5.1 Introduction

Given the high prevalence of mental illness, substance use, and trauma histories among people who are homeless, in this Unit we examine perspectives based on the recovery approach, as a first step towards establishing the need to integrate these orientations into the homeless assistance network.

In mental health, recovery is considered as a process of reclaiming a satisfying life even within the limitations of a mental illness. A review of the literature on mental health recovery identifies a broad range of elements associated with recovery, including person- centred values, hope, increased agency, self-determination, meaning, purpose, awareness, and potentiality.

Nowadays, in the homelessness field, there is a growing trend toward approaches that support client’s choice, empowerment, and recovery: the promising outcomes of recovery-based approaches, could in fact offer a unifying vision for systems of care within the homeless assistance area.

5.2 Learning objectives

In this unit the learners will

• Learn about the interrelation between mental illness and homelessness
• Familiarize themselves with the premises and principles of the Recovery Approach
• Learn the cornerstones of recovery according to the CHIME model: Connectedness, Hope, Identity, Meaning and Empowerment
• Understand the relationship between the Medical Model and the Recovery Model
• Learn to apply the Recovery Approach in treating homeless people
  

5.3 Mental health and recovery

Interrelation between Mental Illness and Homelessness

Compared to the general population, homeless and vulnerably housed people have shown to suffer more commonly of mental health problems. According to Crisis UK, the incidence of common mental disorders is over twice as high in socially marginalized individuals, while psychosis have been found to be 4-15 times more frequent in homeless people. Their risk to die is nearly 5 times higher in comparison with the general population of the same age. In a recent survey of homeless services in England (2019), it has been highlighted how more than two third of the clients of the homeless services are suffering mental disease, many of them undiagnosed.

In many cases mental illnesses played a relevant role in the life stories of those who have lost their housing. Furthermore, considering the stressful condition of homelessness, mental health represents a critical element in determining the capability of an individual to achieve stability in their housing which, if attained, would help to decrease the severity of their mental problems in the long run.

Women appear to be more susceptible to experience some risk factors for both mental illness and homelessness, such as physical and sexual violence as a child, to a greater extent than men. Mental health problems seem to be higher in homeless women (in particular deliberate self-harm and suicidal ideation). Also marginalized black and minority ethnic groups (BME), refugees and asylum seekers show a higher incidence of mental illnesses when compared to the general homeless population.

Here, we consider three main factors underlying the risk of homelessness: poverty, disaffiliation, and personal vulnerability. Marginalized individuals are less able to sustain employment, which implies lower economic power. Delusional thinking reduces the social network that homeless people can rely on, withdrawing them from potential coping resources that are much needed in difficult times. Also, mental conditions have a negative effect on a person’s judgement, compromising his/her ability to think clearly and face adversities.

The complex relationship between mental illnesses and homelessness can lead to an exacerbation of several negative emotional states such as fear, anxiety, depression which are related to a higher risk of substance and alcohol abuse.

Those who suffer from mental conditions tend to be homeless for longer period of times, progressively losing more and more contact with family and friends. The role of proper community and social services is even more relevant considering cases of people suffering from severe mental health problems, who over-represent those experiencing homelessness once they are released from hospitals and jails.

The Recovery Approach

Dealing with mental health problems is difficult due to the large number of individual variables involved in their development. In the last decade the recovery approach has proven to be effective because of its person-centered perspective. Recovery approach is based on two simple premises:

1. It is possible to recover from a mental health condition.
2. The most effective recovery is patient-directed.

The model takes a holistic view of a person’s life. Recovery from mental disorders and/or substance use disorders is «a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.» (Lyon S., 2020)

Four dimensions are considered to support recovery:

• Health: In order to manage or recover from mental illness, people must make choices that support both their physical and mental well-being.
• Home: People need a safe and stable place to live.
• Purpose: Meaningful daily routines such as school, work, family, and community participation are important during the recovery process and for maintaining wellness.
• Community: Supportive social relationships provide people with the love, emotional availability, and respect that they need to survive and thrive.

(Lyon S., 2020)

In the recovery-based approach, the social life of an individual is considered crucial to determine the negative effects of mental disorders and substance abuse. Having supportive and care relationships improve the ability to deal with symptoms of their illness and facilitate recovery. In this process, health professionals, such as psychologists, psychiatrists, and doctors, can provide support to a certain degree, but their intervention can benefit greatly from a positive social interaction in the homeless person’s life. Support groups and community organizations can also play an important role in recovering from mental disorders allowing the person to share his/her experience with other people in need for support.

We shouldn’t forget the importance of housing in recovery from mental health issues. Adequate and stable housing allows the person to feel safe, thus greatly reducing stress and other risk factors that can lead to developing mental health issues or aggravating pre-existing ones. Having access to a decent personal space increases one’s perception of stability, while also providing opportunities to develop sense of responsibility for maintaining the place in a good condition.

According to ten guiding principles, recovery:

• Emerges from hope
• Is person-driven
• Occurs through many pathways
• Is holistic
• Is supported by peers and allies
• Is supported through relationships and social networks
• Is culturally based and influenced
• Is supported by addressing trauma
• Involves individual, family, and community strengths and responsibility
• Is based on respect

(Substance Abuse and Mental Health Services Administration, SAMHSA, 2012)

One of the major strengths of the recovery model is that it focuses on individuals’ skills and abilities rather than on their deficits and pathologies. It increases trust in the individual and allows them to know their own life experience and to become the main actor in the treatment.

Accepting and eventually embracing individual limitations is part of the recovery process, by identifying their weaknesses individuals can focus on the supports they need to dampen the symptoms of their mental health problems. Developing this kind of consciousness helps them to adopt resilient strategies to face their condition, and then to integrate them into their daily life. Acceptance leads to empowerment, choice, self-determination, and community integration, improving the individuals’ ability to mobilize useful resources for managing their symptoms thus increasing their likelihood of success.

Cornerstones of Recovery: CHIME

CHIME is an acronym of Connectedness, Hope & optimism, Identity, Meaning & purpose and Empowerment.

Having meaningful and mutual positive relationships plays a decisive role in boosting one’s motivation and confidence to achieve success. Family and friends can help a recovering person to believe in his/her abilities to change, while also providing motivation to do so. Also, sharing personal life stories with other members of the community that are facing similar challenges (for example battling with substance abuse/dependency) can bring them together to motivate one another through a peer support mechanism. Community groups (such as Alcoholics Anonymous) can also play an important part providing a non-judgmental space to share one’s feelings and emotions associated with the recovery process. After the recovery, older members of these groups can act as role-models, providing guidance and representing the desired arrival point of the journey that other members are enduring. Although one-way helping relationships can lead to a “charity” mechanism which would be detrimental to the recovery process, healthy, mutual, and balanced support relationships are fundamental in establishing a positive social environment that can increase one’s chances to succeed in his recovery process.

• Hope

This is one of the most important components that influence one’s motivation to face the changes involved in the recovery process. It is more than optimism; it is a belief that the person has to be able to get through setbacks and uncertainty to reach his/her final goal. It may emerge progressively during the recovery after a certain turning point, and it must be strong enough to resist moments of despair. It involves trust in oneself abilities to bear failures, risk and further hurt.

• Identity

Another important element is the recovery of a durable sense of self, which could have been lost or taken away in the socially marginalized individuals. One way to regain sense of self is called “positive withdrawal”; based on a research review it implies regulating social involvement and negotiating public space in order to move towards others only when it feels safe and meaningful. By nurturing personal psychological space its possible to develop a broad sense of self, understanding oneself interests, spirituality and so on. This process helps building the sense of social belonging and is generally facilitated by experiences of interpersonal acceptance and mutuality, on the other hand it has to face the barrage of overt and covert messages that come from the broader social context. When an individual is ready for change a process of grieving is initiated, acceptance of the past and building confidence in the ability to move on to a new identity of self may implicate dealing with negative emotions such as grief, despair, and anger.

• Formation of healthy coping strategies and meaningful internal schema

Healthy coping strategies are said to be a crucial element in the recovery process. Medications or psychotherapy can be useful in dampening adverse symptoms of mental illnesses, but they have their downsides too. A well-informed patient should know what they are, what are the advantages provided by such medications and why the medical experts thinks that prescriptions they gave is the best fit for the person’s life journey. A better understanding of these therapies can help developing consciousness about oneself internal traits and emotional mechanisms, leading to a more accurate knowledge of self. Developing coping strategies and problem-solving skills may require the person to become his/her own expert, so to identify key stress points and possible strategies to adopt in response to adversities. Understanding internal self-structure and functioning can help building a sense of meaning and overall purpose which is said to be important to sustain the recovery process. This may lead to the recovery or development of a social or work role, and can also involve renewing, finding or embracing a guiding philosophy, religion, politics or culture. By postmodern perspective this can be described as “developing a narrative”.

• Empowerment and building a secure base

Appropriate living conditions, sufficient economic power, freedom from violence, and access to healthcare have been proposed as important tools to empower a person in the long process of recovery. Combined with self-determination, Empowerment is said to be fundamental in recovery by reducing the social and psychological effects of stress and trauma.

Women’s Empowerment Theory suggests that recovery from mental illness, substance abuse, and trauma requires helping survivors understanding their rights to increase their capacity in making autonomous choices. This means developing the confidence for independent assertive decision making and help-seeking which translates into proper medication and active self-care practices. Another important part of empowerment is achieving social inclusion and overcoming challenging social stigma and prejudice about mental illnesses. Advocates of Women’s Empowerment Theory argue it is important to recognize that a recovering person’s view of self is perpetuated by stereotypes and combating those narratives. Empowerment according to this logic requires reframing a survivor’s view of self and the world. In practice, empowerment and building a secure base require mutually supportive relationships between survivors and service providers, identifying a survivor’s existing strengths, and an awareness of the survivor’s trauma and cultural context (Francis East, J., & Roll, S. J. 2015).

The Recovery Model VS the Medical Model

The recovery model for people with mental illness is opposite to the medical model.

The medical model posits that mental disorders have physiological causes and, until the mid-seventies, many practitioners believed that patients with mental health conditions were doomed to live with their illness forever. This belief particularly affected people with schizophrenia, schizoaffective disorder and bipolar disorder and the focus was strictly on the use of medications for treatment.

The hallmark principle of the recovery approach is instead the belief that people can recover from mental illness to lead full, satisfying lives: it took two decades for this basic belief to gain traction in the medical community. Patients have played an important role in developing this person-centred perspective by expressing their interest in being actively involved in their own treatment. Through patients lived experiences, they showed that by receiving the proper supports they could live active lives in the community. This historical shift in the intervention approach reflects the second basic pillar of the recovery model: the most lasting change happens when the patient directs it.

Even if the medical and the recovery model often appears to be in contrast with one another, researchers suggest that they should be considered complementarily when planning an intervention. The physiological information that emerges from the medical approach must be taken in account to better assess the medical needs on a patient, while involving him/her in first person allows the treatment to be person-centred and thus more effective.

Empirical data gathered by medical research are fundamental to define the appropriate treatments a patient must endure; this has to combine with the personal empowerment and peer support provided by the recovery model to better cope with illnesses resulting in a higher rate of success.

Application of Recovery Approach in Homelessness

The recovery approach is changing the treatment of mental illness, substance addiction and traumatic stress disorders. Nevertheless, this kind of approach has not been yet well integrated in the homeless services.

In the homeless services rarely is followed the recovery approach and very often they provide only care services answering the primary needs. Several actors work to provide the many services needed to help homeless people: housing, emergency shelter, food service, employment assistance, medical care, mental health support, rehabilitation programs, and social services program, but they are often separated by different federal funding streams. The unique challenge is to construct a unified, recovery-oriented model of care across the multidisciplinary network of providers of homelessness services.

Table 1. Guiding the Transformation of Service Systems Using Individual Recovery Principles [1]

Traditional Approach	Individual Recovery-Oriented	Service System Recovery
Recovery may not be possible for everyone.	Recovery is possible for all.	Recovery-oriented systems transformation is possible.
Impact of trauma is not well understood in providing services to people who have histories of homelessness.	The impact of trauma plays a central role in the lives of those receiving services.	Policies, practices, and environments are adapted to accommodate the traumatic response in people receiving and providing services.
Tendency to categorize people in a fixed way: “well” or “sick”; “chronically homeless” or “engaged in services” rather than viewing their lives as a dynamic process.	Dynamic and holistic. Views people within the whole context of their lives. Recovery is a process that takes place along a continuum that is not necessarily linear.	Dynamic and holistic. Views the organization itself as organic. Adjusts policies and practices based on consumer and staff input.
Providers are the experts in the recovery process and know what is best for clients. Compliance is expected. Force and coercion may sometimes occur.	Self-determination and autonomy is encouraged with consumers as experts in their own recovery. Agencies are partners in the recovery process. Force and coercion are antithetical to recovery, undermining trust and connection, and leading to re-traumatization.	Self-determination and autonomy are encouraged among staff and they are appreciated for their expertise. Focus on decreasing power imbalances and acting in collaborative ways. Policies seek to eliminate coercive practices and reduce re-traumatization within the workplace.
Diagnostically driven, symptom-focused.	Strengths-focused, valuing skills and abilities.	Agency strength-focused, values all staff for abilities, skills, and expertise.
Not particularly open to public review.	Information sharing leads to choose, autonomy, greater self-determination, connection, and trust.	Promotes transparency and accountability at all levels by providing information openly.
Relationships are based on hierarchies and positional authority. Power sharing is limited.	Power is shared. Collaborative relationships are based on authenticity, honesty, and recognition of power imbalances.	Collaborative. Values all members of the organization as contributors to the well-being of the agency. Acknowledges power imbalances and seeks to share power when possible.

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Table 1 contrasts the traditional approach (“recovery may not be possible for everyone”) with individual recovery- oriented values (“recovery is possible for all”), and envisions how individual recovery-oriented values can transform service system values, to create a new paradigm of recovery- oriented care and systems transformation (“recovery-oriented systems transformation is possible”). This table is a useful guide for translating individual recovery values for transformation of systems of care.

To integrate recovery principles into systems of care for people experiencing homelessness, one useful starting point is to focus on developing relationships that promote recovery, empowerment, hope, and person-centred values. People in recovery from mental health and substance use problems identify having a dependable and reliable person they can trust as both their most significant need and the most significant facilitator of recovery. Many individuals who have moved out of homelessness attribute their success to personal connections with others. Often, the process of rebuilding selfhood happens within the relationship to a service provider. Research suggests that outreach is a critical step toward engaging individuals who are homeless “to establish a personal connection that provides the spark for the journey back to a vital and dignified life”. Reconnecting to a viable sense of self and community is a crucial step in the recovery process for people who have experienced homelessness

Consumer integration is one concrete strategy for developing a recovery-orientation in homeless service programs. Integrating people with experiences of homelessness, mental health issues, substance use, and trauma into staff and leadership roles in programs is a necessary step toward transforming organizational culture and service delivery models. A consumer-run and consumer-staffed homeless service program fall into three categories: consumer-run services (managed and operated by a majority of consumers); consumer-partnership services (consumers deliver services in partnership with non-consumers); and consumer volunteers and employees (consumer-staffed)

Being inspired by the principles of the Recovery Approach, the integration contributes to a recovery orientation by promoting the empowerment of consumers in all stages of the process: as “recovery ambassadors,” consumer staff members serve as the embodiment of the core recovery principle: hope.

A successful project: The Connecticut Experience

The state of Connecticut has been a leader in the introduction of recovery-oriented care and began its recovery initiative in 2000, before recovery came to the forefront of the national agenda. From the beginning, it was a systemic initiative aimed at transforming the system of care as one that “identifies and builds upon each individual’s assets, strengths, and areas of health and competence to support achieving a sense of mastery over his condition while regaining a meaningful, constructive sense of membership in the broader community”

The Connecticut initiative included a collaboration with Yale University’s Program for Recovery and Community Health to create a Recovery Education and Training Institute to train providers in areas such as being a recovery guide, person-centred planning, recruiting and working with peer staff, peer support, cultural competency, motivational interviewing, and other topics.

It is worth highlighting two lessons from the Connecticut experience:

The first lesson learned is that recovery does not refer to any one service, intervention, or support, but rather what people in recovery themselves do to facilitate their own recoveries. This is important because it highlights the importance of involving consumers, being person-centred, and working collaboratively with all stakeholders to develop a shared sense of what a recovery-oriented system of care should look like.

The second important lesson from Connecticut’s experience is that recovery cannot be simply “added on” to existing services, but must be an overarching goal and value integrated on a systemic level to transform and realign policies, practices, procedures, services, and supports.

These lessons provide important precedents that could help inform the adoption of a recovery orientation across the homeless assistance network.

In conclusion, empowerment of the individual in recovery is a fundamental cornerstone of the process, which is non-linear, must be strengths- based, and needs to build upon the multiple abilities of the individual. Recovery could become an overarching goal and value that could transform and realign the policies, practices, procedures, services, and supports of the homeless assistance network. These changes have the potential of improving the lives of millions of people experiencing homelessness.

5.4 Further reading

• Sheperd et al., Making Recovery a Reality, 2008.

[1] Source: Prescott L, Harris L. (2007). Moving Forward, together: Integrating Consumers as Colleagues in Homeless Service Design, Delivery and Evaluation. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. Manuscript Submitted for Publication.