship with the client before discharge occurs.

The effectiveness of the model was first tested in an NIMH-funded RCT conducted between 1991 and 1993. Our results demonstrated that CTI was associated with a significant, lasting reduction in post-discharge homelessness among men with severe mental illness following discharge from a large municipal shelter in New York City. Over the 18-month follow-up period, the average number of homeless nights was 30 for the CTI group and 91 for the USO group (p < .01). Since that time, other researchers have implemented adaptations of the CTI model with various populations in a range of service delivery settings.

CCHPS investigators are currently conducting a second NIMH-funded RCT with men and women following discharge from inpatient psychiatric treatment. This trial is being carried out with the support of the New York State Office of Mental Health. Other clinical and research adaptations of CTI are currently underway in a variety of other settings. Further details about the CTI model are available here. LINK HERE TO CTI HOME PAGE

HIV Risk Among Homeless Mothers     ^top

Investigators: Carol Caton, Nabila El-Bassel, Susan Barrow, Daniel Herman ,Bella Schanzer, Andrew Gelman. Francine Cournos

Despite evidence for overlapping risk factors for homelessness and HIV/AIDS, the prevalence of HIV/AIDS and associated risk behaviors has yet to be systematically studied in a representative sample of homeless women. Moreover, it is not known how the homeless experience is related to drug and sexual HIV risk behaviors or to what extent these risk behaviors are influenced by persistent residential instability. There is evidence to suggest that homeless women with chronic residential instability may have greater HIV risk behaviors compared to women for whom homelessness is a new experience. Further knowledge addressing these unanswered questions is a critical prerequisite for the development of effective preventive interventions in this area.
Funded by the National Institute on Drug Abuse, a study of HIV risk among homeless women is being carried out in concert with the New York City Department of Homeless Services, the main providers of shelter care for homeless women in the five boroughs of New York City. A representative sample of approximately 600 homeless women from both family and single adult shelters will be tested for HIV prevalence with the OraSure HIV test based on oral mucosal samples. STI (chlamydia, gonorrhea, trichomoniasis) testing will be based on urine samples. The research team will be responsible for pre/post-test counseling, test results, and referral for treatment for positive assays. The qualitative and quantitative study findings will inform whether risk prevention interventions are most appropriately focused on homeless women alone or including their male partners, whether interventions should be made available on-site in crisis shelter locations to facilitate access to these services, whether HIV risk prevention services require integration with mental health and substance abuse treatment services, and whether specialized risk prevention interventions for homeless women with multiple homeless episodes are warranted.

Primary Aims
To estimate the prevalence of HIV and other STIs in a random sample of homeless women.
To examine the relationship between HIV prevalence, STI prevalence, and homelessness among a randomly selected sample of homeless women.
To investigate the relationship of drug and sexual HIV risk behaviors and homelessness in a random sample of homeless women.
From a multisystem perspective, to ascertain the impact of the ontogenetic level (childhood sexual abuse, mental health status, mental disorder, and alcohol and drug use, attitudes, AIDS knowledge) microsystem level (intimate partner violence; loss of children; frequent residential moves), and exosystem level (availability of stable housing, social support, access to services) on HIV risk behaviors in relation to chronicity of homelessness.

Joint Crisis Plans for Adults with SMI     ^top

Investigators: Claire Henderson, Daniel Herman, Graham Thornicroft

Funded by MacArthur Foundation

A Joint Crisis Plan (JCP) is a simple treatment technology intended to ameliorate the impact of psychiatric crises among persons with SMI. Developed by the consumer, the treatment staff of his or her mental health provider, an independent facilitator, and, if requested by the consumer, a family member or peer, it aims to promote the empowerment of the consumer in his or her care and to facilitate early detection and treatment of relapse of psychosis. It is designed to be held by the consumer and other designated treatment providers and/or family members and can contain a range of information, including treatment preferences in an emergency when he or she might be too ill to express coherent views. Subject to the wishes of the consumer, the JCP contains: information on early warning signs of relapse and advance treatment statements; contact details of primary and secondary professionals for routine and emergency care as well as other members of the consumer’s support network; details of medication, psychiatric and physical diagnoses, allergies; and who has a copy of the JCP.

We believe that the JCP is a promising model for preventing psychosocial consequences, including homelessness, that frequently occur during periods of relapse for adults with SMI.

The main aims of this study are:

1. To adapt the JCP for use in the context of NYC’s complex multi-tiered mental health treatment system;
2. To test the feasibility of implementing JCP with adults with SMI in NYC;
3. To inform the design and planning of a future grant proposal for a full-scale randomized controlled trial of JCP with this population.

Development of Housing First as an Evidence-Based Practice     ^top

Principal Investigators: Sam Tsemberis, Robert Drake, Peter Messeri

Housing First is an innovative model of providing housing and services to homeless persons with SMI. The Housing First model operates on the belief that even the most severely ill and multiply impaired individuals can be housed immediately in permanent independent housing without requiring treatment or sobriety as a prerequisite. Housing First programs provide consumers with immediate access to permanent independent housing (an apartment of their own) and the supports needed to succeed in independent housing.
By making housing a first priority, this model directly addresses the social exclusion that homelessness entails, challenging the gradual and partial versions of social integration that “housing readiness” programs offer.
The Housing First approach was developed at the Pathways to Housing program in New York City. Since 1992, the Pathways program has served more than 550 homeless consumers in New York City and a northern suburb, and replications of the model are currently underway in Washington, D.C., Philadelphia, Chattanooga, Hartford, Ft. Lauderdale, and Denver. Housing First represents the first empirically validated approach to helping multiply impaired, chronically homeless persons attain permanent housing. Because the model needs further articulation and validation, the goal of this study is to produce a manual, a fidelity scale, and training procedures for Housing First. This pilot project is an important first step in a long-term process intended to confirm effectiveness of the model, to study modifications to the model, and to study the process of model dissemination.

Main aims of the study are:

1. To explicitly describe the Housing First approach with a program manual. Expert managers, providers, and consumers will participate in developing the manual. The manual will define consumer-driven philosophy, program practices, and Assertive Community Treatment (ACT) as it is applied in the context of Housing First.
2. To develop a Housing First fidelity measure that represents key principles of the model. Again, all stakeholders will participate in this process.
3. To specify a training approach for Housing First, based on using the manual, standardized training and supervision techniques, and the fidelity scale in a model-guided approach to implementation.
   References

The Context of Contemporary Homelessness Among the Severely Mentally Ill: A Study of Policymaking at the Nexus of Housing and Mental Health     ^top

Investigators: David Rosner, Susan Barrow, Eliot Sclar, Maryanne Schretzman

The successful prevention of homelessness demands an understanding of the broad context within which homelessness and interventions to combat it occur. Though some local-level policy debates have been described in the homeless literature, we lack first-hand accounts of the decisions that have shaped and responded to homelessness in the large urban centers where the nation’s homeless populations are concentrated. Yet clearly policies that influence the nature, availability and location of low-cost housing as well as those that affect how, where, and for whom mental health services are provided not only influence the extent of homelessness, the characteristics of local homeless populations, and the nature of the social exclusion that homeless persons experience, but also set the conditions within which specific approaches to homelessness have evolved, and affect the diffusion and transportability of evolving intervention strategies.

The purpose of this study is to further our understanding of this context by using historical methods to describe and compare the evolution of mental health and housing policies in two major US cities. We will use primary written and oral sources to document the policies that have influenced the forms urban homelessness has taken in different locales as well as the issues and decisions involved in local policy responses. In keeping with the Center’s dual focus on population-level and high-risk prevention efforts, a central concern will be the relative prominence of housing versus mental health services in local policy responses to homelessness among people with SMI. By illuminating the context within which key policy and program planning decisions are made, findings from this study have the potential to improve the likelihood that relevant, effective interventions will actually reach those in need.

Our specific aims are:

1. To use primary written sources and oral history interviews with key informants to document and compare how mental health and housing policies have evolved in two large US cities over the last five decades and examine their role in shaping contemporary manifestations of and responses to homelessness;
2. To identify social, political, economic and intellectual conceptual issues – including decision-makers’ theories about causes of homelessness – that inform each city’s housing and mental health policies as well as the organization and emphasis of local responses to homelessness among people with mental illness;\
3. To establish a mechanism, through the use of periodic follow-up interviews of key informants, for monitoring changing policy initiatives in communities around the country.
4. To create an archive of primary written materials and oral histories documenting the long-term transformation of housing, homelessness, and mental health policies.

Shared Living Arrangements: Effects on Housing Stability, Clinical, Outcomes and Quality of Life     ^top

Investigators: Brendan O’Flaherty, Ingrid Gould Ellen, Robert Rosenheck, Susan Barrow

Many current discussions of developing housing models for homeless persons with SMI proceed from the assumption that living independently, typically in a solitary household, is the optimal arrangement for most such persons. While this approach draws support from mental health consumer preference surveys, housing policies and mainstream ideologies that favor small households, and a presumed absence of relatives or others with whom people with SMI might share housing, single person households are in fact atypical in US society. Given the shortage of affordable housing units in the US, especially in urban areas, this emphasis on placing persons with SMI into new, solitary households may not lead to the most effective use of available housing resources. Policymakers therefore should explore the relative advantages and disadvantages of various alternative strategies, including approaches that encourage re-housing of homeless persons with SMI in existing households that include other persons. No research to date has examined the effect of moving into this type of housing arrangement on persons with SMI. The current study employs existing data sets (ACCESS and the Panel Study on Income Dynamics) to begin an exploration of this question. Results will inform the development of further research in this area, which we believe will have important implications for the creation of innovative housing models and policy for homeless persons with SMI.

Our specific aims are:

1. To describe the housing situations, household size and composition of the settings used by ACCESS participants during the twelve and eighteen-month follow-ups.
2. To analyze the stability of living arrangements of varying size and composition over the 12- and 18-month follow-up periods and to compare ACCESS participants’ rates of movement across different types of living situations to those of other low income individuals.
3. To identify characteristics of ACCESS participants (demographic, clinical, personal history) who were most likely to become stably housed in existing households and examine whether household size mediates the effects of individual characteristics on housing stability.
4. To describe the clinical, legal, and quality of life outcomes associated with living in households of varying sizes and composition, and to test the causal role of household variables using standard econometric techniques.

Streetworks Project     ^top

Development of a housing initiative for mentally ill homeless young adults.
(2005 NARSAD Award, July 2005-June 2007)

Investigators: Bella Schanzer

While the number of homeless late adolescents and young adults is substantial, we know of no research that has tested the effectiveness of any intervention to help such individuals gain and keep housing. We propose to develop an intervention to prevent perpetuation of homelessness in this group. Because of high levels of psychiatric comorbidity in this group, our plans focus on its implications throughout. We propose a staged approach to identifying behavioral barriers that impede homeless young adults from making optimal use of shelter and housing opportunities, and then developing an intervention designed to ameliorate these barriers. In phase one, we will survey approximately 40 clients of the Streetworks Project, a drop-in program for homeless late adolescents and young adults, to clarify links between Axis I and II psychopathology, social functioning, and housing history, including recent efforts to gain housing. In phase 2, we will apply results of this study to the design of the intervention, seen preliminarily as an adaptation of Dialectical Behavior Therapy (DBT). Phase three will consist of a small feasibility study of this intervention.

Methods for Trajectory Analysis     ^top

Investigators: Mary Clare Lennon and William McAllister

Research tracking people over time who are homeless and mentally ill clearly indicates that the course of psychiatric disorder or homelessness can vary across individuals. Some people, for example, may become homeless for one period in their lives, others may have repeat episodes, while yet others find themselves without homes chronically (e.g., Kuhn and Culhane 1998). These patterns often matter, not only for the affected person’s quality of life, but also for targeting services (e.g., certain interventions may be more effective for individuals sharing specific histories) and for studying interventions (e.g., interventions may create multiply patterned groups). The fundamental goal of this pilot study is to explore the utility of a recently developed procedure—and optimal matching (OM)—for identifying similar trajectories of mental illness and homelessness for persons who are homeless or at risk of homelessness.

Background and Significance
Center themes emphasize the highly contextualized nature of homelessness and mental illness and their unfolding over the life course. For example, individuals differ in the occurrence, recurrence and co-occurrence of homelessness and mental illness over time. Until recently, however, researchers interested in classifying individuals into groups characterized by different courses or temporal stages relied primarily on subjective criteria or summary quantitative data. The subjective approach, however, becomes impractical once the number of individuals or time periods becomes large. And the summarizing quantitative data (such as average duration of homelessness) ignores the timing and sequencing of episodes of homelessness. Optimal matching methods permit the analyst to capture timing, duration and sequencing of events and to classify individuals together who share similar patterns over time.

OM works through a two-step process. In the first step, a distance matrix of Levenshtein (edit string) distances is produced by identifying the “cost” of transforming one persons’ housing sequence into another person’s housing sequence. The method seeks to find the smallest cost of such a transformation (i.e., the “optimal” cost). Setting costs, therefore, is a critical component of the analysis. In addition, the way the method is usually applied does not allow for asymmetric transitions, i.e., for assigning different weights going from homelessness to housing versus going from housing to homelessness. The second step in OM is to cluster the distance matrix resulting from the optimal matching process. A large variety of clustering techniques can be used: hierarchical and non-hierarchical clustering; parametric clustering; and the block modeling of network analysis (the distance matrix resulting from OM can be thought of as a valued, undirected network). And the term “hierarchical clustering” covers a large variety of agglomerative and divisive algorithms.

Specific Aims

• Explore the possibility of transforming data to capture the nuanced meaning of asymmetric transitions
• Identify best ways to conceptualize and create cost weights
• Investigate these different clustering approaches to understand which ones are more appropriate for OM in the study of homelessness

MISSING VALUE IMPUTATION     ^top

Investigators: Peter Messeri, Andrew Gelman, Grazia Pittau

Incomplete and missing information is an inevitable aspect of social science research, particular longitudinal studies that involve hard-to-reach populations. Although statistically rigorous methods for imputing or modeling item and case nonresponse are available, they remain underutilized techniques in the homeless and mental health research literature. To promote appropriate use of missing data methods, this pilot will develop a set of computer programs that allow for imputation of missing information for a combination of continuous, ordered and categorical variables. The programs implement a novel graphic approach to inspecting whether the assumptions for imputation are met. Finally the results are extended using multi-level methods to data involving repeated observations in which sample attrition is a major source of incomplete information. The programs are applied to the CHAIN data set--a longitudinal study of persons living with HIV in New York City.

As a result of this pilot, Center investigators will have ready access to a set of missing value procedures that have been evaluated and validated using both real data. Furthermore, building on the results of the pilot project, we propose to prepare a grant application developing methods for diagnosing the goodness-of-fit of different missing data imputation procedures.