Addressing Self-Defined Goals Improves Psychiatric Status of Homeless People
WESTPORT, CT (Reuters Health) Nov 30 - The mental health status of homeless individuals with severe mental illness is improved when psychiatric rehabilitation programs address clients' self-defined needs and goals, according to a study conducted in New York City.
Dr. David L. Shern, currently of the University of South Florida, in Tampa, and associates recruited 168 homeless subjects with serious and persistent mental illness and randomized them to an experimental program, "Choices," or standard treatment. The study is described in the December issue of the American Journal of Public Health.
The researchers describe the Choices program as "similar in structure to an intensive case management program." Its features included participation in a low-demand day center that offered assistance in obtaining health, mental health, dental and social services, and assisted in developing and implementing individual rehabilitation plans.
The team reasoned, Dr. Shern told Reuters Health, that "if we could engage clients by literally putting them in charge, having them make the decisions about how their treatment would be directed, we could engage them in relationship that ultimately would result in us being much more effective than we had been previously."
Using such instruments as Lehman's Quality of Life Scales and the Colorado Symptom Index, the investigators observed significantly greater reductions in anxiety, depression, and thought disturbances in the Choices participants than in the control group.
Choices participants also had significantly less difficulty in obtaining food, a place to sleep, and keeping clean. At 24 months, 38% of subjects in the Choices program were residing in community settings, compared with 24% of the control subjects. In addition, those in the experimental program reported consistently greater improvement in six of seven life areas.
"The thought of giving clients more control is something program staff really struggled with," Dr. Shern said. "The magic is, you find when you really do that, the things they want are not that unreasonable, that they can make choices for themselves and their choices have consequences, and you talk through that with them. You start to develop a relationship because you've become allies."
One key to the program's success, Dr. Shern pointed out, was a sense of accountability on the part of program staff.
On the other hand, he added, "Barriers to implementing such a program on a larger scale are innumerable: the way we fund and pay for services, the fact that we haven't structured a system in our communities so that anyone is really in charge of these so-called 'throw-away people.'"
Most important, Dr. Shern added, is "the political will to actually address these issues and to develop ways to pay for services like this for a very disenfranchised group."
Am J Public Health 2000;90:1873-1878.
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