The Continuum of Care: Is It an Effective Way of Helping Homeless People with Mental Illness/Substance Abuse Recover? - Feng-Hang Chang

Introduction
Homelessness is a growing social and public health problem in developed countries (1). In the U.S., approximately 3.5 million people experience homelessness, and the number is steadily increasing every year (2). Most people who are homeless have suffered severe hardship, including physical and sexual abuse, childhood trauma, poverty, disability, and disease (3). Moreover, homeless people showed a higher prevalence of mental disorders, such as schizophrenia (54.8%), bipolar disorders (19.8%), and substance-related problems (60.5%) compared with people who were not homeless (4).
Helping homeless people with mental illness/substance abuse go back from the street to a stable and independent life is a big challenge. To help them improve and maintain their health and well-being, the intervention does not only have to aim on housing situation, but also have to stress on the treatment of improving their mental health or/and drug abstention(5).
The Continuum of Care is a nationwide standard homelessness intervention strategy recommended by the Department of Housing and Urban Development (HUD) (6). It is a community plan which organizes and delivers housing and services to meet homeless people's needs, especially for those with mental illness and/or substance abuse disorders. The components of a Continuum of Care model include: 1) outreach, intake, and assessment, 2) emergency shelter, 3) transitional housing, and 4) permanent housing and permanent supportive housing (See figure1).


Figure 1 Components of a Continuum of Care Homeless System

This approach includes two key characteristics: 1) the provider determines when a client is "housing ready," and 2) the participants are required to get psychiatric and substance abuse treatment. Additionally, two assumptions are contained in this model: 1) homeless adults need transitional and permanent housing in order to develop the daily living skills they either lost or never had; 2) housing readiness depends on a period of sobriety and compliance with psychiatric treatment if deemed necessary. If the individuals demonstrate more compliance with treatment and sobriety, they can get less restrictive residences; if they fail to comply or relapse, they will return to a more restrictive environment (7).
Although the Continuum of Care is a linear process as stressing on restoring clients' mental health and stop using substance, the effect is not as good as we thought. First, clients report a lot of frustration and dissatisfaction in this program since the "journey" of graduating from the program is very long and complicated, which lead them to give up (8). In addition, comparing with other programs (i.e., Housing First or Pathways to Housing program), the Continuum of Care program shows lower effect on many aspects such as psychiatric symptoms, psychiatric hospitalization, substance use rate, and residential stability (7,9,10). Especially for homeless people with addiction, the Continuum of Care presents less than ideal result (11). These results indicate the program and the factors that contribute to its low effect need to be examined.

The criticisms of the Continuum of Care
1. Disobeying Maslow's Hierarchy of Needs
One of the most likely reasons that the Continuum of Care intervention does not work as well as expected is that it ignores the point that housing is one of the basic needs of human beings that need to be satisfied.
Based on Maslow's Hierarchy of Needs, the fulfillment of the lower level needs is a prerequisite to addressing the higher needs (12). In Maslow's hierarchy, the first level of needs, we call it the physiological needs, including food, drink, shelter, sleep, and sex, is the foundation of human beings' motivation. The second level is safety, including security, stability, and protection. The third level of need is belonging and love. The fourth level is esteem needs, which are fulfilled by mastery of the environment and the prestige of social recognition. The fifth level is the need for self-actualization, is to maximize one's unique potential in life. Once the lower needs are satisfied, the higher needs can be pursued (12).
For homeless individuals, apparently, the basic physiological and safety needs can hardly to be satisfied without stable housing. Stable housing forms the foundation on which an individual can establish daily routines and begin to address other issues (13). Contrarily, living in an unstable or bad environment may expose one to the cold, promote sleepless, and cause food shortage and cooking difficulties. Moreover, living on the street or temporary shelters can expose one to dangerous situations, which hardly offers security and stability, the safety needs. If those basic needs are not satisfied, how can we expect homeless people to pay attention on the mental health and substance abuse treatment?
Many studies support this statement. Studies showed that Homeless people perceive the basic needs of food, shelter, and safety as higher priority needs than health issues (14-16). Gelberg and Gallagher (1997) found that competing priority is an important nonfinancial barrier to the utilization of health services homeless people tend to pursue the housing and necessity prior to anything else. Kyle and Dunn (2008) also found empirical evidence that stable and appropriate housing situation can benefit mental ill people's health and quality of life.
Nevertheless, the Continuum of Care regards housing as an outcome, like employment, of therapeutic intervention rather than a precondition before healthcare (17). People cannot get permanent houses if they fail to comply with mental health/substance abuse treatment. However, this process disobeys the Maslow's Hierarchy of Needs and the empirical evidence. In fact, it seems to put the cart before the horse. If we want those people to comply with treatment, we have to let them see the value of treatment. But how can we expect them to value the treatment if their basic needs are not satisfied? The housing should not be seen as a "result" or "reward," but a necessity and human right.
2. Inducing the reactance
The reactance theory can also explain the limited success of the Continuum of Care. The reactance is the psychological response that people may experience when they perceive their freedom is threatened (18). It motivates people to restore the threatened freedom by adopting or strengthening a view or attitude that is contrary to the threatening message (18).
As an intervention focusing on recovery from disease and substance abuse, the Continuum of Care does not provide much autonomy to homeless people. First, the homeless people are "required" to attend treatment and have to "graduate" from the program. If they fail to show their capability of engagement and attendance in the treatment, they cannot get a permanent house (7). In the process, the treatment is like a mandate and requirement, which can probably become a freedom-threatening message to those individuals who want a house. Second, the providers are the ones to decide whether a client is "housing ready" or not. The client does not have much opportunity to get involved in the decision-making process but only wait for the judgment like a student or prisoner. This process may increase the sense of losing control. Some research supports this statement. Owen, Rutherford, and Jones (1996) found that clients feel dissatisfied and frustrated with a system that provides what it thinks they need, rather than what they say they need. Third, in the intervention process, if the clients relapse, they will be sent back to a more restrictive environment, such as a collective shelter, which may deprive their freedom and independence. Actually, most of emergency shelters and transitional housing are dirty, dangerous, disempowering, and associated with a range of negative outcomes such as negative affect and lowered independent functioning (19). It leads some clients to drop out of the system to resume their "normal lives," independently, on the street (8).
As a result, the Continuum of Care may not only induce the clients' reactance by threatening their freedom, but also influence their independence and satisfaction. Further, the clients may choose to go back to the street due to fail to follow the "rules" and fear of losing their independence. These can all cause the intervention to fail.
3. Fail to address other factors which may influence the compliance with treatment
Finally, the model regards the adherence to prescribed treatment and sobriety as the capacity of housing readiness. The client who is not able to maintain the compliance at any level or relapse into alcohol and drug use will be seen as lack of capacity. However, even if compliance with treatment is one indication of understanding whether a client is able to maintain his/her life, this postulation overlooks other factors which may influence a client's healthcare use, including taking prescribed medication and visiting the psychiatric clinic regularly.
In fact, a lot of factors can influence one's healthcare use. Based on Andersen's Behavioral Model, the factors including demographic factors (such as age and gender), social structural factors (such as education, ethnicity, and culture), health beliefs, community and personal enabling resources (such as transportation, income, insurance coverage), illness level, and many other environmental factors (such as stigma, policy, and prevailing norms of the society) may all affect an individual's healthcare use and health behaviors (20). Although having a disadvantage on any of these factors may contribute to ones' difficulty of using healthcare, homeless people could be even more vulnerable on several aspects than others. For example, they are usually lack of health insurance, health related knowledge, and social resources like family support and community support, income, and are usually stigmatized (21). Among these factors, stigma is one of the biggest barriers that we need to highlight (3).
Some researchers contend that homeless people face tremendous stigma in life and healthcare due to the stigma on poor and mental illness (4). The stigma may not only come from the social public, but also come from health providers. A phenomenological study shows that homeless people encounter serious barriers while entering healthcare services. These barriers include being labeled or stigmatized, being treated with disrespect, and feeling invisible to healthcare providers (3). Applying the knowledge to the adherence of treatment, the failure to comply wider treatment may due to the negative experience during the process of healthcare. While homeless individuals are facing stigmas and disrespects from the healthcare providers, it becomes extremely hard for them to seek help continually. Further, homeless people with mental illness tend not to consistently seek mental health care due to the fear of facing social reject (22). All these factors can affect a homeless individual's willingness and compliance with psychiatric/substance abuse treatment. As a result, while they fail to comply with treatment, it is unfair to postulate they lack "readiness" regardless of other personal and environmental factors.

Intervening program: A Home with Rehab
To develop a more effective intervention program for the recovery of homeless people with mental illness/substance abuse, we have to avoid making the same mistakes as the Continuum of Care does. The new intervention program I recommend is “A Home with Rehab.” This program has several new characteristics. First, when a client enters in the program, we help him/her get a home first by providing a safe apartment and necessities. The “home” is free for the first month, but after that, the client needs to pay for at least 30% of the rent and expenses, which can motivate him/her to manage his/her money or find a job. Second, if the client has mental illness/ substance abuse that needs treatment, rehabilitation will be offered after the client settles into the housing. A case manager will develop a relationship with the client, and discuss the rehabilitation plan with him/her in an empowering way rather than in a forcing way. Family members, if there is any, will also be invited to join the meetings. After completing counseling, the client can decide whether or not he/she wants to participate in psychiatric/substance abuse rehabilitation. Third, each client is cared for by a strong professional health team, including a case manager, physicians, psychiatrists, occupational therapists, nurses, rehabilitation counselors, and social workers. If the client has any health or life needs, he/she can seek help from the case manager, and the manager will call for the required personnel. For example, if the client wants to find a job, the case manager will gather the clients’ occupational therapist and rehabilitation counselor to discuss the issue with the client, make a job search or work skills training plan, and help him/her find a job. Fourth, health education group activities will be provided to the clients in the apartment. The health education goals include improving personal health behaviors, enhancing necessary health services use, and increasing their seeking and participating in psychiatric rehabilitation and substance cessation. The communication will decrease the reactance among the clients by sending unthreatened messages. Last but not least, the program stresses “anti-stigma” education for health providers. To make sure all of the health providers in our program have indiscriminate attitude and respect toward the clients, all of the providers need to take the anti stigma training and be evaluated before and after entering the program.
To attain these goals, the execution of the program is very important. I will now elaborate the details of this program and discuss how this intervention avoids the flaws of the Continuum of Care. First of all, based on Maslow's Hierarchy of Needs, the basic needs should be fulfilled prior to other needs. Therefore, we will help the clients settle into the stable housing and get necessities before conducting psychiatric or substance abstention rehabilitation. After satisfying the basic needs, we can expect that clients will have more motivation to improve their health, well-being, and other higher level needs. Some studies have shown that homeless individuals with mental illness who are placed directly into permanent housing first are more likely to stay engaged in a program and be residentially stable compared to those who get treatment first (2). Furthermore, the types and conditions of housing should also be considered. A dirty, crowded, and disordered shelter may not make clients feel secure. To satisfy the clients' needs for safety, the program will offer an independent, comfortable, or at least well-organized, apartment.
Next, the intervention will avoid inducing clients' reactance. The "mandate" of complying with treatment before getting a house will be eliminated since it threatens the clients' freedom of choice. Our message will not stress the need to complete rehabilitation before getting housing. On the other hand, we will let the clients know that they have the freedom to decide whether or not to engage in their treatment services. We will send positive messages such as "Wanna get rid off the pills? It's time to make your own decision." "The door to AA group is open for you anytime." "Wanna find someone to listen to your feelings? The Psych clinic welcomes you." These messages will be put in the flyers posted on the walls where clients can see easily, and in the health education groups that people can get when they participate in the activities. The healthcare providers will also provide those messages to clients during the meetings.
Additionally, to increase the power of persuasion, we will invite some successfully recovered homeless people to speak to the clients, or show videos about their own recovery stories. Based on the study, the similarity between the communicator and the clients can increase the power of persuasion and decrease resistance (18). The modeling theory also asserts that people tend to imitate the behaviors from those whom they identify as models (23). Therefore, it is important to build up those "models," for example, those successful homeless people, and demonstrate their engagement in rehabilitation. If engaging in rehabilitation could be shown as problem-solving and rewarding, such as bringing a more independent life, more people may like to adopt this behavior (23). As a result, clients will more likely to comply with treatment.
Finally, to encourage homeless people with mental illness/substance abuse to keep seeking treatment, we will aim to remove barriers that they may face in the healthcare system. The case managers will meet with the clients regularly and explore if they have any difficulty of using health services. If there are barriers which interfere with the clients' health services use, for example, the client is lack of knowledge about when and where to seek for rehabilitation; we will help them to eliminate the barriers, for example, by using health education.
In addition, based on the problem I addressed before, one big challenge for homeless people is the stigma from healthcare providers. According to the stigma theory, a stigma is an attribute that is socially defined as “deeply discrediting,” spoiling one’s identity and disqualifying one from full social acceptance (24). The homeless population has been facing a public stigma for a long time based on people's negative perceptions related to the poor, the mentally ill, and substance abusers (24). Moreover, many people's perception of homeless people is influenced strongly by the media or by the unsavory behaviors of a few but highly visible homeless people (4). Unfortunately, healthcare providers show the similar negative attitudes toward homeless people when homeless people walk in and seek help (25, 26). Because of that, our primary task is to remove the stigma from healthcare providers. Ways to change attitude include education and direct contact, which both focus on increasing healthcare providers' familiarity with the homeless population and decreasing the unknowns (6). In addition, interaction with the stigmatized population is regarded as a key to reducing discrimination and prejudice (6). Based on that, delivering adequate knowledge about the homeless population to health providers is very important, as is helping them get in experience with treating homeless people (25). These are all effective ways of removing the barriers and helping homeless people enter and continue following the treatment.
In conclusion, in helping homeless people with mental illness/substance abuse recover and return to the community, we should help them settle in a stable and safe house first in terms of satisfying their basic needs. Next, the health services should be provided in an acceptable way. We can offer abundant information and services and encourage them to comply with treatment by using some persuasive techniques, but the clients should have the right and autonomy to make treatment decisions. Even if they fail to comply with treatment, their needs and barriers need to be understood rather than blamed. One of the biggest barriers, stigma, especially needs to be addressed and removed to help clients comply with treatment. Therefore, education for health providers and increased opportunity for them to interact with homeless people is important.
It is never easy to help homeless people recover from illness and return to their lives. That is why it is so important to develop an effective intervention program and make relevant policies. We may not be able to build up a "perfect" program; however, we can always improve the programs by examining the problems of the ones we are using. The process will help us find more possibilities in the future.








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