Housing Programs Effective, but Studies Plagued by Limitations

Evidence for three program types aimed at reducing homelessness among patients with mental illness was rated as “moderate” in papers published as part of the “Assessing the Evidence Base” series in the March Psychiatric Services.

Supported housing, recovery housing, and residential treatment for people with substance use disorders were each rated as having a moderate level of evidence for effectiveness.

In each case, authors reviewing the evidence for the program types indicated that the programs should receive support from policymakers but are challenged by a lack of a clear definition of service methods, treatment duration, and treatment standards. For instance, regarding recovery housing—which provides supervised short-term housing to help stabilize people with substance use disorders so that they can take their first steps toward recovery in a supportive environment—reviewers stated “studies consistently showed positive outcomes, but the results were tempered by research design limitations, such as lack of consistency in defining the program elements and outcome measures, small samples, and single-site evaluations and by the limited number of studies.”

Similarly, regarding residential treatment for people with substance use disorders, reviewers stated that “a number of randomized, controlled trials were identified, but various methodological weaknesses in study designs—primarily the appropriateness of the samples and equivalence of comparison groups—decreased the level of evidence.”

Even with regard to supported permanent housing—which consumers consistently rated more positively than other housing models—“methodological flaws limited the ability to draw firm conclusions.”

In an editorial accompanying the reviews, Sam Tsemberis, Ph.D, said that the lack of clear program definition applies to “the innumerable group homes, board-and-care homes, adult homes, and other forms of not-well-defined or regulated congregate housing used in most states as permanent housing for people with mental illness.”

Tsemberis is the founder of Pathways to Housing and the “housing-first” model, a supported housing program that began in New York City in 1992 and has been replicated in cities around the country. The program provides “housing first”—without the precondition that consumers participate in mental health or substance use treatment—but also provides supportive-treatment services in the areas of mental and physical health, substance abuse, education, and employment. Since its founding, Pathways has housed more than 600 people in New York alone, and the program maintains an 85 percent retention rate even among individuals not considered “housing ready” by other programs, according to the Pathways website at http://pathwaystohousing.org/our-model/.

In an interview with Psychiatric News, Tsemberis said more research, development of “program fidelity,” and an increased focus on program evaluation are crucial for the great variety of housing models. “There is a great need to be clear about the kind of programs we are operating,” he said. “What kind of programs are helping what kind of person under what kind of circumstances?”

The review of supportive housing is posted here. The review of recovery housing can be accessed here. The review of residential treatment for people with substance use disorders is posted here. To listen to an audio interview with Sam Tsemberis, Ph.D., please click here.