Navigating Complex Implementation Contexts: Overcoming Barriers and Achieving Outcomes in a National Initiative to Scale Out Housing First in Canada

The scaling out of Housing First (HF) programs was examined in six Canadian communities, in which a multi‐component HF training and technical assistance (TTA) was provided. Three research questions were addressed: (a) What were the outcomes of the TTA in terms of the development of new, sustained, or enhanced programs, and fidelity to the HF model? (b) How did the TTA contribute to implementation and fidelity? and (c) What contextual factors facilitated or challenged implementation and fidelity? A total of 14 new HF programs were created, and nine HF programs were sustained or enhanced. Fidelity assessments for 10 HF programs revealed an average score of 3.3/4, which compares favorably with other HF programs during early implementation. The TTA influenced fidelity by addressing misconceptions about the model, encouraging team‐based practice, and facilitating case‐based dialogue on site specific implementation challenges. The findings were discussed in terms of the importance of TTA for enhancing the capacities of the HF service delivery system—practitioners, teams, and communities—while respecting complex community contexts, including differences in policy climate across sites. Policy climate surrounding accessibility of housing subsidies, and use of Assertive Community Treatment teams (vs. Intensive Case Management) were two key implementation issues.     

Housing for People with Serious Mental Illness: A Comparison of Values and Research

This article contrasts values associated with the delivery of housing programs for people with serious mental illness with the typical topics pertaining to housing that are studied by researchers. Six values were identified through a search and content analysis of the literature on housing for people with serious mental illness. A second review of the literature was conducted to identify research on housing for this population. A comparison of findings from the two reviews suggested that whereas values concerned with the therapeutic benefits of housing had received considerable research attention, those concerned with a citizenship dimension had received relatively little. The findings are discussed in terms of their implications for the delivery of housing services and for housing research.     

A Social Ecological Approach to Investigating Relationships Between Housing and Adaptive Functioning for Persons with Serious Mental Illness

This paper seeks to advance mental health—housing research regarding which factors of housing and neighborhood environments are critical for adaptive functioning, health, and recovery for persons with serious mental illness (SMI). Housing and neighborhood environments are particularly important for persons with SMI because of the prevalence of poor housing conditions among this population. Most mental health—housing research has been limited by a focus on problems in environments and functioning. The paper seeks to expand the mental health—housing research agenda to consider protective factors that promote community integration and adaptive functioning. We provide an account of how social ecology theory transformed a research program, from examining individual risk factors to investigating the functioning of persons in the contexts of their housing and neighborhood experiences. The resulting housing environment framework—physical aspects of housing and neighborhoods, social environment of neighborhoods, and interpersonal relationships tied to housing—allows for identification of opportunities for health promotion and facilitation of participation in community-based settings. This program of research draws upon several methods to understand the social experience of persons with SMI living in community settings—survey research, qualitative interviews, Geographic Information Systems, participatory research, and visual ethnography. In this paper, we present how social ecology theory was instrumental in the development of new housing environment measures, the selection of appropriate research methods, and framing research questions that are building a new empirical base of knowledge about promoting adaptive functioning, health, and recovery for persons with SMI living in community settings.     

Pilot Effectiveness of a Stress Management Program for Sheltered Homeless Adults With Mental Illness: A Two-Group Controlled Study

This study examined the effectiveness of a stress management intervention for sheltered homeless adults with mental illness. Twelve intervention participants received a 6-week, 1-hour psychoeducation group combined with a 20-minute meditation. Eleven matched pairs did not receive intervention and served as controls. At 1 week post study, intervention participants reported a statistically significant reduction in perceived stress (Z=??2.285, p < .02, d=??1.176) compared to controls. No differences were found at 1 week post study between intervention and control participants on reported quality of life. This study provides pilot data on the effectiveness of an occupation-based stress management program for sheltered homeless adults and warrants further study.     

Understanding Systems Change in Early Implementation of Housing First in Canadian Communities: An Examination of Facilitators/Barriers,Training/Technical Assistance,and Points of Leverage

We present interim findings of a cross‐site case study of an initiative to expand Housing First (HF) in Canada through training and technical assistance (TTA). HF is an evidence‐based practice designed to end chronic homelessness for consumers of mental health services. We draw upon concepts from implementation science and systems change theory to examine how early implementation occurs within a system. Case studies examining HF early implementation were conducted in six Canadian communities receiving HF TTA. The primary data are field notes gathered over 1.5 years and evaluations from site‐specific training events (k = 5, n = 302) and regional network training events (k = 4, n = 276). We report findings related to: (a) the facilitators of and barriers to early implementation, (b) the influence of TTA on early implementation, and (c) the “levers” used to facilitate broader systems change. Systems change theory enabled us to understand how various “levers” created opportunities for change within the communities, including establishing system boundaries, understanding how systems components can function as causes of or solutions to a problem, and assessing and changing systems interactions. We conclude by arguing that systems theory adds value to existing implementation science frameworks and can be helpful in future research on the implementation of evidence‐based practices such as HF which is a complex community intervention. Implications for community psychology are discussed.     

Community Implementation Successes and Challenges of a Cognitive-Behavior Therapy Group for Individuals with a First Episode of Psychosis

CBT for psychosis has recently been called a best practice, suggesting that studies have demonstrated its efficacy with many populations. Community settings are encouraged to implement best practices such as CBT yet many factors can make the implementation of CBT challenging. Issues such as clinician resistance, setting, as well as client variables (refusal, denial of symptoms, etc.) come into play. Examples of successes and challenges of a community based study of CBT groups for first episodes will be described. The strategies used to overcome these challenges and the successes of the program will be presented.     

Camping Programs for Children with Chronic Illness as a Modality for Recreation, Treatment, and Evaluation: An Example of a Mission-Based Program Evaluation of a Diabetes Camp

Summer camps have been recognized as a valuable means of delivering services to children with chronic illnesses. Although these camps exist in abundance across the United States, they have been largely underrepresented in the clinical psychology literature. Particularly, there is a staggering discrepancy between the number of camps in existence and the number of published articles pertaining to the systematic evaluation of these camps. We outline the potential benefits of camping programs for children who are chronically ill, describe the importance of systematically evaluating them, and provide a model for this evaluative process. We describe an evaluation of a diabetes summer camp and present implications of this study for camp decision makers and clinical psychologists working in pediatric medical settings.     

The Citizenship Project Part II: Impact of a Citizenship Intervention on Clinical and Community Outcomes for Persons with Mental Illness and Criminal Justice Involvement

This study assessed the effectiveness of an intervention based on a theoretical framework of citizenship on reducing psychiatric symptoms, alcohol use, and drug use, and increasing quality of life for persons with serious mental illness (SMI) and criminal justice involvement. One-hundred fourteen adults with SMI and a history of criminal justice involvement participated in a 2 × 3 longitudinal randomized controlled trial of a four-month citizenship intervention versus usual services. Linear mixed model analyses were used to assess the intervention’s impact on quality of life, symptoms, and substance use. After controlling for baseline covariates, participants in the experimental condition reported significantly increased quality of life, greater satisfaction with and amount of activity, higher satisfaction with work, and reduced alcohol and drug use over time. However, individuals in the experimental condition also reported increased anxiety/depression and agitation at 6 months (but not 12 months) and significantly increased negative symptoms at 12 months. Findings suggest that community-oriented, citizenship interventions for persons with SMI and criminal justice histories may facilitate improved clinical and community outcomes in some domains, but some negative clinical findings suggest the need for post-intervention support for intervention participants. Implications for practice and future research are discussed.